|Year : 2020 | Volume
| Issue : 1 | Page : 60-64
Analysis of primary rhinoplasty in elderly patients
Aret Cerci Ozkan
Department of Emergency and First Aid, Avrupa Vocational High School, İstanbul, Turkey
|Date of Submission||13-May-2019|
|Date of Acceptance||23-Jun-2019|
|Date of Web Publication||31-Dec-2019|
Dr. Aret Cerci Ozkan
İncirli Caddesi Bayrak Apt. No 89/7, Bakırkoy, İstanbul
Source of Support: None, Conflict of Interest: None
Background: The upper limit of rhinoplasty age increases as the concept of old age shifts forward. Rhinoplasty operations of this era have their own characteristics. The aim of this study is to point out these characteristic features and propose solutions to the problems observed in our series. Materials and Methods: Between 2014 and 2018, 32 primary rhinoplasties were performed on patients over 55 years of age. A comprehensive preoperative evaluation was done in all cases. Wider skin undermining was a prerequisite to overcome skin redundancy. Proper elevation of the droopy nose was the primary goal. Placement of a wide and homogeneously crushed cartilage graft over the lower and upper lateral cartilages was applied in all patients for structural support in addition to standard measures. In patients with extreme droopiness, a deep temporal or rectus fascial sling was applied between the columella and the nasal dorsum to support tip elevation. Results: The follow-up period was 6 months–4 years. All of the patients were satisfied with the postoperative results except for one case having dorsal irregularities and one case with postoperative relapse of the droopiness. Revisional operations of these patients were performed with the utilization of deep temporal fascia. A pulmonary embolus was encountered in one patient in 56 years of age at the 39th-postoperative day. She was hospitalized, and an anticoagulant treatment was applied. Conclusion: The most important problem in this age group is the droopiness of the tip. The use of a wide and homogeneously crushed septal cartilage graft over both the upper and lower lateral cartilages and autologous fascial sling rising and stabilizing the tip may help to prevent its relapse.
Keywords: Advanced, age, cartilage, crushed, fascial, rhinoplasty, sling
|How to cite this article:|
Ozkan AC. Analysis of primary rhinoplasty in elderly patients. Turk J Plast Surg 2020;28:60-4
| Introduction|| |
Primary rhinoplasty is one of the most sophisticated esthetic operations. It is usually performed in patients over 18 years of age. However, the upper age limit for its execution is not clearly determined. With the increased importance of self-image and the shift of aging concept forward, the upper limit of rhinoplasty age is forced to advanced ages. Thus, it is not rare for rhinoplasty surgeons to meet a patient at an advanced age and to make an appointment with them for a primary rhinoplasty operation. However, rhinoplasty operations in advanced age have their own characteristics that a rhinoplasty surgeon should be familiar with. The anatomical changes in skin quality, changes in cartilage characteristics, and changes in the underlying bone framework require special considerations in the aging nose. The aim of this study is to determine common features in our series and suggest solutions to overcome these specific problems.
| Materials and Methods|| |
Between 2014 and 2018, primary open-approach rhinoplasty operations were performed on 32 patients over 55 years of age. These patients were retrospectively analyzed by meticulous archive investigation. The mean age of these patients was 59 years (55–72 years). Twenty-three of the cases were female and nine of them were male.
Comprehensive preoperative evaluation, tests, graphics, and consultations were done to all of the patients with specific considerations, especially for diabetes mellitus, hypertension, coronary artery disease, and other systemic diseases. Anamnesis and examination regarding the presence of nasal trauma, allergy, sinus problems, presence of previous nasal surgery, and medications were obtained meticulously. Changes in facial bone, and muscle and fat compositions and proportions were scored precisely over the anamnesis forms. Teeth were checked initially since deficiency of teeth may indicate maxillary and mandibular resorption. The degree of inferior migration of malar soft tissue, nasolabial fold deepness, jowl formation, loss of malar highlights, and involutional changes along the infraorbital rim was inspected. Such changes caused by aging together with the degree of elastosis of the skin gave important clues on the additional problems for the nose operation of the aging patient.
All patients were informed about the expected results, possible risks, and complications of the operation, and their written consents were obtained.
As a peroperative precaution, compressive stockings were used, and a very conservative technique was preferred in all patients. Wider skin undermining was required to overcome the skin redundancy caused by diminished skin elasticity and sun damage. The proper elevation of the droopy nose with the utilization of strut graft, lateral steal, interdomal and transdomal sutures, and a cap graft combination was accomplished. A very conservative extramucosal reduction of the nasal dorsum was performed, combined with low-to-low lateral osteotomies and correction of internal valve deficiency with the use of bilateral spreader grafts. Septum deviation was also corrected conservatively. Wide and homogeneously crushed cartilage graft over the lower and upper lateral cartilages was applied to all cases for additional structural support [Figure 1]. In the selected cases with extreme droopiness, a deep temporal (three cases) or rectus fascial (two cases) sling was applied between the columella and nasal dorsum to support the tip elevation [Figure 2]. A thin layer of a finely diced cartilage graft piece glued with clotted blood was used in all patients for the camouflage of minute nasal dorsum irregularities. Silicone intranasal splint for 2–3 days, fine strips over the nasal skin for 12–16 days, and a thermoplastic splint for 7–9 days were all applied routinely in all patients. Hospitalization was minimum 24 h after the operation and 48 h in some rare patients. All of the patients were discharged from the hospital without any perioperative complications.
