Rhinoplasty with advancing age

Differences in Nasal Shapes and the Degree of Changes Over a Decade or More: A Paired Analysis

OBJECTIVES

This study investigated age-related differences in nasal morphometry and the degree of changes within an individual over at least a 10-year period by pairing previous and recent three-dimensional reconstructed computed tomography (CT) images.

METHODS

Forty-eight adult Korean patients who underwent at least two CT scans of the nasal region with an interval of at least 10 years were selected. Patients were categorized into six subgroups according to sex and age (20-39 years, 40-49 years, and ≥50 years) at the time of initial imaging. Eight nasal parameters were measured on the initial and recent images, and paired comparisons between the two images were performed based on the data. The differences in the degree of change by age were also analyzed.

RESULTS

Over an average image interval of 12 years, men exhibited an increase in the nasofrontal angle (3.2°±5.4°, P=0.041), profile nasal length (1.7±1.7 mm, P=0.002), and nasal bridge height (1.2±1.6 mm, P=0.002). Conversely, they showed a decrease in the nasofacial angle (-2.3°±2.9°, P=0.010). Women also demonstrated an increase in the nasofrontal angle (2.5°±5.2°, P=0.010), profile nasal length (1.4±1.9 mm, P<0.001), and nasal bridge height (1.3±1.6 mm, P<0.001). However, they exhibited a decrease in the nasofacial angle (-2.0°±2.1°, P<0.001), glabella angle (-9.1°±9.8°, P<0.001), and pyriform angle (-8.5°±10.1°, P<0.001). With the exception of the nasal bridge height (P=0.036) and pyriform angle (P=0.022), the degree of changes in most parameters did not show significant differences across age groups.

CONCLUSION

Our findings indicate that the aging nose exhibits a greater nasal length with inferior angulation of the nasal tip, with an increase in the nasofrontal angle, profile nasal length, and nasal bridge height, along with a decrease in the nasofacial angle. The degree of most nasal morphologic changes demonstrated no significant differences by specific age group.

Gender Considerations in Rhinoplasty

SUMMARY

Precise nasofacial analysis ahead of rhinoplasty is imperative. Features common to the White masculine nose are reviewed in a stepwise fashion and contrasted with those of the White feminine nose. A solid understanding of the cisgender male, masculine nose enables the plastic surgeon to determine the changes required for a successful facial feminizing rhinoplasty as a part of facial gender confirmation surgery.

The Impact of Age on Anthropometric Changes Following Rhinoplasty

Background: There are several factors affecting the results of rhinoplasty, and the predictability of outcomes still remains insufficient. Objective: To associate the rhinoplasty results with patients' age by anthropometric measurements. Methods: Retrospective chart review of patients undergoing rhinoplasty who were divided into decades of age. Anthropometric measurements were carried out using Rhinobase® Software. Wilcoxon t test was used for the postoperative 3 months and 2 years analysis. p values of <0.05 were considered statistically significant. Results: A total of 243 patients (median age: 37.1; M:F = 68:175) were included in the study: group I (19-29 years) n: 80; group II (30-39 years) n:71; group III (40-49 years) n: 48; and group IV (50-61 years) n: 44. In group IV, the highest value of difference (Δ) was seen in the midfacial height with the number of 5.5 ± 1.1 (mm) (<0.001). The values of nasal length, tip projection, and midfacial height parameters showed significant differences in both group III and group IV. Conclusions: Unfavorable age-related changes in long-term postoperative period following rhinoplasty can occur in patients above 40 years of age.

Two-year outcomes of temperature-controlled radiofrequency device treatment of the nasal valve for patients with nasal airway obstruction

Background

The objective of this study was to evaluate long-term symptom improvements in patients with nasal airway obstruction (NAO) secondary to nasal valve collapse (NVC) following minimally invasive temperature-controlled radiofrequency (TCRF) treatment.

Methods

A prospective, single-arm, multicenter study in patients >18 years with NAO due to NVC. Inclusion criteria were response to nasal valve dilation (e.g., modified Cottle maneuver) and baseline Nasal Obstruction Symptom Evaluation (NOSE) Scale score ≥60. Patients were treated in the nasal valve region with a TCRF device and followed through 2 years. A responder was ≥20% reduction NOSE Scale score or ≥1 reduction in severity class.

