Scar Tissue in Rhinoplasty: some is normal, a lot is not

When the nose heals after rhinoplasty, the body produces healing tissue to allow the soft tissue envelope to re-adhere and drape over all of the structure (bone and cartilage) of the nose. The amount of scar tissue is variable person to person. In general, the thicker the skin is to begin with, the more scar tissue will form. Over time, through a process of soft tissue remodeling and contraction (sometimes called shrink wrap), the soft tissue envelope thins to better show the definition of the nose. However, the capacity of the skin to contract is finite and if there was too much reduction to the size of the nose relative to the ability of the skin to contract, the scar never thins to the ideal point, resulting in permanent thickening. This is most common in the lower third of the nose, especially just above the tip after a hump is lowered. This specific problem is called a polybeak deformity.

The best way to prevent such problems is to be strategic in the surgery and not to reduce the nose beyond the ability of that individual skin envelope to contract. The thicker the skin, the less size reduction should be attempted and the focus should be more on shape improvement . If this problem happens, subsequent treatment must be thoughtful and deliberate to prevent further problems. I usually use the following guidelines when treating someone with an excess scar tissue or polybeak deformity following previous rhinoplasty:

1. Start with conservative measures such as kenaolg (steroid) injections or taping.
2. Wait at least 1-2 years before considering revision–thick skin takes longer to settle and contract.
3. If revision surgery is performed, avoid treatment simply through “scar removal” or soft tissue thinning. This will tend to stimulate more soft tissue injury and more scar tissue. Or even worse, if done aggressively can cause vascular damage and unevenness/atrophy to the skin envelope. Revision should be focused on shape improvements–sometimes requiring that the nose be made bigger but better in shape and proportion to stretch the excess skin and scar and result in improved shape and definition.

These concepts are advances rhinoplasty topics and as such this type of problem is best tackled by an experienced nose surgeon with lots of revision experience.