|Figure 1: The illustration of the settlement of a wide and homogeneously crushed septal cartilage piece onlay over both the upper and lower lateral cartilages|
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|Figure 2: The illustration of the settlement of a fascial sling between the nasal dorsum and the columellar region to support the tip position and the settlement of a wide and homogeneously crushed septal cartilage piece onlay over both the upper and lower lateral cartilages together|
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| Results|| |
The mean total operation time was 3:25 h (3:10–3:45 h). The follow-up period was 6 months–4 years. All of the patients were satisfied with the postoperative results, except one case having minute dorsal irregularities after the subsidence of the edema and one case with late postoperative relapse of the droopiness. Revision operations of these patients were performed with the utilization of deep temporal fascia. In the first-revision patient, the deep temporal fascia was used for camouflage of the nasal dorsum. In the second-revision patient, the deep temporal fascia was used as a fascial sling rising the nasal tip. It was preferred to wait for at least 1 year for revision operations. In two patients with a bulbous tip, prolonged tip edema was encountered. Massage and subcutaneous injection of diluted triamcinolone acetonide were applied to solve this problem.
In three patients, breathing problems due to relapse of conchal hypertrophy were encountered. A second nasal conchal radiofrequency treatment was applied to reduce the volume of the lower turbinates.
Temporary postoperative wrinkle formation was also encountered in three patients caused by the folding of the sun damaged and the less elastic skin due to an elevation of droopy tip. These wrinkles faded in 2–3 weeks without any need for revision.
A pulmonary embolus was encountered in one female patient of 56 years of age at the 39th-postoperative day. She was hospitalize, and an anticoagulant treatment was applied after which she was completely cured.
| Discussion|| |
The cutoff age of this study was determined as 55 years because to our opinion, the quality of nasal skin, the strength of cartilages, ligaments, and attachments, and the quality of bone of this age are as satisfactory as the younger patients.
Wider skin undermining to overcome reduced elasticity, conservative dorsal reduction, elevation of the droopy tip with the use of a strut graft, transdomal and interdomal sutures, lateral steal, and correction of internal valve deficiency by the utilization of spreader grafts are all well-known practices in rhinoplasty operations of cases with advanced age. However, the placement of a wide homogeneously crushed thin cartilage piece over both the lower and the upper lateral cartilages performed in our patients is a highly favorable supplementary technique and a new concept in patients with advanced age [Figure 1], [Figure 3], and [Figure 4]. This wide and homogeneously crushed cartilage graft acts as a subcutaneous cartilaginous skeleton under the aged skin and prevents the formation of irregularities as well as wrinkles. It also acts as a supporter of the scroll area where some degree of attenuation and fragmentation of the fibroelastic attachments due to advanced age may appear. The senior author reserves the use of a crushed cartilage graft to the tip and supratip areas but not to the nasal dorsum because the use of a crushed cartilage graft over bony dorsum may result in irregularities in the late postoperative period. At least cartilage coverage by fascia should be considered if it is crucial to use crushed cartilage over the dorsum. It is suggested to use diced cartilage graft over the nasal dorsum to smoothen the minute surface irregularities.
|Figure 3: A female patient having a primary open-approach rhinoplasty in 57 years of age with prominent tip bulbosity and nasal hump. (a) preoperative anterior view, (b) postoperative 6th-month anterior view, (c) preoperative lateral view, and (d) postoperative 6th month lateral view|
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|Figure 4: A female patient having a primary open-approach rhinoplasty in 55 years of age with a long and bifid tip and a nasal hump. (a) preoperative anterior view, (b) postoperative12th-month anterior view, (c) preoperative lateral view, and (d) postoperative 12th-month lateral view|
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Utilization of either deep temporal or rectus fascia as a sling to suspend the tip is also a very helpful technique in supporting the droopy nose in cases with advanced age. This is also a novel and very favorable technique that is applied in patients with extremely droopy noses in our series. The settlement of this fascial sling between the columella and cartilaginous dorsum by suturing the lower and upper edges with a proper degree of tension protects the tip position and prevents its downward displacement in the late postoperative period. The tip rests over this fascia, like it is “lying down over a hammock.” In addition, the fascial sling covers the cartilaginous tissues of the tip. This soft-tissue coverage nicely camouflages the cartilage edges and prevents the occurrence of graft visibility. The senior author prefers the fixation of the proximal border of the fascia over the nasal dorsum first. Then, the distal border of the fascia is fixated to the medial crura of the lower lateral cartilages and the strut graft. This allows better adjustment of the position of the fascia and the tip. Then, two additional sutures are placed in the middle of the side edges of the fascia and side edges of the cap graft [Figure 2] and [Figure 5]. The drawback of the utilization of these autologous fasciae is a donor-site morbidity due to the scar formation at either scalp or inframammary region. The rectus fascia is usually reserved for bald male patients because the utilization of deep temporal fascia can cause a visible scar over a bald scalp. Hair loss around the scar tissue at the donor site may also cause morbidity, but this was not observed in our patients. A wise alternative to use of autologous fasciae can be the use of either an acellular dermal matrix graft piece or a bovine pericardial graft piece as a tip-supportive sling. The senior author, unfortunately, does not have any experience with the utilization of these allografts as soft-tissue support to this area.
