What autologous dermis does that cartilage cannot, which findings indicate reinforcement rather than structure, and how it is used alongside a support graft at revision.
Cartilage grafts answer the question of shape — what the nose is built to hold. Dermis answers a different question entirely: what the covering over that shape is able to withstand. At revision, the two questions are sometimes equally important, because skin that has already been operated on once does not always behave the way it did the first time.
This page covers what dermis is used for and why, in the specific context of skin that has thinned by the time of a second operation. It is not about choosing between cartilage sources for structure — that decision is set out in Running Out of Graft Material. And it is not about thin skin as a first-surgery condition, which is planned for differently and covered in Thin Nasal Skin.
Dermis is a layer of the patient's own skin tissue, used not to build shape but to add thickness and coverage over a framework that will sit under skin thinner than it once was. It is placed alongside a structural graft, not instead of one. Whether it is needed is decided by examining the covering itself — how thin it has become, and whether an edge or transition beneath it is already visible or likely to become visible once new structure is added.
On this page
- What dermis does that cartilage cannot
- Which findings indicate reinforcement rather than structure
- Why thinned skin changes what the nose can hold
- How dermis is used alongside a support graft
- How thinning is assessed alongside the rest of the revision workup
- What patients notice before they have a name for it
- What this does not mean
- Frequently asked questions
What dermis does that cartilage cannot
Cartilage — whether from the septum, the ear, or the rib — is a support material. It holds a shape and resists being pushed out of position. What it does not do is add thickness to the layer that sits on top of it and determines how much of the framework beneath shows through.
Dermis is taken from the patient's own skin, most often from a site where the resulting scar is easily hidden, and it behaves as connective tissue rather than as a rigid support. Placed over a cartilage framework, it adds a soft layer of padding and coverage between the graft and the visible surface of the skin. It does not make a nose taller or straighter. It makes what is underneath less visible and less likely to show a sharp edge.
The distinction matters because the two materials are solving different problems, and a plan that only accounts for structure while ignoring coverage can produce a nose that is correctly shaped but shows every contour of the graft beneath the skin — particularly at revision, where the skin has often been worked on once already and has less of its own natural cushioning left than it started with.
Which findings indicate reinforcement rather than structure
Not every revision needs dermis, and the decision is made by examining the skin directly rather than by assuming that a second operation automatically calls for it. Three findings point toward reinforcement being part of the plan.
Visible thinning on examination. Skin that has become noticeably thinner than typical for the area — often over the bridge, where previous grafts or a previous implant sat closest to the surface — is the clearest indicator.
A palpable edge from the existing framework. Where the surgeon can feel — or, in more advanced cases, see — the contour of what is underneath through the skin, that is a sign the current covering is not providing enough of its own buffer.
A history that predicts further thinning. Where the first operation involved a difficult removal, prior infection, or a porous implant that required more disruption of the tissue above it — as described in Gore-Tex and Silicone at Revision — the skin is more likely to be thin even where it does not yet look dramatically so.
Where none of these findings are present, the plan proceeds with structural grafting alone, and dermis is not added simply because the operation is a revision.
Why thinned skin changes what the nose can hold
Skin thickness is not a cosmetic detail — it is one of the physical limits the reconstruction has to work within. Thin skin shows more of what sits beneath it, which affects the plan in three concrete ways.
Edges and transitions between graft segments become visible where thicker skin would have hidden them, so the framework has to be built with smoother, less abrupt junctions. Height and projection are planned more conservatively, because a raised structure under thin skin reads more sharply than the same structure under a fuller covering. And where the skin is thin enough that these concerns cannot be fully addressed by careful graft shaping alone, adding a layer of dermis over the framework becomes the more direct answer — thickening the covering itself rather than only softening the shape underneath it.
How dermis is used alongside a support graft
| Cartilage graft | Dermis | |
|---|---|---|
| Function | Provides shape and structural support | Adds thickness and coverage over the structure |
| Placed | As the framework itself | Over the framework, between it and the skin surface |
| Decided by | What shape and support the plan requires | How thin the covering has become and what it needs to hide |
| Used alone? | Yes, where reinforcement is not indicated | No — it reinforces a structure, it does not replace one |
Dermis is never the only material in a revision plan. It is layered over a cartilage framework that has already been decided on its own terms, using septal remnant, ear cartilage, or rib as covered in Running Out of Graft Material. The sequence in planning is structure first, then coverage — the surgeon does not choose dermis before deciding what it needs to sit over.
Where it is used, it is typically placed over the areas most exposed to view and most affected by thinning — commonly the bridge and the transition toward the tip — rather than across the entire reconstruction, since not every part of the nose carries the same degree of thinning or the same visibility risk.
How thinning is assessed alongside the rest of the revision workup
Skin thickness is not judged in isolation from everything else the surgeon is assessing at a revision consultation. It is one finding among several — alongside available graft material, the condition of any existing implant, and the overall structural plan — and it is checked at the same time as those other findings rather than as a separate, later step.
In practice, this means the surgeon examines the skin over the bridge and supratip area by gentle palpation, comparing its thickness and mobility to what would be expected for the patient's general skin type, and looks specifically for areas where an underlying edge or contour is already faintly visible or palpable. Where a previous implant is present, its removal is anticipated to potentially reveal further thinning that was not fully apparent while the implant was still in place and supporting the tissue from beneath — which is one reason the final decision about dermis is sometimes confirmed once the implant has actually been removed and the true state of the covering can be seen directly, rather than finalised purely from the pre-operative examination.