Results

A total of 122 patients were treated and 91 reached 2 years. The mean baseline NOSE Scale score was 80.3 (95% CI, 78.1-82.6). The adjusted mean change in score at 2 years was -45.8 (95% CI, -53.5 to -38.1), p < 0.001; a 57.0% improvement. The 2-year responder rate was 90.1% (95% CI, 82.3%-94.7%). Significant and sustained symptom improvement was achieved in subpopulations based on sex, age, body mass index, baseline NAO severity, nasal surgery history, NVC mechanism, septal deviation, and other anatomic contributors of NAO. No serious adverse events with a relationship to the study device and/or procedure were reported.

Conclusions

Minimally invasive TCRF device treatment of the internal nasal valve for NAO is well tolerated and leads to significant and sustained improvement in NAO symptom severity through 2 years, including in patients with both static and dynamic NVC, septal deviation, turbinate enlargement, or prior nasal surgery.

Level of Evidence

2b.

Analysis of select esthetic nasal parameters in virtually planned orthognathic patients

PURPOSE

Bony changes after orthognathic surgery are always followed by changes of the overlying soft tissues. Therefore, morphologic changes of the nose may be expected after procedures involving the maxilla. The purpose of this study was to evaluate the changes in the nasal region due to orthognathic surgery using computed tomography (CT) images of virtually planned patients.

METHODS

35 patients who underwent Le Fort I osteotomy, with or without bilateral sagittal split osteotomy, were included. 3D measurements on preoperative and postoperative images were performed and analyzed.

RESULTS

The results revealed that aesthetically acceptable results can be achieved by orthognathic surgery alone.

CONCLUSIONS

According to the results of this study, it can be concluded that it is best to reserve decisions on rhinoplasty to the post-orthognathic period.

Skin Tensioning Concept in Rhinoplasty Using a Semifixed Support Mechanism

BACKGROUND

As the skin on the nose shows outwardly, if we do not consider the volume of skin on the nose that is reduced, the results may be unsatisfactory. Although redraping the skin over a wide area may help, excess skin cannot be adequately controlled in some cases.

MATERIALS AND METHODS

During skin tensioning, a semifixed support mechanism was applied to keep the nasal tip stable and maintain its position while simultaneously allowing stretching and mobility in accordance with its normal function. The dorsal and infratip/columellar skin was stretched by using the support of the most projected part of the nasal tip. The skin was pulled posteriorly to obtain sufficient tensioning and excised at the columellar incision line.

RESULTS

Of the 94 patients who underwent skin tensioning, 82 were women, and 12 were men. The ages of the patients ranged from 18 to 59 years. Ninety-one patients were primary rhinoplasty patients, and 3 patients were secondary rhinoplasty patients. Skin tensioning was performed in 31 patients with overprojection, 24 patients with thick skin, 17 patients with low skin elasticity, 12 patients with excessive skin elasticity, 7 patients with an advanced long nose, and 3 patients with scar tissue due to previous surgery. No serious complications, either functional or aesthetic, related to skin tensioning was encountered.

CONCLUSION

The skin tensioning technique using a semifixed support mechanism helped to achieve a required reduction with a sufficiently defined appearance of the nose in patients with difficult skin.

Epidemiology and patterns of nasal bone fracture in elderly patients in comparison to other age groups: an 8-year single-center retrospective analysis

Background: Nasal bone fractures are the most common type of facial bone fracture, but are under-studied in adults above 65 years of age. Therefore, we investigated the epidemiology and patterns of nasal bone fractures among older adults in comparison to different age groups.Methods: This retrospective study included 2,321 nasal bone fracture patients who underwent surgery at our hospital from January 2010 to December 2017. The patients were classified by age as preschoolers, school-age children, young and middle-aged adults, and the elderly. We performed pairwise comparisons between elderly patients and each other age group in terms of sex, cause of injury, and fracture type.Results: The 2,321 nasal bone fracture patients included 76 elderly patients (50 men [65.8%] and 26 women [34.2%]). In these patients, the two most common injury causes were falling or slipping down (n = 39; 51.3%) and road traffic accidents (n = 19; 25.0%). According to the Stranc and Robertson classification, the most common force vector was lateral, and plane 2 fractures with lateral forces predominated.Conclusion: The elderly showed similar patterns of nasal bone fractures to those observed in young and middle-aged adults, but significant differences from preschoolers (in the injury vector and plane of fracture) and from school-age children (in the sex ratio and plane of fracture). However, elderly patients presented significantly different epidemiological characteristics compared to the other three groups. Therefore, it is necessary to improve the quality of life of the elderly and prepare for the upcoming super-aged society by taking steps to reduce the incidence and severity of fractures. Possible options for doing so include strengthening individual-level safety factors and expanding the social safety net for the elderly.

