Rhinoplasty with Advancing Age

Use of Functional Rhinoplasty in the Aging Nose: Medicare Database Analysis

Introduction: Nasal obstruction is a common clinical problem. It has become more recognized that the internal and external nasal valves are the areas of greatest resistance. There are changes with aging that can contribute to nasal valve compromise. This study sought to evaluate the utilization of functional rhinoplasty, septoplasty, and inferior turbinate reduction procedures in the Medicare population. Methods: The annual procedure data were obtained from the Part B National Summary Data File from 2000 to 2019. Functional rhinoplasty procedures using current procedural terminology (CPT) for rhinoplasty (30400, 30410, 30420, 30465), septoplasty (30520), and inferior turbinate reduction (30801, 30802, 30130, 30140, 30930) procedures were analyzed. Results: There was increased use of CPT codes 30465, 30410, and 30420 with a decrease in 30400. There was an overall increase in codes 30520 and 30140. When adjusting for the Medicare population per 100,000 enrollees, there was increased use of 30465 and 30140 and decrease in 30520. The charges and payment trends were similar to the overall use of CPT codes. Discussion: There is an overall increase in use of nasal airway procedures including functional rhinoplasty in the aging population.

Assessment of Aesthetic Results of 100 Patients Who Underwent Rhinoplasty-Rhinoplasty Outcome Evaluation

BACKGROUND

To assess the long-term aesthetic results of rhinoplasty and predict the final outcome.

METHODS

The sample was composed of 100 patients (34 men and 66 women) between 23 and 57 years old (mean, 34.8) operated on exclusively for aesthetic reasons. The time elapsed from the operation ranged from 3 to 13 years with a mean of 6.8 years. The study used Rhinoplasty Outcome Evaluation questionnaire, a simple, reliable, validated, and widely used inventory.

RESULTS

The vast majority of patients (93%) were satisfied postoperatively with scores > 50% (67 patients had scores > 80%). Only 7 patients had scores less than 50%. The mean score was 82.4 ± 1.7% with a median of 87%. In addition, it seems that the results of the operation remain high through time with a small decline along age groups and years elapsed. Women were found more satisfied than men (P = 0.03).

CONCLUSIONS

The study concludes that the results of aesthetic rhinoplasty, if performed by skilled and experienced surgeons, are very satisfying and stable throughout time.

Oriental nose occidentalization and perinasal shaping by augmentation of the underdeveloped anterior nasal spine

BACKGROUND

Augmentation of an underdeveloped anterior nasal spine (ANS) occidentalizes the Oriental nasal shape. The objective of this study was to investigate the effect of ANS augmentation using an injectable filler, assessing volumetric changes with 3-dimensional images and measuring 2-dimensional images.

METHODS

Forty Japanese patients were treated and evaluated before and after the augmentation. Local anesthetic was injected on the ANS for analgesia. To augment the underdeveloped ANS, approximately 0.5-1.0 ml of calcium hydroxylapatite filler was injected between the medial crura footplates and the ANS. Two-dimensional measurements and superimposable 3-dimensional volumetric assessments were performed pretreatment and 7 days posttreatment. Patients rated their satisfaction using a 5-point scale.

RESULTS

A significant decrease in nasal width and nostril axis inclination and an increase in nasal tip projection and columellolabial angle were observed by 2-dimensional measurements. Superimposable 3-dimensional color images reinforced the results of the 2-dimensional measurements and showed volumetric soft-tissue changes in the nasal and perinasal areas and the lower cheeks. Ninety percent of the patients were either "satisfied" or "very satisfied" with the results. Posttreatment traction pain and edema resolved in 5 days. Side effects such as hematoma, nodules, and skin necrosis were not observed.

CONCLUSIONS

Objective assessments showed significant effects of this treatment, with good patient satisfaction and minimal levels of discomfort and side effects. Together these results demonstrate that this treatment is safe and effective for Oriental nose occidentalization and perinasal shaping and is also useful for predicting rhinoplasty results.

The value of spreader grafts in rhinoplasty: a critical review

The value of spreader grafts in rhinoplasty cannot be underestimated. Various studies have demonstrated that they play a valuable role in the restoration of nasal dorsum aesthetics, provide support for the nasal valve and maintain the straightened position of the corrected deviated cartilaginous septal dorsum. However, there is still controversy on the extent of its value in nasal patency. This study reviews the literature and describes the values and limitations of spreader grafts in rhinoplasty and the alternatives to classic spreader grafts.

