Rhinoplasty in Older Individuals
All of rhinoplasty can be distilled down to the fundamental points of aesthetic balance and functional harmony. Rhinoplasty in older patients provides no exception to this tenet. However, the challenge of rhinoplasty in this patient population is substantially different than in traditionally younger patients seeking this procedure. In fact, oftentimes these patients are presenting secondary to functional disorders that have become intolerable when combined with the normal aging effects on the nose. Our older patients generally neither want nor do we recommend dramatic transformations.
The effects of aging on the infrastructure of the nose have been well documented. If you think in more general terms, you will note that newborns have a nasal dorsum that is concave (naturally scooped) with an upturned tip while in the elderly, the tendency is for the dorsum to appear convex with a ptotic (droopy) tip. Not all people will experience age-related changes to the same degree nor will all patients necessarily find this cause for concern.
When examined more specifically, we note changes that occur generally in all bodily tissues and those changes that are specific to the nose. Overall, skin shows a loss of elastic fibers and atrophy (shrinkage) of collagen along with a deterioration in cellular repair mechanisms, our tissues’ restorative processes. In the nose, the skin thickens in the lower portion while thinning develops in the upper aspect. This feature has several consequences. Subtle bony irregularities, that may have always been present, will now become more noticeable. In women, the supratip depression (a small dip in the nasal profile just above the tip) becomes exaggerated and the width of the nasal dorsum decreases. Furthermore, loss of skin elasticity leads to redundancy and to a diminished ability of the skin to contract and redrape. As a result, wide undermining (elevation) of nasal skin becomes an integral technical component of rhinoplasty in the aging nose.
The most significant changes to the older individual’s nose occur in the cartilaginous portions. The bony pyramid (bridge) remains fixed, although the bones themselves often become brittle and readily fracture. With aging, weakening of the connective tissue in the “scroll area” connecting the middle and lower cartilages results in their gradual separation and, occasionally, fragmentation. Meanwhile, downward rotation of the tip and absorption of the fat pad in the subnasale (portion where the upper lip meets the middle portion of the nostril) cause a more acute nasolabial angle as well as retraction of the columella, all leading to a more apparent drooping of the tip. Atrophy or buckling of the cartilages themselves will lead to loss of intrinsic tip cartilage support. Together, this loss of tip support results in tip drooping, increased tip bulbosity, a lengthened nasal appearance, a hanging columella, and altered nasal airflow patterns.
Functionally, the changes in cartilaginous and soft tissue structure often lead to loss of nasal valve function and progressive nasal obstruction (for more information on this, see our section on nasal valve collapse). Separation of the tip cartilages from the septum combined with tip ptosis result in nostril shape change. The loss of support of the lower edges of the upper lateral cartilages (middle cartilage in bridge of the nose) leads to a decrease in the internal valve angle. More significantly, the tip cartilages, malpositioned and weakened with age, are inadequate to support the nostrils and collapse on moderate to deep inspiration. Such patients require a more aggressive intervention to support the nasal tip and external nasal valve. Atrophy of the dilator naris (a facial muscle responsible for nostril flaring) further reduces the patient’s ability to support the nasal valve. Finally, progressive nasal mucosal dryness coupled with major alterations in the normal airflow patterns results in progressive nasal obstruction.
Finally, the surgeon must be aware that the overall dimensions of the face also change with time. The upper third of the face increases in proportion secondary to a receding hairline, while the lower third of the face decreases due to absorption of the maxilla (upper jaw) and mandible (lower jaw) along with muscle and subcutaneous atrophy. The middle third subsequently appears longer because of the relative lengthening of the nose. When performing rhinoplasty in our older patients, we therefore concentrate on bringing balance to the face by shortening the elongated nose.
In general, patients in midlife (fourth to sixth decades) have a well imprinted body image and a clear conception of an ideal appearance. They respond best to conservative and subtle changes that maintain a natural look and return the nose to its pre- aged appearance. On the other hand, those patients who have only recently become dissatisfied with their nose, who want significant changes or who are in the midst of some major life event, such as divorce or death of a loved one, are carefully evaluated, as they may be unsuitable candidates for surgery at the present time.
As described, the aged nasal tip is often ptotic or droopy in appearance, resulting in an apparent dorsal hump. All we need do to see this is to look at photographs of our grandparents in comparison to their younger counterparts. It always appears as if a dorsal hump has grown with time; in truth, this is an optical illusion since our noses don’t grow substantially after the age of maturity. Rather, the tip supporting mechanisms have weakened and, as the tip drops creating an acute nasolabial angle, the dorsum appears more prominent in contrast to the tip.
To correct these changes, the tip must be rotated and re- projected. Drs. Solieman and Litner follow a specific surgical sequence to allow the skeletal supports to be optimally maintained. This allows Drs. Litner and Solieman to preserve a high dorsal profile, which is particularly important for the older patient whose conservative self- image is not compatible with a retroussé (retrusive) nasal tip. Furthermore, maintenance of maximal underlying skeletal support is critical to promote smooth redraping of inelastic skin. Finally, the relative dorsal hump will often vanish or need minimal rasping after restoration of appropriate tip projection and rotation. As such we find that once the tip is re- projected and rotated, significant hump reduction and osteotomies (controlled bony fractures) are relatively less common in these patients. This fact is particularly important, as the airway in older patients is more prone to compromise after osteotomies.
The ptotic tip found in the aging nose often exacerbates an already compromised nasal airway. In our experience, the source of nasal obstruction in these older patients is all too often erroneously ascribed to septal deviation, while valve collapse is overlooked. Many of these patients do not present with a “pure” isolated defect, but rather a combination of external valve collapse, septal deviation, and some internal valve collapse. Drs. Solieman and Litner take time to correctly diagnose the causes of nasal obstruction, as this can significantly alter the treatment strategy.