The Ageing Nose: Challenges and Solutions

Purpose of Review

Rhinoplasty has traditionally been considered an elective procedure for younger patients. However, increasingly older patients are undergoing nasal surgery for both functional and aesthetic indications. We provide an overview of the common problems with rhinoplasty in the elderly and the surgical techniques that can be reliably utilised to address them to produce predictable and longstanding results.

Recent Findings

Outcomes from studies of older rhinoplasty patients emphasise the need for a tailored approach that preserves natural structures. However, if reinforced structural support is required, especially in functional cases, grafting techniques such as septal extension grafts, spreader grafts and alar strut grafts are required. Furthermore, special consideration must be made for the nasal skin in older patients, and utilisation of dorsal onlay grafts is often necessary.

Summary

Surgery for the ageing nose is a complex challenge for the rhinoplasty surgeon. Preoperative assessment is critical and must include detailed facial analysis that considers the amplification of facial asymmetry due to the ageing process and an appreciation that expectations in this population may differ from younger patients. A comprehensive understanding of the age-related anatomical changes in the nasal structure and the wide repertoire of operative techniques are required to restore form and function.

[Symptoms, causes, and treatment options of geriatric nose]

With increasing age, structures of the internal and external nose change. Many elderly patients complain about rhinitis with nasal obstruction, endonasal crusting, epistaxis, intermittent rhinorrhea, and olfactory disorders. These symptoms are mainly caused by atrophy of the mucosa and the olfactory epithelium, but may also be an expression of drug side effects. Additionally, there are changes in the shape of the nose (continuous growth, altered elasticity of supporting structures) and in the dermis, which may develop tumors due to its sun-exposed position. These multiple internal and external changes of the nose can be summarized by the collective term "aging nose," whose treatment options are complex. These range from conservative (nasal care, medication changes, hemostatic measures) to surgical lines of therapy (septorhinoplasty, tumor excision, vascular ligation) and will require further scientific study in the future.

Rhinoplasty in the Older Adult

BACKGROUND

Rhinoplasty in older adults requires unique consideration of the aging nose.

OBJECTIVES

The purpose of this study was to systematically review the literature pertaining to rhinoplasty in the aging population, review the senior author's experience, and describe techniques aimed at addressing age-related features. It was hypothesized that consistent age-related nasal dysmorphology is described in the literature and standard rhinoplasty techniques may effectively address these changes. Furthermore, it was hypothesized that rhinoplasty is more commonly performed for posttraumatic and functional indications than for aesthetic reasons.

METHODS

A literature review including publications describing rhinoplasty in patients over 55 years old was conducted. Additionally, a retrospective review of the senior author's cases was performed. Pre- and postoperative photographs were used to compare anthropometric changes. Demographic factors, surgical indications, and operative details were collected.

RESULTS

Nine articles met the study criteria. Manifestations of the aging nose included soft tissue atrophy, bony fragility and resorption, tip ptosis, internal and external valve collapse, and worsening dorsal hump. Twenty-seven patients were included in this institutional review. Primary indication for rhinoplasty was posttraumatic deformity in 17 (63%) patients and nasal obstructive symptoms in 10 (37%) patients. Tip refinement and ptosis were addressed through tip grafts (70%), columellar struts (26%), and caudal septal extension grafts (67%). Nasal obstruction was relieved through septoplasty (96%), turbinate ablation (85%), and spreader grafts (70%).

CONCLUSIONS

This study presents a systematic review of rhinoplasty in the older adult as well as a retrospective review of the senior author's patients. Unique considerations specific to this population should be integrated into treatment planning.

LEVEL OF EVIDENCE: 4

The Facial Aging Process From the "Inside Out"

The normal course of aging alters the harmonious, symmetrical, and balanced facial features found in youth, not only impacting physical attractiveness but also influencing self-esteem and causing miscommunication of affect based on facial miscues. With this evidence-based paper, the authors aim to provide a comprehensive overview of the latest research on the etiology and progression of facial aging by explaining the aging process from the “inside out,” that is, from the bony platform to the skin envelope. A general overview of the changes occurring within each of the main layers of the facial anatomy is presented, including facial skeleton remodeling, fat pad atrophy or repositioning, changes in muscle tone and thickness, and weakening and thinning of the skin. This is followed by an in-depth analysis of specific aging regions by facial thirds (upper, middle, and lower thirds). This review may help aesthetic physicians in the interpretation of the aging process and in prioritizing and rationalizing treatment decisions to establish harmonious facial balance in younger patients or to restore balance lost with age in older patients.