Effect of the sequence of lateral osteotomy and hump removal on the aesthetic outcome

BACKGROUND

The authors hypothesized that by modifying the sequence of the rhinoplasty procedure they could avoid comminuted fractures resulting in suboptimal cosmetic results.

METHODS

Percutaneous perforated lateral nasal osteotomies were performed in 36 fresh human cadaver heads. In the first group of 19 cadaver heads with big nasal humps, the perforations of the lateral wall were done before and digital infracturing after hump removal in 10 cases (subgroup A1). In the remaining 9 noses with big humps, the perforations and digital infracturing were performed after hump removal (subgroup group A2). In a second group of 17 cadaver heads with small humps, perforations were performed before hump removal in 8 cases (subgroup B1), and in the remaining 9 cases, the lateral walls were perforated after hump removal (subgroup B2). The number of fractured nasal bones was counted. In addition, the size and shape of the nasal bone fragments were described in a blinded fashion.

RESULTS

Analysis of the number of fractured nasal bones yields higher rates for "osteotomies after" (8.44 vs. 5.83) and hump size "big" (8.37 vs. 5.76), with some influence of age and gender.

CONCLUSIONS

The pattern of fractures after perforations of the lateral wall seems to be more regular if the perforations are done before the removal of bigger humps. In noses with small humps or no hump, no difference is seen regarding the sequence of the perforations in relation to hump removal.

Restorative rhinoplasty in the aging patient

OBJECTIVE

The objective of this study is to review our favorable experience in performing rhinoplasty in aging patients.

METHODS

All patients aged 65 years or greater who underwent rhinoplasty, either esthetic or functional, by the senior author (Y.D.) from August 1997 to July 2005 with a minimum follow up of 1 year were retrospectively reviewed.

RESULTS

A total of 51 patients met the inclusion criteria and had complete records available for review. The average age was 69.5 years (range, 65-82 years) with 24 female and 27 male patients. All but two patients underwent open rhinoplasty. Eighteen procedures represented secondary rhinoplasties. Seven patients required auricular cartilage grafts, and 11 patients required costal cartilage grafts. One costal cartilage graft was aborted as a result of excessive calcification. All patients underwent columellar strut placement, 92% underwent internal valve grafts, and 80.4% underwent grafting of the external nasal valves. Nasal osteotomies were performed in only 23.5% of patients, all with the percutaneous technique. Revision surgery was necessary in only three (5.8%) patients, all of whom required grafting of the external valve (not performed primarily). In each of these cases, no significant external valve collapse was noted preoperatively. Premaxillary augmentation with diced or crushed cartilage grafts was performed in 81.8% (n = 18) of patients with an edentulous maxillary arch.

CONCLUSIONS

Aging patients present unique technical challenges in rhinoplasty that warrant a comprehensive approach to restore internal and external valve competency and tip support. Consideration of prophylactic external valve grafts in addition to the routine use of internal valve grafts and columellar struts may help decrease the need for revision surgery in this patient population. Reasonable functional and esthetic outcomes can be expected in the aging patient.

Combined open rhinoplasty with spreader grafts and laser-assisted uvuloplasty for sleep-disordered breathing: long-term subjective outcomes

PURPOSE

To subjectively assess the long-term outcomes of combined functional open rhinoplasty with spreader grafts and laser-assisted uvuloplasty (LAUP) for polysomnogram (PSG)-confirmed sleep-disordered breathing (SDB).

METHODS

Postoperative Epworth Sleepiness Scale (ESS) questionnaires were given to 30 patients and compared with preoperative ESS. Patients were also asked questions concerning postoperative improvement in upper airway breathing, nasal appearance, and snoring. Statistical analysis used 2-tailed parametric and nonparametric tests.

