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 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 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).