|Figure 5: A female patient having a primary open-approach rhinoplasty in 72 years of age with extremely droopy nasal tip and a prominent nasal hump. (a) preoperative anterior view, (b) postoperative 16th-month anterior view, (c) preoperative lateral view, and (d) postoperative 16th-month lateral view|
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The septocolumellar suture may also be utilized to elevate, project, and stabilize the tip. There is evidence of satisfactory and permanent results. Nevertheless, in practice of the senior author, its effect is temporary. In 2–3 months, the contribution of this suture over the tip diminishes; hence, it can only be used as a temporary stabilizer.
Tongue-in-groove technique is another reliable technique used to elevate and stabilize the nasal tip. Nevertheless, it should always be kept in mind that this technique has risks such as loss of tip sensitivity, columellar retraction, stiffness of the nasal tip, and tip over-rotation. In addition, even a minute degree of septal deviation may cause a tilt of the nasal tip to the deviated side. Furthermore, there is evidence for significant loss of its rotation effect during the 1st year. Therefore, this technique should be applied very cautiously.
Repair of the Pitanguy ligament has been recently claimed to be effective in elevating and stabilizing the nasal tip. Pitanguy ligament originates in the midline of the lower third of the nasal superficial musculoaponeurotic system, extends down to the tip along the midline of the nasal dorsum, turns backward at the nasal tip, and runs between the medial crura of the lower lateral cartilages inserting into the base of the columella. Doubtlessly, repair of this ligament will also help to suspend the nasal tip. However, in patients with advanced age, the strength of Pitanguy ligament would also diminish as other tip-supporting structures.
The senior author prefers to preserve the cephalic portion of the lower lateral cartilages, and the cephalic excess of the lateral crura is incised and placed under the lateral crura. This technique is very effective in preserving the scroll area which is especially important in patients with advanced age.
In some cases with advanced age, it is possible to encounter with a bulky tip and even with a rhinophyma. It is highly recommended to explain every drawback of a bulbous tip to these patients.
The treatment of the rhinophyma is of course quite different than rhinoplasty. Numerous physically destructive modalities exist for the treatment of rhinophyma, falling primarily into three categories: mechanical destruction, directed electrical energy/radiofrequency, and directed laser energy. If a rhinoplasty of a patient with a bulky tip is scheduled, it is crucial to create a strong columella and tip support with appropriate cartilaginous grafts such as a strong strut graft and a strong cap graft to overcome the bulkiness of the tip to some extent. Subdermal soft-tissue trim may also be required in such patients to reduce the thickness of the nasal tip.
Maxillary alveolar hypoplasia in a patient with advanced age may cause a divergence of the medial crural feet and columellar shortening. This process may also boost the droopiness of the tip. In such cases, use of a strong strut graft, an approximation of the foot plates with u-shaped sutures, and utilization of a cap graft are all recommended practices to correct this age-related deformity.
The nasal bones become more fragile in the advanced age group. Thus, all kinds of osteotomies require special care to avoid making unfavorable fractures. The use of powered devices may be a good alternative to provide more precise osteotomies that may prevent undesired fractures. Patient selection, in cases, with advanced age is related mainly with general health problems such as hypertension, diabetes mellitus, and coronary heart disease. Concern for the risk of dissatisfaction is not stressful in the advanced age group as they are usually more satisfied than cases with young age.
Anticoagulant prophylaxis in rhinoplasty of patients with advanced age is another issue which is not well studied. Venous thromboembolism is uncommon in any nose operation, and there are no specific venous thromboembolism prophylaxis guidelines for them. There is significant heterogeneity in venous thromboembolism prophylaxis. ENT UK venous thromboembolism prophylaxis guidelines may be followed for anticoagulant prophylaxis.
The senior author has faced a quite late (39 days) pulmonary embolism in one patient. All consulted anesthesiologists, internalists, and cardiologists stated that this situation is unrelated to nose surgery. The senior author does not use any thromboembolism prophylaxis regimen in any of his rhinoplasty patients.
| Conclusion|| |
Rhinoplasty in advanced age is a reality of the modern world. However, it has special considerations that should be respected by rhinoplasty surgeons for obtaining satisfactory results. The most important problem in this age group is the droopiness of the tip. The use of a wide and homogeneously crushed septal cartilage graft piece over both the upper and lower lateral cartilages and autologous fascial sling rising and stabilizing the tip may help to prevent its relapse.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]