RESULTS

Thirty patients (average age 55 years) with an average (+/- standard deviation) preoperative apnea-hypopnea index (AHI) of 37 +/- 27 and mean follow-up times of 21 months were evaluated. A statistically significant 50% (P < .001) postoperative decrease in average ESS was observed. Patients with severe (AHI > 30) and very severe obstructive sleep apnea (OSA) (AHI > 60) also had statistically significant (61% and 66%, respectively, P < .001) postoperative decreases in average ESS. In all patients, subjective upper airway breathing was statistically improved (P < .008), graded as significantly in 47% and moderately in 33% of patients. According to the patient's bed partner, snoring was improved and/or decreased in 76% of patients (P = .008). All patients were satisfied with the postoperative cosmetic appearance of their nose (P < .0001). Finally, 90% of patients stated that they would have the procedure again (P = .009) and 90% stated that they would recommend the procedure to a friend or relative with the same condition (P = .009).

CONCLUSION

Subjective assessment at long-term follow-up for combined open rhinoplasty with spreader grafts and LAUP for PSG-confirmed SDB produced a statistically significant decrease in excessive daytime sleepiness, even in patients with very high AHI, with high patient satisfaction.

Island rotation flap for nasal reconstruction

BACKGROUND

Nasal reconstruction options are often dictated by size and location of the defect. Local flaps are often considered of little utility for larger or more complex defects. The authors' modification of the island rotation flap allows increased versatility and single-stage reconstruction for many more defects of varied sizes and locations.

METHODS

A retrospective review of all cases of nasal reconstruction using the island rotation flap over a 3.5-year period was undertaken.

RESULTS

Ninety-two island flap reconstructions were performed for defects ranging from 0.8 to 4.0 cm. For defects smaller than 2.5 cm, there were no cases of flap loss. Five percent of the patients required a second procedure, whereas 95 percent were reconstructed in a single stage. Five percent required treatment for prominent scars. Follow-up was over 2 years.

CONCLUSIONS

The laterally based blood supply of the nasal island rotation flap is reliable and robust. Patients treated with this flap had good healing and good symmetry and required minimal revision. Single-stage reconstruction with this flap requires both proper flap design and extensive undermining of the entire nasal soft-tissue cover. Nasal symmetry is maintained despite the defect and donor flap being on the same side of the nose. The authors present their technique for the island rotation flap for nasal reconstruction and information on its reliability and acceptance.

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.

Augmentation rhinoplasty with dermal graft and review of the literature

Nasal augmentation required following a trauma or a rhinoplasty operation poses a challenging problem to many plastic surgeons. Currently, allografts and autologous tissues are used for nasal augmentation; however, an ideal technique has not yet been described. Although preferred for augmentation of different parts of the body, pure dermal graft use has not been described for nasal augmentation. The authors performed nasal augmentation using a dermal graft in 90 patients in their hospital between 1994 and 2000, and they followed up the patients for 6 months to 8 years. In this article, the early and late results of dermal grafts for nasal augmentation are presented, and their advantages and disadvantages are discussed with a review of the literature. It was concluded that the easily obtained dermal graft could be an appropriate alternative in nasal augmentation, though it has not been used widely for this purpose.

Anthropometric facial analysis of the African American woman

OBJECTIVE

To assess the differences in facial proportions between African American and Caucasian women. Differences within the African American population are sought.

DESIGN

Anthropometric survey.

PARTICIPANTS

Volunteer sample of African American women (N = 108), aged 18 through 30 years, with African American parents and no previous facial surgery or trauma.

INTERVENTION

Photographs and 16 standard anthropometric measurements were taken in concordance with the 9 neoclassical canons. Results were compared with the North American white standard and the neoclassical canons, and an intragroup evaluation was performed. One-way analysis of variance, 99.7% confidence intervals, and t tests were used to test differences for significance.

MAIN OUTCOME MEASURES

Anthropometric measures.

RESULTS

Compared with white women, the following measurements were found to be significantly different (P<.003) in African American women: special head height was shorter; forehead height II was longer; nose length was shorter; lower face height was longer; height of the calva was shorter; forehead height I was longer; and ear length was shorter. In addition, most horizontal measures were wider, ie, eye-fissure width, nasal width, mouth width, and facial width. The nose and ear have greater angles of inclination. Of the 9 neoclassical canons, the orbital proportion was found to include the most proportional subjects (30.6%), followed by the nasoaural proportion (13.0%) and the nasofacial proportion (9.3%). Subcategorization based on nasal dorsal height yielded the most significantly different measures.

CONCLUSIONS

African American female facial anthropometric measures, especially those of the horizontal dimension, differ significantly from those of young white subjects. The average African American woman does not fit the neoclassical standard of facial proportion.

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.