Rhinoplasty in the Older Adult
Rhinoplasty presents with a unique set of problems and challenges when performed in older adults. Moreover, the ageing nose is often defined by the following features: 1) ptotic nasal tip, 2) dorsal pseudo-hump, 3) nasal lengthening, 4) counter-rotation, and 5) acute nasolabial angle. In order to address these issues, plastic surgeons prioritize performing tip de-rotation with tip refinement, increasing tip projection and relative columellar lengthening through columella strut grafts, decreasing the overall nasal length, correcting the dorsal hump, supporting the internal nasal valves through dorsal spreader grafts, and correcting septal deviation and inferior turbinate hypertrophy, if present. This article presents a review the technical considerations in older age rhinoplasty and presents a case series of patients who underwent rhinoplasty at 55 years old or older. This case series illustrates how specific techniques were performed in order to address the aforementioned deformities and how these corrections were reflected through changes in anthropometric measurements from pre to post-operative (i.e. 12 months) timepoints.
Methods/Technique
:Demographics and operative details were analyzed. Information collected included basic demographic factors, which included ethnicity and insurance status, indications, reasons, and motivations for surgery, history of prior rhinoplasties, operative report details, which include the use of osteotomy, septoplasty, septal caudal extension grafts, L columellar strut grafts, spreader grafts, auto-spreader grafts, and tip onlay grats, anti-coagulation medications, age at the time of rhinoplasty, co-morbidities, ASA status, and tobacco status, and post-operative events, which included complications and incidence of revision rhinoplasties. Three-dimensional photographs were assessed using VECTRA (Canfield Scientific, Parsippany, N.J.) at two different time points (pre-operative and post-operative at 12 months). Standard facial anthropometric measurements, including nasal tip projection, nasolabial angle, nasal tip angle, were taken.
Results/Complications
:In our retrospective review of 27 patients, the vast majority were Caucasian (85%) and female (85%). Most underwent rhinoplasty for functional (89%) and aesthetic (70%) reasons, as opposed to traumatic (48%) events. This was similarly found in the literature, in which studies detail the utilization of septoplasty, turbinate co-ablation, spreader grafts, and spreader flaps in addressing symptoms of nasal obstruction, as well as the use of septal caudal extension grafts, L columellar strut grafts, and tip grafts to achieve tip projection and refinement. In terms of post-operative outcomes, there were no complications recorded, but five patients received revision rhinoplasties. Other post-operative surgeries included fat grafting, nasal valve reconstruction, and cartilage reconstruction.
Our case series include four patients who underwent rhinoplasty at an age greater than fifty-five years old. The first was a 72-year-old Caucasian female with internal valve collapse (inverted V), turbinate hypertrophy, and S-shape nasal deformity; she received septoplasty and turbinate ablation in order to address nasal obstructive symptoms; rib cartilage was harvested for dorsal augmentation and projection. The second patient was a 67-year-old male septal deviation, internal valve collapse (inverted V), as established by a positive Cottle maneuver, and saddle nose deformity; he underwent spreader grafts and auto-spreader grafts in order to address internal valve collapse, lateral crural articulating grafts for external valve incompetence, septoplasty and turbinate ablation for nasal obstructive symptoms, and tip onlay graft and septal caudal extension graft for tip refinement and projection. The third patient is a 69-year- old female who received spreader grafts and auto-spreader flaps for internal valve collapse, articulated alar rim grafts for external valve incompetence, osteotomies for nasal stabilization, and an infralobular graft for tip projection. The fourth patient was a 57-year-old Asian female presented septal deviation, internal valve collapse (inverted V), turbinate hypertrophy, external valve collapse, with slit like nares. Spreader grafts, turbinate ablation, and septoplasty were performed to resolve nasal obstruction; osteotomies were done to stabilize the bony vault; dorsal reduction was performed through rasping after tip complex refinement with a tip onlay graft. For these four patients, there were increases in Goode’s ratio, a measure of tip projection and in nasolabial angle after rhinoplasty.
Conclusion
:Rhinoplasty presents unique challenges and technical complexities when performed in the older adult population. This study details specific procedural approaches through a case-series, and assesses these techniques through a report of anthropometric measurements at pre- and post-operative timepoints. Our analyses found that indications for rhinoplasty and surgical techniques vary tremendously amongst patients who undergo rhinoplasty. General considerations include the restoration of tip projection and refinement, relief of nasal obstruction, correction of the dorsal hump, and stabilization of the nose and dorsum. In all, certain techniques did confer objective changes in anthropometric measurements, and also provided favorable aesthetic and functional outcomes within our cohort of 27 patients. To fully understand the long-term clinical outcomes of older age rhinoplasty, future studies could incorporate a combination of surveys to assess functional outcomes, anthropometric measurements, and specific techniques performed by plastic surgeons.