Techniques inCosmetic Surgery

Rhinoplasty with Advancing AgeRod J. Rohrich, M.D., Larry H. Hollier, Jr., M.D., Jeffrey E. Janis, M.D., and John Kim, M.D.Houston and Dallas, Texas

Rhinoplasty in the aging patient poses a unique set ofchallenges to the plastic surgeon. Aging patients usuallyhave different expectations and motivations than theiryounger counterparts; therefore, open communicationand frank discussions are paramount to define realisticgoals. Anatomically, changes in skin quality, cartilagecharacteristics, underlying bony framework, and the nasalairways mandate special considerations to optimize thefunctional and aesthetic results. This review will present apractical approach to the management of the nose in theaging patient. (Plast. Reconstr. Surg. 114: 1936, 2004.)

CHANGES IN AESTHETIC FACIAL PROPORTIONS

There are standardized proportions and re-lationships that have been established whendescribing the aesthetically pleasing face.1,2 Inthe younger patient, the face can be dividedinto thirds by drawing horizontal lines adjacentto the menton, nasal base, brow (at the level ofthe suborbital notch), and the hairline. Classi-cally, the upper third is the least important ofthese subdivisions, as it can vary with the hair-line and hairstyle.

In the aging patient, there is a relative short-ening of the lower third secondary to muscleatrophy of the orbicularis oris, fatty tissue ab-sorption, and maxillary alveolar hypoplasia.3–5

The maxillary alveolar hypoplasia is the resultof tooth loss and subsequent bony resorption.The result of this lower third shortening is aconcomitant lengthening of the upper andmiddle thirds, including a relative lengtheningof the nose (Fig. 1).

The nasal dorsum and tip also undergo aes-thetic changes throughout the life cycle. Inyouth, the nasal dorsum is usually concave witha slight upturned tip. As an adult, the dorsumstraightens with a normally forward-projectingtip. With age, however, the nasal dorsum takes

on a more convex character secondary to thedownward rotation of the lobule and relativecolumellar retraction (Fig. 2).6

SKIN QUALITY

The skin quality of the face and nosechanges with advancing age.7 Intrinsic cellularchanges combined with prolonged exposure tothe sun and other elements results in actinicchanges and diminished skin elasticity.3 On amicroscopic level, the dermis becomes thinnerwith decreased dermal collagen and an in-crease in disorganized elastin and fibrillin.8–11

Frequently the alae and tip take on a fuller, lessnatural-appearing character. This is the result of anincreased density of sebaceous glands and can beespecially prominent in the male patient, leading tothe development of rhinophyma.

The result of these changes is that externalskin incisions in the areas of thickening lead toprominent scarring. Incisions where the skin isthinner, such as the columella and dorsum,however, generally heal with minimal scarring.The decreased skin elasticity and generalizedskin redundancy mandate wider nasal skin un-dermining and more significant underlyingstructural alteration to affect a noticeable aes-thetic result.12

THE NASAL TIP COMPLEX

The nasal tip undergoes perhaps the mostsignificant changes in the aging patient, which,in turn, affects the remainder of the nasal aes-thetics.13,14 Therefore it usually is the area thatneeds the most refinement. Specifically, the tip

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center, and the Division of Plastic Surgery, Baylor Collegeof Medicine. Received for publication August 4, 2003; revised September 4, 2003.

DOI: 10.1097/01.PRS.0000143308.48146.0A

1936

takes on a drooping character with an elon-gated tip. The underlying structural etiology ofthis is multifactorial3,5,15,16:

• Attenuation, fragmentation, and potentialossification of the fibroelastic attachmentsbetween the upper and lower lateral carti-lages with resultant downward migration ofthe lateral crura (Fig. 3).

• Weakening or loss of suspensory ligamentsupport with loss of medial crural support(Fig. 4).

• Thickening and possible ossification of thecartilages, leading to greater prominence.

• Thickening of the overlying skin and subcu-taneous tissue with concomitant increasedvascularity, leading to increased bulkinessand weight of the tip.

