Rhinoplasty for the aging nose.

Because cosmetic rhinoplasty is often viewed as a transformative

rather than restorative procedure, it is not surprising that rhinoplasty
is only rarely considered by both patients and physicians in the
management of the aging face. Successful correction of aging jowls,
eyelids, and brows can appear out of balance in the presence of an aging
or drooping nose. In our practices, we use a limited open rhinoplasty
procedure as an important adjunct to rhytidectomy, blepharoplasty, and
brow-lift in selected patients. The procedure is designed to correct
age-related nasal tip ptosis and its resultant structural and functional
consequences.
The hallmark of nasal aging is the loss of support for the lower
one-third of the nose. The major and minor tip support mechanisms have
been documented to weaken with age. The secondary effects of these
changes include a http://www.womanwisdom.com/tag/boob-job/ relative dorsal hump as a result of
decreased tip
projection, and a longer nose as a result of lobular depression and
derotation. In addition, the columella becomes shortened and the alae
can collapse secondary to the weakened cartilaginous support and atrophy
of the nasal musculature. Finally, the nasal airway is compromised when
collapse of the caudal margin of the upper lateral cartilages narrows
the angle of the nasal valve.

The ideal candidate for an aging-nose rhinoplasty has developed tip

ptosis and deprojection over a number of years. Patients with

significant dorsal irregularities or notable nasal deviation will

require a more extensive procedure. A simple test to determine the
candidacy of a patient for this procedure involves manually rotating the
patient's nasal tip superiorly with an index finger. A substantial
decrease in the dorsal hump prominence, along with physician and patient
satisfaction with the new tip position, indicates that the patient is a
good candidate. Frequently, patients in whom the nasal valve is
compromised may notice an improvement in nasal airflow with this
procedure, as well.

The procedure itself must be tailored to the characteristics of the

individual patient, primarily the degree of tip ptosis and the
contribution of the various anatomic elements. The well-described
"tripod/pedestal concept" facilitates conceptualization of the
tip rotation that is the goal of this procedure.
We use a graded approach or algorithm of increasingly complex nasal
tip modifications as dictated by the patient's anatomy (figure 1).
We begin with the simplest and least invasive approach. A patient with
mild tip depression and an excessively long caudal septum can be treated
with a simple excision of the caudal septum, with or without a hemi- or
complete transfixion incision of the excess mucoperichondrial flap.
Suture septocolumellar fixation can be performed via this approach in
patients with laxity in the ligaments connecting the medial crural footplate to the septum.

[FIGURE 1 OMITTED]

For patients whose tip ptosis is more extensive, the open

rhinoplasty technique may be preferable. This procedure involves making
a midcolumellar incision and undermining the nasal skin and soft-tissue
envelope, thereby achieving wide exposure of the nasal tip and dorsal
structures. The open approach should be performed in conjunction with a
transfixion incision. A strut harvested from the cartilaginous nasal
septum is placed in a pocket that has been dissected between the medial
crura and sewn into place with absorbable sutures.

For patients with excessively long lateral crura and for those with

persistently ptotic tips despite more conservative maneuvers, lateral

crural segment excisions may be performed. A wedge or rectangular
segment of lateral crura is excised, and the free edges of the crura are
reapproximated.

A tip graft can be used for patients who require more extensive tip
projection, rotation, and reshaping. The graft provides additional
support to the medial crural limb of the tripod, and
http://presslayer.com/tag/contact-the-best-cleveland-surgeon/ it directly
projects and rotates the nasal tip.

For elderly patients with severe nasal tip ptosis that requires
more extensive correction, the previously described steps can be
augmented by a skin excision "nose-lift." An incision is made
at the rhinion, and the nasal tip is lifted by overlapping the excess

skin/soft-tissue envelope of the nasal dorsum over the incision. Any

amount of skin/ soft-tissue envelope that overlaps the skin of the radix is excised. Thus, the nasal tip
is lifted and supported by the tightened
skin/soft-tissue envelope.

By performing a combination of the above-described techniques in a

stepwise fashion, the surgeon can restore the aging nasal tip and
fashion a more youthful projection and angle of nasal rotation. In
selected patients who have undergone more commonly performed aging face
procedures, the result will be a more harmonious appearance (figure 2).

[FIGURE 2 OMITTED]

Suggested reading

Johnson CM Jr., Anderson JR. Nose-lift operation: An adjunct to

aging-face surgery. Arch Otolaryngol 1978;104:1-3.

Johnson CM Jr., To WC. A Case Approach to Open Structure

Rhinoplasty. Philadelphia: W.B. Saunders, 2004.

Slavit DH, Lipton RJ, Kern EB, McCaffrey TV. Rhinolift operation in
the treatment of the aging nose. Otolaryngol Head Neck Surg
1990;103:462-7.

Howard D. Stupak, MD; Calvin M. Johnson, Jr., MD

From the Department of Otolaryngology, Yale University School of

Medicine, New Haven, Conn. (Dr. Stupak), and the Hedgewood Surgical
Center, New Orleans (Dr. Johnson).

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