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.

Changes in the Facial Skeleton With Aging: Implications and Clinical Applications in Facial Rejuvenation

In principle, to achieve the most natural and harmonious rejuvenation of the face, all changes that result from the aging process should be corrected. Traditionally, soft tissue lifting and redraping have constituted the cornerstone of most facial rejuvenation procedures. Changes in the facial skeleton that occur with aging and their impact on facial appearance have not been well appreciated. Accordingly, failure to address changes in the skeletal foundation of the face may limit the potential benefit of any rejuvenation procedure. Correction of the skeletal framework is increasingly viewed as the new frontier in facial rejuvenation. It currently is clear that certain areas of the facial skeleton undergo resorption with aging. Areas with a strong predisposition to resorption include the midface skeleton, particularly the maxilla including the pyriform region of the nose, the superomedial and inferolateral aspects of the orbital rim, and the prejowl area of the mandible. These areas resorb in a specific and predictable manner with aging. The resultant deficiencies of the skeletal foundation contribute to the stigmata of the aging face. In patients with a congenitally weak skeletal structure, the skeleton may be the primary cause for the manifestations of premature aging. These areas should be specifically examined in patients undergoing facial rejuvenation and addressed to obtain superior aesthetic results.Level of Evidence IV 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 .

Rhinoplasty Combined With Centrofacial Lipofilling to Optimize Facial Proportions

Background

The perceived appearance of the nose is influenced by its foundations (ie, malar areas, lip, and chin). The association of nasal hump and centrofacial volume deficiency is not uncommon.

Objectives

We evaluated and analyzed the role of centrofacial lipofilling simultaneously to rhinoplasty to sculpt facial proportions and shapes all in one procedure.

Methods

Volumes and placement of fat graft were determined preoperatively. Centrofacial microfat grafting was performed concomitantly to the rhinoplasty. Treated areas were malar, upper lip, pyriform aperture, and chin.

Results

From January 2016 to January 2019, concurrent lipofilling was performed in 23 rhinoplasties. Fat graft volumes ranged from 2 to 31 mL.

Conclusions

Centrofacial lipofilling is a simple and effective tool that can easily be associated with rhinoplasty techniques to optimize the results and may even influence the procedure towards a more conservative approach.

Level of Evidence: 4

Soft Tissue Thickness Variations of the Nose: A Radiological Study

BACKGROUND

Soft tissue thickness (STT) is a major factor affecting the outcome in rhinoplasty. However, limited information is found in the literature on the age- and gender-related variations of the nasal STT.

OBJECTIVES

The purpose of this study was to measure STT at various landmarks over the nasal framework and compare the age- and gender-related differences.

METHODS

STT measurements were made at 11 landmarks in 325 patients by employing magnetic resonance imaging. Patients were divided into subgroups to compare the STT differences between female and male and between the age groups as young, middle age, and elderly.

RESULTS

Soft tissue was thickest at the nasion and thinnest at the rhinion. The soft tissue coverage was significantly thicker in the male population at the supratip, tip, nasal bones, upper lateral cartilages, and alar lobules, whereas it is thicker in females at the rhinion. Average thickness of the soft tissues over the entire nasal framework increases with age except the rhinion.

CONCLUSIONS

The STT is variable over different parts of the osteocartilaginous framework. Gender and age influence the STT. The soft tissue is thicker at the distal half of the nose in male patients, and these areas become gradually thicker with age, whereas the soft tissue over the midvault becomes thinner. Increasing age presents a particular challenge to achieve predictable results in rhinoplasty, and an understanding of the soft tissue envelope allows for improved aesthetic outcome.

LEVEL OF EVIDENCE 2

Age- and Gender-Related Variability in Nasal Tip Support

BACKGROUND

The age at which nasal tip support changes start to occur is unknown. Evaluation of nasal tip support is difficult, especially as the ideal nasal tip support pressure remains elusive. The aim of this study is to determine the nasal tip support pressure alterations relative to age and sex.

OBJECTIVES

The aim of this study is to determine the changers in resistance of the nasal tip support in relation to age and sex.

