Rhinoplasty in the Aging Patient

Personal Philosophy

Rhinoplasty is a complex operation that requires precise preoperative diagnosis to select the appropriate surgical technique. Owing to variations in nasal anatomy and aesthetic expectations, no single technique is appropriate for all patients. Each rhinoplasty patient presents the surgeon with a diversity of nasal anatomy, contours, and proportions that require a series of organized maneuvers tailored to the patient's anatomic and functional needs. The surgeon must also be skilled at manipulating and controlling the dynamics of postoperative healing to attain optimal long-term aesthetic results. A necessary prerequisite is the skill to visualize the ultimate long-term healed result while manipulating the nasal structures.

Anatomy

Aging of the nasal structures and external contour of the nose is influenced by a variety of genetic and environmental factors. Additionally, the nasal shape changes over time as well. In children, the nasal dorsum is typically concave and assumes a more straight or convex shape in early adult life. This convexity is further enhanced in midlife by the development of a drooping, ptotic tip. In addition to these changes to the appearance of the nose, nasal function tends to deteriorate over time as the nasal airway changes.

As patients age, the skin thins with loss of elasticity, subcutaneous fat deposits resorb, and the underlying soft tissues atrophy. With these changes, the underlying support structures of the nose, such as the lower lateral cartilages and nasal bones, become skeletonized or visible. In addition, skin hydration is diminished, and the skin becomes less pliable. This affects the skin's ability to contract and redrape after the cartilaginous and bony structures of the nose are reduced.

The most significant changes over time occur in the upper and lower lateral cartilages. These cartilages are connected by a fibrous union at the cephalic margin of the lateral crura, the scroll region. As the nose ages, the upper and lower lateral cartilages begin to separate and fragment. This may result in collapse of the internal nasal valve and lateral wall. As one ages, the middle nasal vault will tend to collapse as the upper lateral cartilages move inferomedially. Loss of support of the medial crura and stretching of the fibrous attachments from the posterior septal angle and nasal spine to the medial crural footplates result in their posterior movement and retraction of the columella. These changes also occur by loss of the fat pad below the medial crura and resorption of the premaxilla. With loss of support of the medial crura and separation of the lateral crura from the upper lateral cartilages, the nasal tip may become ptotic, with an appearance of increased length and a more acute nasolabial angle.

With aging, the nasal bones may become brittle and are more readily fractured. Care must be taken during osteotomies to avoid excessive narrowing of the bony vault or comminuted fractures of the nasal bones. Periosteal elevation is not recommended in the aging patient and, if used, should not extend to the point of the intended lateral osteotomies, to avoid loss of periosteal support. Although undesirable in the younger patient, greenstick fractures can be effective in the older patient. Finally, dorsal hump reduction must be executed with great precision to minimize irregularities of the bony nasal vault as the skin over the dorsum tends to be very thin.

Preoperative Assessment

Preoperative assessment of the rhinoplasty patient includes the assessment not only of the anatomic and functional components but also the emotional and psychological factors. As with all facial aesthetic surgery, it is important for the physician to discuss motivation and aesthetic goals of rhinoplasty surgery with the patient. It is critical to elucidate what aesthetic changes the patient desires. Older patients have developed a self-image over many years and must be prepared for the planned surgical changes. Many older patients do not want to look dramatically different, and thus conservative changes are generally most appropriate. Patients who desire dramatic changes warrant careful evaluation prior to consideration as surgical candidates.

In this age group, a thorough preoperative medical examination is mandatory. Many of these patients have comorbid medical conditions. A careful medical history and physical examination are critical prior to performing this type of surgery. It is often a good idea to consult with the patient's primary care physician prior to scheduling surgery. Many of these patients take medications that can affect clotting; these medications should be stopped at least 2 weeks before surgery.

Surgical Technique

Preoperative Considerations

The surgical approaches to the nose include nondelivery techniques (cartilage-splitting or retrograde approach), delivery of bilateral chondrocutaneous flaps, and the external rhinoplasty approach. Selection of the approach should be based on both operative objectives and surgical experience. When only conservative volume reduction of the lateral crura and dorsal hump reduction are planned, a nondelivery approach (cartilage-splitting or retrograde approach) will suffice. However, when more complex nasal tip work is required, delivery of bilateral chondrocutaneous flaps or the external rhinoplasty approach should be used. The external approach is preferred when complex tip grafting or middle nasal vault reconstruction is planned. Regardless, the surgeon should select the least invasive approach possible to avoid disruption of nasal support mechanisms and maximize the functional and aesthetic result.

External incisions can be used with greater frequency in older patients because the skin is less likely to scar unfavorably. Nasal skin in the aging patient also has multiple rhytids that can aid in camouflage. Even though it is rarely necessary, direct excision of skin from the nasal dorsum or supratip can be performed to aid redraping of the skin or elevating the severely ptotic nasal tip. Because of the thin skin found in the aging nose, even the smallest irregularities or asymmetries can become noticeable. As a result, debulking of underlying subcutaneous fat and muscle tissue should not be performed. This subcutaneous tissue should be preserved to maximize camouflage of the cartilage and bone. Tip grafts should also be limited unless the patient has medium to thick skin. If they are used, they should be carefully sculpted and camouflaged to avoid visible edges. With thin skin, a thin layer of perichondrium or superficial temporal fascia can be applied over the graft, with an understanding that it will create temporary edema of the grafted area that should resolve over 6 to 12 months.

When treating the aging nose, the nasal tip should be managed first to set tip projection and rotation before completing profile alignment. After setting appropriate tip projection, dorsal hump reduction may not be needed. Frequently, older patients will also benefit from augmentation of the radix to create a straight profile. This strategy of increasing tip projection and raising the radix allows the surgeon to preserve a high dorsal profile while also creating a favorable tip-supratip relationship ( Figure 33-1 ). As mentioned earlier, only conservative changes should be made in the nasal contour because older patients tend to have a set self-image. The nose should also be in harmony with the patient's other facial features.