• Maxillary alveolar hypoplasia with resultantdivergence of the medial crural feet andcolumellar shortening.

All of the above factors contribute to down-ward rotation of the lobule, creating an acutecolumellar-lobule angle and a shortening of thevertical dimension of the lower third of the face.17,18

The aesthetic result is a relatively longer nasallength and a droopy tip appearance (Fig. 5).

FIG. 1. Changes in aesthetic facial proportions with age.

FIG. 2. Changes in nasal characteristics with age.

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THE NASAL AIRWAY

Functional nasal airway obstruction is a com-mon complaint in the aging patient.19–23 Theusual causes of obstruction, namely septal ab-normalities and inferior turbinate hypertro-phy, can be seen in this age group. Otheranatomic changes associated with advancedage can produce obstructive symptoms. Thedrooping nasal tip complex results in a moresuperior redistribution of airflow within thevestibule (Fig. 6).5,12,24 This change in flow dy-namics can produce obstructive symptoms.Furthermore, internal nasal valve collapse sec-ondary to downward migration and separationof the upper and lower lateral cartilages canalso produce symptoms.

The operative goals of correction of nasalairway obstruction are no different in the aging

patient than in the younger adult. Specifically,the septum and inferior turbinates are ad-dressed appropriately. It should be noted thatthe mucoperichondrium abutting the septumbecomes thin and fragile with advancing age,making it more difficult to cleanly dissect with-out perforation. Furthermore, bleeding can bean issue in these patients, not only because ofincreased vessel fragility but also because thesepatients frequently have underlying hyperten-sion, which must be controlled preoperatively,intraoperatively, and postoperatively. Inferiorturbinate surgery is usually performed utilizingan extramucosal technique, rather than raisingmucosal flaps, to minimize postoperativebleeding and scarring.25

Aside from the septum and inferior turbi-nates, the drooping tip and collapsed internal

FIG. 3. Migration/separation of the lower lateral cartilage from the upperlateral cartilage with aging.

FIG. 4. Ligamentous/fibrous tissue support of the cartilaginousframework.

1938 PLASTIC AND RECONSTRUCTIVE SURGERY, December 2004

nasal valve must also be addressed. To restoreproper airway flow dynamics, the tip needs tobe cephalically rotated. This can be accom-plished utilizing the technique described be-low. Furthermore, dorsal spreader grafts canbe used, if needed, to address the collapsedinternal nasal valve (Fig. 7).26–28

THE BONY VAULT

In general, the midface retrudes with agerelative to the rest of the craniofacial skeletonbecause of differential remodeling.29 This leadsto a posterior displacement of the pyriformaperture. As the pyriform aperture serves asthe scaffolding for the nasal pyramid, posteriordisplacement of this structure leads to a con-comitant retruded nasal profile. Furthermore,the loss of pyriform height can distort the alarbase-columellar relationship. These changes

must be taken into account when analyzing thefacial proportions for rhinoplasty.

The bony nasal pyramid itself also becomesmore brittle and fragile as a result of naturalprocesses in aging. The clinical implications ofthis are that osteotomies become more unpre-dictable in their outcome, as they are moreprone to comminution.28 Therefore, osteoto-mies should be avoided, if possible, in the ag-ing nose. If they are performed, it should bedone in low-to-low fashion using the percuta-neous external technique,30,31 and should becomplete, rather than in greenstick fashion, togive a more regular break.

THE DORSUM

The prominent dorsal hump often seen inthe aging nose may be a relative finding owingto the drooping nasal tip. Therefore, the tip

FIG. 5. Demonstration of the relative dorsal hump with increased nasallength and droopy tip with age (left, photograph; right, illustration).

FIG. 6. Changes of nasal airflow dynamics with age. (Left) Youthful nose: predisposition forinferior third airflow; (right) advancing age: downward rotation of tip displaces airflow superiorly.

