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Case Study 7: Revision Rhinoplasty for a Bulbous Nose with Very Thick Skin and a Large Septal Perforation

Nov 15, 2023
3 min read

Updated: Oct 3

Case summary

  • Patient: 48-year-old man from Turkey

  • Procedure: revision rhinoplasty with septal perforation repair

  • Surgeon: Prof. Dr. Suleyman Tas, Prof. Dr. Suleyman Tas Clinic, Istanbul

  • Challenges: extremely thick skin, a bulbous tip, a large septal perforation, previous surgery

Case Study 7: Revision Rhinoplasty for a Bulbous Nose with Very Thick Skin and a Large Septal Perforation

The patient's concerns

This patient had undergone nose surgery before and was left with a bulbous, poorly defined nose. Inside, a large hole in the septum (septal perforation) caused crusting, whistling, dryness and breathing discomfort. On top of this his skin was extremely thick and oily, which is the most difficult skin type to reshape in rhinoplasty.

Why this case was difficult

Revision rhinoplasty is always more complex than a primary operation: scar tissue replaces normal planes, and cartilage that was removed earlier is no longer available for support. Three further factors made this nose especially demanding:

  • Very thick skin hides the cartilage framework and does not shrink easily onto a smaller shape. Reducing the framework alone would only create a larger "dead space" filled with scar, making the tip look even rounder.

  • A large septal perforation meant the main source of cartilage for grafts was missing, and the perforation itself needed repair.

  • Age and previous surgery reduce tissue elasticity and blood supply.

How the nose was treated

Instead of simply reducing, the strategy was to build a strong, projecting framework that could stretch and define the heavy skin envelope. Structural cartilage grafts provided support and tip definition, while the soft tissue under the skin was carefully thinned to reduce bulk without compromising circulation. The septal perforation was addressed as part of the same operation to restore the inner lining and improve breathing. Where the septum could not supply enough cartilage, alternative graft sources such as ear or rib cartilage are used. Read more about male revision rhinoplasty.

Aftercare for thick skin

Thick-skinned noses need more active aftercare: prolonged taping, sometimes medications that reduce oil gland activity, and occasionally small steroid injections to control swelling in the supratip area. Patience is essential, because tip definition in thick skin continues to improve for 18 months or more.

Result

Despite the extremely thick skin and large septal perforation, the patient achieved an excellent result that met his expectations: a better-defined, more refined nose in harmony with his face, together with functional improvement.

Frequently asked questions

Can a very thick-skinned nose look defined after surgery?

Yes, but through structural support rather than aggressive reduction, and with longer healing.

Can a septal perforation be closed?

Many perforations can be repaired or reduced with flaps and grafts, depending on their size and location.

How long does swelling last in thick skin?

Visible improvement comes early, but the tip can take 12–24 months to fully refine.

Next step

See other challenging cases on the case studies page and the rhinoplasty page, or contact Prof. Dr. Suleyman Tas Clinic for an assessment by Prof. Dr. Suleyman Tas.

How soon can I go back to work after nose surgery?

Most patients return to desk work once the cast is removed at about a week, when the swelling and bruising around the eyes have largely faded.

Will my result look like this one?

Every nose starts from different anatomy — skin thickness, cartilage strength and any previous surgery change what is achievable. A case shows what was possible for that patient, not a promise for every nose.

About the author

Prof. Dr. Suleyman Tas is a European Board-certified plastic, reconstructive and aesthetic surgeon based in Istanbul with over 20 years of experience, author of Rhinoplasty in Practice (CRC Press) and founder of the Closed Atraumatic Rhinoplasty Course. Read verified patient reviews or book a consultation.

This article is for general information and does not replace an individual medical consultation.

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