Rhinolift operation in the treatment of the aging nose

Surgical and Nonsurgical Management of the Nasal Skin-Soft Tissue Envelope

Management of the skin-soft tissue envelope (SSTE) in rhinoplasty is challenging and critical for the overall outcome. The preoperative identification of patients with thick or thin skin and with preexisting skin conditions may contribute significantly to the postsurgical result. Most publications and textbooks focus on the management of the osseocartilaginous framework, but the SSTE management is often not addressed in detail. However, nonsurgical treatments, such as skin preconditioning, topical steroid-injections, oral isotretinoin, and topical vitamin A derivatives, may provide strong benefits. In this article, we reviewed the literature to present a comprehensive review on the available surgical and nonsurgical approaches pre-, intra-, and postoperatively dealing with SSTE in rhinoplasty.

Rhinoplasty as an Adjunct to Facial Rejuvenation

Rhinoplasty typically is not considered a part of the repertoire facial rejuvenation surgery but the same involutional changes that affect the other structures of the face also impact the nose and midface. Comparatively little has been written about nasal rejuvenation. Rhinoplasty may be an under-recognized but a useful adjunct to the rejuvenation of the aging face. The aging nose presents unique pathology due to the involutional changes that affect the cartilage and supporting structures. A comprehensive facial rejuvenation plan should address these progressive effects.

Nasal Obstruction and Rhinoplasty: A Focused Literature Review

BACKGROUND

There is a significant variation in the assessment, treatment, and outcomes of nasal airway obstruction and management in the published literature. This study aimed to: (1) define key components of the nasal airway, (2) identify frequent causes of nasal obstruction, and (3) review existing treatment methods.

METHODS

A systematic review of the literature was performed, and 135 studies were included via the following criteria: English, human subjects, and a primary endpoint of nasal airway improvement. Exclusion criteria were: abstract only, no airway data, pediatric patients, cleft rhinoplasty, sleep apnea, isolated traumatic nasal reconstruction, and cadaveric-only or animal studies.

RESULTS

The relevant obstructive sites include the ENV, septum, inferior turbinates, INV, and nasal bones. Addressing the alar rim alone may be insufficient, and inspection of the lateral wall and crura may be indicated. Correction of septal deviation involves attention to the bony base. Mucosal sparing treatment of inferior turbinates improves outcomes. INVs are a major source of nasal obstruction, and treatment includes spreader grafts. The bony nasal vault can contribute to nasal obstruction, including due to surgical osteotomies.

CONCLUSIONS

Anatomic causes of airway obstruction include the alar rims and lateral nasal walls, deviated nasal septum, inferior turbinate hypertrophy, decreased INV angle, and narrowed nasal bones. Treatments include graft placement; septoplasty; mucosal sparing turbinectomy; and lateral wall support. Pitfalls include failing to address the bony septum, over-resection of inferior turbinates, and narrowing of the nasal vault. Appreciation of airway management during rhinoplasty will improve functional outcomes.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

External Approach for the Treatment of the Aging Nasal Tip

Changes seen in the nose from increased skin elasticity, weakened nasal cartilages, and detachment of ligaments can lead to cosmetic and functional impairment. Esthetically, the nasal tip droops, the nose lengthens, the columella shortens, and the ala collapse. Functionally, the internal and external nasal valves weaken, the anterior nares narrow, and airway turbulence increases, thus contributing to the effect of nasal obstruction. Skin redundancy of the elderly nose may compromise outcomes when typical rhinoplasty techniques are applied. Herein is described a technique pioneered by Fred Stucker, involving a direct external approach to address the aging nasal tip. The technique can be performed under local anesthesia and in combination with other procedures for the aging nose, such as rhinophyma excision or septoplasty for the aging nose.

How to cite this article

Hu M. External Approach for the Treatment of the Aging Nasal Tip. Int J Head Neck Surg 2016;7(3):165-167.

[Treatment of nasal valve stenosis]

Nasal valve dysfunction is one of the most common causes of obstructed nasal ventilation. In most cases the cause is congenital, but iatrogenic occurrence after functional-aesthetic rhinoplasty is not infrequent. To diagnose nasal valve dysfunction, a thorough anamnesis, inspection, endoscopy, and palpation is required. If conservative therapy using rhinologic substances, as well as outer and inner stenting do not achieve the desired outcome, and the dysfunctional site can be localized, surgical procedures are indicated to improve nasal valve function. Numerous procedures and techniques are available, amongst which the most important ones shall be elucidated and discussed in the present article. These include septoplasty, septorhinoplasty, and enlargement of pyriform aperture stenosis, as well as corrections of the upper and lower lateral cartilages.