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should be addressed before any dorsal humpreduction is performed.28 Otherwise, therewould be a propensity for overresection of thedorsum, with a subsequent open roof defor-mity. Because osteotomies are usually neededto address the open roof and osteotomies areto be avoided, if possible, in the aging nose,this would result in a likely suboptimaloutcome.

If intrinsic dorsal aesthetic deformities stillpersist after tip complex modification, anopen approach with component nasal dor-sum surgical technique is employed.32,33 Skel-etonization is performed with special caretaken to maintain the periosteal attachmentto the bony sidewalls, as this provides neededexternal support for the nasal pyramid afterosteotomy. Extramucosal hump excision/reduction is performed to avoid internal na-sal valve dysfunction and also to preserve aclosed space for the placement of dorsal orspreader grafts.

Simple rasping is used to address smaller(�3 mm) dorsal hump reductions. Occasion-ally, trimming of the upper lateral cartilagescan be performed to help avoid lateral fullness.Larger reductions (�3 mm), however, necessi-tate the creation of submucous tunneling andsharp release of the upper lateral cartilagesfrom the septum. This technique helps toavoid injury to the cartilage and/or mucoperi-chondrium. As the skin is thinner in these

patients, underlying irregularities in the dor-sum are more apparent. If irregularities needto be addressed, it can be done using mor-selized onlay septal cartilage grafts. Other po-tential sources include temporalis fascia grafts,conchal cartilage grafts, or allograft.

THE CONSULTATION

Aging patients frequently have a distinct setof psychological stressors and motivations thatdrive the patient to seek rhinoplasty at theirstage in the life cycle. These stressors must beelucidated preoperatively to define realisticgoals and choose the appropriate surgicalcandidates.

Some aging patients have had long-standingdesires for changes in their nasal aesthetic ap-pearance.12 Because dramatic changes are of-ten implausible in the aging patient, these spe-cific, but unrealistic, desires must be temperedwith realistic expectations of what can be safelyperformed in this population subgroup. Fur-thermore, specific stressors, such as the recentloss of a spouse or divorce, must be identifiedpreoperatively so that surgery can be delayeduntil a more appropriate, psychologically sta-ble time.

To maximize postoperative satisfaction withthe aesthetic result, it is important to choose anappropriately motivated patient.12,34,35 Exam-ples of motivations of the ideal candidate in-clude enhanced economic independence,

FIG. 7. Illustration of spreader grafts used to maintain the internal nasalvalve, restore the dorsal aesthetic lines, and prevent visible demarcation fromthe bony vault to the middle vault (left, dorsal view; right, basal view).

1940 PLASTIC AND RECONSTRUCTIVE SURGERY, December 2004

midlife career change, nasal airway obstruc-tion, a history of nasal trauma/fracture, and aprevious unsatisfactory rhinoplasty.28

After the patient history, a specific nasal his-tory is taken, including any history of nasaltrauma, allergies, sinus problems, history ofprevious nasal surgery, and current medica-tions. The nasal examination is subsequentlyperformed after the mucosa is shrunk withoxymetazoline spray. Special attention is paidto possible septal deviation, inferior turbinatehypertrophy, the internal nasal valves, and themucosa itself.

Standardized nasal digital photographs areobtained and computer imaging is utilized.The role of computer imaging is invaluable inthis subpopulation because of its ability to helpthe patient visualize the often-subtle changesof aging and also to help better educate thepatient on what realistic changes can beexpected.

The second preoperative consultation isused to review expectations and computer im-ages, answer questions, and develop an appro-priate surgical plan.

OPERATIVE GOALS AND TECHNIQUES

Although each operative plan should be spe-cifically tailored to each individual patient, thereare certain common goals in performing rhino-plasty in the older nose28: perform tip derotationwith tip refinement; increase tip projection andrelative columellar lengthening; decrease theoverall nasal length; correct the dorsal hump;address and support the internal nasal valves;and correct septal deviation and inferior turbi-nate hypertrophy, if present.

To achieve these endpoints, certain opera-tive tenets should be followed:

• Wide skin undermining to offset decreasedskin elasticity and redundancy.