Why timing relative to a previous operation matters
How long ago the previous surgery took place is a relevant, though not decisive, piece of context. Skin that thinned as a direct mechanical consequence of a difficult implant removal, described in Gore-Tex and Silicone at Revision, may show that thinning relatively soon afterward. Skin that has thinned gradually under the pressure of a long-standing implant, by contrast, can take years to reach a degree of thinning that becomes clinically significant. Neither pattern is more or less legitimate a reason to reinforce the covering — what matters at the point of a new revision is the current state of the tissue, established by direct examination, not how long it took to get there.
What patients notice before they have a name for it
Patients rarely arrive at consultation saying "I think my skin has thinned." More often, they describe something more specific and harder to categorise on their own — that they can see a faint outline of the graft underneath when the light hits their profile a certain way, that the skin over the bridge looks slightly translucent compared with the rest of their face, or that a contour they never used to notice has become more visible over the months or years since their last surgery. These descriptions, imprecise as they are, are useful starting points for the surgeon, because they often correspond closely to the clinical finding of thinning even before formal examination confirms it.
Part of the consultation, in these cases, is translating what the patient has noticed into a specific clinical assessment — distinguishing, for instance, between an outline that is visible because the skin has genuinely thinned and one that is visible because the underlying graft itself has a sharper edge than it should, which is a different problem with a different solution, sometimes addressed by refining the graft's shape rather than by adding a covering layer over it.
What this does not mean
Using dermis does not mean the reconstruction has gone poorly, and it is not a sign of a more difficult or riskier revision than one that does not use it. It is a planning response to a specific physical finding — thinned skin — in the same way that choosing rib cartilage is a response to a specific finding about available structural material.
It also does not mean the skin will feel or look artificial afterward, and it is not a substitute for the body's own healing process. The graft is placed to integrate with the surrounding tissue over the normal course of recovery, in the same way any autologous graft does; it does not create an instant or separate layer that behaves differently from the rest of the skin around it.
And it does not mean every patient with thinned skin needs it. Where thinning is mild and the framework beneath it is designed with smooth transitions and conservative height, careful shaping of the cartilage graft alone is sometimes enough, and adding dermis where it is not needed is not standard practice.
Frequently asked questions
Where is the dermis taken from?
From the patient's own tissue, at a site chosen so the resulting scar is easily concealed. The exact site is discussed at consultation as part of the overall surgical plan.
Does adding dermis make the nose look thicker or less defined?
It adds a layer of soft coverage, not bulk in the sense of changing the shape. Its purpose is to smooth what shows through the skin, and the framework beneath it is still what determines the overall shape.
How do I know if my skin has thinned since my first surgery?
This is assessed at examination by the surgeon, sometimes alongside what a previous operation is known or suspected to have involved. It is not something a patient can reliably judge on their own from the outside.
Is dermis used in first-time rhinoplasty as well as revision?
It can be, where thin skin is present at a first surgery, but the circumstances and planning differ from a revision case. First-surgery thin skin is covered separately in Thin Nasal Skin.
Does this add significantly to the length of the operation?
Harvesting and placing a dermis graft adds some time, but it is planned into the overall operative window in advance rather than treated as an unplanned extension.
Will the area where the dermis was taken be visible?
The donor site is chosen specifically because it heals discreetly. Individual healing varies, and this is discussed in detail during consultation.
Can I request dermis reinforcement even if the surgeon does not think I need it?
The decision is based on direct examination of the skin's actual thickness and mobility. Adding a graft that is not indicated does not improve the outcome and introduces an additional donor site without a corresponding benefit, so the recommendation follows the finding rather than the request.
Does dermis grafting affect how the nose feels to the touch afterward?
As the graft integrates over the normal course of healing, the treated area generally comes to feel consistent with the surrounding tissue. Any specific concerns about sensation are discussed individually, since healing responses vary between patients.
About the author
Dae-hee Han, MD — Board-Certified Plastic Surgeon (specialist certificate No. 2045, issued 3 March 2014; medical licence 00394, issued 26 February 2009). Master’s degree, Ajou University School of Medicine. Training at the Craniofacial Center, Chang Gung Memorial Hospital, Taiwan (2013), and the IFAAS Mini Fellowship, University of Florida, USA (2016). Three rhinoplasty papers published in SCIE-indexed international journals. More than 4,500 nose surgeries — Dr. Han’s career total from 2017 to 2025, counted from medical records. Eighteen years in practice since medical licensure in 2009; thirteen years as a board-certified plastic surgeon. He carries out consultation, surgery and follow-up personally; fee guidance is given by the clinic’s consultation manager.
Last reviewed: 2026-08-15
Clinic information
Edition Plastic Surgery Clinic & Dermatology
6F, OPUS 407, 407 Gangnam-daero, Seocho-gu, Seoul 06614, Republic of Korea
One minute on foot from Gangnam Station Exit 10
Tel +82-2-591-0100 · editionprs@gmail.com
Consultation hours: Monday to Friday 10:00–19:00 · Saturday 10:00–17:00 · closed Sundays and public holidays
Disclaimer
Individual results may vary. Bleeding, infection, swelling, asymmetry, and scarring can occur. Please decide after a full consultation with a board-certified specialist.
This page is general medical information. It is not a diagnosis, and it does not promise a particular outcome. Surgical fees are given after an in-person consultation.