Wide-Open Dorsal Approach Rhinoplasty for Droopy Noses

BACKGROUND

Because rhinoplastic surgery predominantly deals with the osseocartilaginous skeleton, droopy noses with thick skin remain a problem to be solved. In these noses, neglecting excess skin can impair long-lasting and complete correction of the nasal deformity. As these noses already require redundant dorsal skin resection, surgical manipulations can be executed entirely through the dorsal skin excision window instead of the transcolumellar approach.

OBJECTIVE

The wide-open dorsal approach rhinoplasty (WoDAR) was developed to allow removal of excess dorsal skin and reconstruction of the nasal osseocartilaginous framework through the excised dorsal skin avoiding a transcolumellar incision.

MATERIALS AND METHODS

Nine male patients with thick skin and significantly ptotic noses were operated with WoDAR. The cosmetic appearance of the noses was evaluated by the patients before and after the operation using a visual analog scale (VAS). The nasal obstruction symptom evaluation (NOSE) scale was evaluated individually preoperatively and postoperatively. The nasolabial angle (NLA) was measured preoperatively, at the third, twelfth, and twenty-fourth months postoperatively. Dorsal scars were evaluated by means of the Stony Brook's scar evaluation scale (SBSES).

RESULTS

Patients (mean age: 51.4 ± 4.8 years) were followed for an average duration of 20.6 ± 8.4 months. Cosmetic evaluation revealed that the mean patient preoperative VAS score was 23.3 ± 25.6, whereas the postoperative VAS score was 92.6 ± 14.8. Preoperative and postoperative NOSE scores were 79.5 ± 16.5 and 11.5 ± 11.5, respectively. The mean preoperative NLA was 72.9 ± 2.9° and at the third and twelfth month postoperatively was 92 ± 6.5 and 91 ± 5.4. The NLA measurements of all four patients followed for 24 months revealed less than 2° derotation compared to third postoperative month. The mean SBSES score was 4.1 ± 0.8 out of 5.

CONCLUSION

WoDAR allowed esthetically and functionally pleasing outcomes. This advantageous technique can be regarded as a surgical alternative for carefully selected aged patients with severely ptotic, thick-skinned noses who might otherwise end up with unsatisfying results both for surgeon and patients.

Peak nasal inspiratory flow: a useful and handy tool for the diagnosis of nasal obstruction in the elderly

The global population is aging, with the over-65 age group expected to double in the USA by 2030. Three subcategories of elderly people have been identified: "young old" (from 65 to 74 years), "older old" (from 75 to 84) and "oldest old" (85 or more). Rhinosinusitis is a common disease that affects more than 31 million people in the USA every year. Nasal obstruction is one of the most common symptoms in patients affected by rhinosinusitis. An accurate nasal obstruction evaluation in the elderly is becoming of increasing interest for medical doctors, especially for geriatricians. Peak nasal inspiratory flow (PNIF) is a cheap and easy method for assessing nasal patency. The purpose of the study was to compare young old normal PNIF values with older old normal PNIF values. Charts relating PNIF normal values in the elderly with various explanatory variables have been provided. PNIF measurements were performed in 113 volunteers aged 65-84 years. One hundred and five of them fulfilled the study criteria and were self-reported healthy elderly. None of them complained of nasal symptoms. Data were statistically analyzed and figures and tables were produced relating PNIF to height, sex and age. PNIF values decreased with age (p = 0.0053) and were significantly lower in the "older old" sub-cohort than in the "young old" group (p = 0.007). Nasal obstruction in the elderly is a common problem and appropriate diagnosis and treatment are important for improving their quality of life. The measurement of PNIF could be useful in evaluating elderly patients who complain of nasal obstruction.

Rhinoplasty with advancing age

Rhinoplasty in the aging patient poses a unique set of challenges to the plastic surgeon. Aging patients usually have different expectations and motivations than their younger counterparts; therefore, open communication and frank discussions are paramount to define realistic goals. Anatomically, changes in skin quality, cartilage characteristics, underlying bony framework, and the nasal airways mandate special considerations to optimize the functional and aesthetic results. This review will present a practical approach to the management of the nose in the aging patient.

Rhinoplasty with advancing age: characteristics and management

Rhinoplasty in the aging nose is a distinctly different entity whose unique characteristics must be appreciated by the rhinoplasty surgeon to optimize the functional and aesthetic results. Although the aesthetic and functional goals are similar to those in younger patients, the operative techniques necessary to achieve these goals in older patients differ. This article reviews the changes that occur in progressive aging of the nose and discusses the unique aspects in the management of the aging nose.

The aging nose

Mature adult rhinoplasty requires more sophisticated planning and flawless execution in order to achieve an optimal result. The improvement not only engenders a more pleasing feature, it also provides approximately 5 years' rejuvenation to the face. These patients possess thin skin, weak support structures, and vulnerable nasal function, rendering the rhinoplasty more enigmatic. The medical and emotional issues should be resolved prior to surgery.