• Tip suturing to alter the nasal tip (medialcrural, interdomal, transdomal)36,37 ratherthan more destructive methods (Fig. 8).

• Conservative dorsal hump removal (andonly after the tip has been initially addressedto prevent overresection).

• Restoration of proper nasofacialproportions.

• Autogenous septal grafts, if needed (columel-lar strut, dorsal spreader grafts); harvest withcare because of thin mucoperichondrium.

• A conservative cephalic trim, with at least a6-mm rim strip.

• Minimal osteotomies.• Extramucosal inferior turbinate resection to

minimize bleeding.

The authors’ preferred operative sequenceis similar to that of a primary rhinoplasty: (1)general anesthesia (although some surgeonsmay prefer intravenous sedation, dependingon the patient’s general condition and co-morbidities); (2) infiltration with local anes-thetic; (3) transcolumellar stairstep incisionfor an open approach; (4) septal harvest andreconstruction; (5) inferior turbinate resec-tion/outfracture; (6) initial tip adjustmentwith suture techniques (derotation/increaseprojection); (7) dorsal hump reduction/possible onlay grafting; (8) final tip refine-ment; (9) controlled percutaneous osteoto-mies, if necessary; (10) closure of incision;and (11) internal and external nasal splints.

FIG. 8. Tip suturing techniques. (Left) Medial crural-septal suture to stabilize and unify the columellar strut and medial crura;(center) transdomal suture to refine the tip and increase projection; (right) interdomal suture to correct domal asymmetry.

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CASE ANALYSIS

This 71-year-old woman with a history of cleft lip and palateand two previous rhinoplasties presented with complaints ofa plunging nasal tip and a dorsal hump. Nasal analysis con-firmed a relative dorsal hump with increased nasal length,severe plunging nasal tip, naasolabial angle less than 85 de-grees, and left alar base collapse consistent with history ofcleft lip.

The operative goals were (Fig. 9) upward tip rotation/refinement and simultaneous nasal shortening, an increasednasolabial angle (to 90 degrees), and no osteotomies.

The operative sequence included the following: an openapproach with stairstep transcolumellar approach; resection ofold scar tissue; placement of a columellar strut with medialcrural-septal spanning suture to rotate the tip and increase thenasolabial angle to 90 degrees; placement of interdomal andtransdomal sutures to refine the tip; placement of a three-layerinfratip lobular septal cartilage graft to increase projection and

increase tip definition; 3-mm caudal septal resection; no osteot-omies; and closure/external contouring splint (Fig. 10).

CONCLUSIONS

Rhinoplasty in advancing age presents aunique set of challenges to the surgeon. Differ-ent psychological circumstances and particularanatomic characteristics mandate careful at-tention to this particular subset of patients.Specifically, the nasal tip complex appears todroop secondary to loss of underlying support.This may, in turn, give the appearance of arelatively prominent dorsal hump, which maybe overresected if not addressed properly. Theuse of osteotomies is minimized secondary tothe underlying fragility of the nasal pyramid.

FIG. 9. Gunter graphic operative diagrams.

1942 PLASTIC AND RECONSTRUCTIVE SURGERY, December 2004

The nasal airway flow dynamics are altered; thismay present as nasal airway obstruction. Thetip complex and internal nasal valves must beaddressed, in addition to septal deviation andinferior turbinate hypertrophy, to correct this

problem. In all, rhinoplasty in the aging pa-tient can be rewarding to both the surgeon andthe patient with an excellent aesthetic andfunctional outcome if surgeons adhere to thepreceding principles.

FIG. 10. Views (27 months postoperatively) of the aging nose demonstrating drooping tip,lengthening of nose, and relative dorsal hump (left, preoperative; right, postoperative).

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Rod J. Rohrich, M.D.Department of Plastic SurgeryUniversity of Texas Southwestern Medical Center5323 Harry Hines Boulevard, HX1.636Dallas, Texas 75390-8820rod.rohrich@utsouthwestern.edu

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