METHODS

This prospective clinical study was conducted between January and April 2019 at a tertiary health facility. Nasal tip resistances were measured in four different age-groups (20-29, 30-39, 40-64, and > 65 years) with a digital Newton meter. A total of 159 patients with a minimum of 36 patients per group were included in the study. Nasal tip resistance measurements were compared among nasal tip displacement distances of 2, 3, and 4 mm, focusing on age and sex.

RESULTS

The nasal tip resistance of the 20-29 age-group was significantly higher at 2, 3, and 4 mm nasal tip displacement distances, when compared with the 30-39 and 40-64 age-groups, whereas compared to the > 65 years group, it was significantly higher at 3 and 4 mm nasal tip displacement distances (p < 0.005). Nasal tip resistance of males was found to be significantly higher than that of females, at 3 and 4 mm nasal tip displacement distances (p < 0.001).

CONCLUSIONS

Nasal tip resistance is higher in males and universally decreases significantly after 30 years of age while remaining constant at later ages. Therefore, surgeons should prefer nasal tip resistance increasing techniques in the rhinoplasty operations that are performed on patients even from early years of age, in order to maintain and strengthen the nasal tip resistance.

LEVEL OF EVIDENCE IV

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.

Premaxillary Injection for Perioral Rejuvenation and Lip Enhancement

BACKGROUND

This is the first study to evaluate the effect of premaxillary filler injection on nasal tip projection, upper lip projection, and upper lip vermilion height.

OBJECTIVES

The primary objective of this study was to analyze the change in nasal tip projection (measured by the Goode ratio) and the change in upper lip projection (measured by the Z angle) following premaxillary hyaluronic acid injection. A secondary objective was to measure the change in upper lip vermilion height. We hypothesized that treated subjects will show an increase in nasal tip projection, upper lip projection, and upper lip vermilion height.

METHODS

Twenty volunteer patients with signs of perioral aging or poor upper lip projection were enrolled in this prospective cohort study and underwent premaxillary hyaluronic acid filler injection between November 2017 and June 2018. Nasal tip projection, upper lip projection, and upper lip vermilion height were assessed from baseline and posttreatment photographs based on the Goode ratio, Z angle, and lip vermilion height ratio, respectively.

RESULTS

No significant change was noted between pre- and posttreatment Goode ratio measurements (P = 0.841). There was a significant decrease in Z angle and therefore significant increase in upper lip projection with treatment (P < 0.001). The lip vermilion height ratio demonstrated a trend of increased upper lip vermilion height but this did not achieve statistical significance (P = 0.561).

CONCLUSIONS

Premaxillary filler treatment resulted in a significant increase in upper lip projection. Premaxillary filler injection when performed in a safe manner is a valuable treatment option for perioral rejuvenation.

LEVEL OF EVIDENCE: 4

Three-Dimensional Analysis of Age-Related Orbital and Midfacial Bone Remodeling in Asians

BACKGROUND

Facial bony changes vary among races, yet few studies have been conducted in Asians.

OBJECTIVE

To analyze the aging of orbital and midfacial bones in Asians.

METHODS

Based on the two-dimensional data obtained from the computed tomography scanner of imaging department, 3D reconstructions were conducted to take measurements (orbital diagonal diameter, orbital width, orbital area, maxillary angle, midfacial height, pyriform angle, pyriform width, and pyriform area).

RESULTS

In this retrospective study of 261 subjects, a significant decrease in the orbital diagonal diameter, orbital width, and midfacial height was found in men, whereas women displayed a significant increase in the pyriform width and a significant decrease in maxillary angle and midfacial height by three-dimensional analysis.

CONCLUSION

This study verifies the minor female changes in the orbital region and less dramatic male changes in the midfacial region compared with that in Caucasians. Individualized treatment should be performed according to different genders and races. Further exploration of facial bone metabolism may have valuable implications for Asians.

Perioperative Management of the Facelift Patient

In this article, the authors set out to lay a foundation for successful perioperative management of the facelift patient. They describe the changes of normal facial aging in an attempt to help one recognize the universal way the face is affected by aging. Having a clear understanding of these factors may help to guide the physician with procedures necessary to offer the patient for a desired outcome. Also, the authors emphasize the preoperative assessment and postoperative care necessary to ensure a successful, low-risk operation with minimal downtime and beautiful results, meeting the patient's expectations.

Histological and Anthropometric Changes in the Aging Nose

BACKGROUND

Rhinoplasty in the elderly requires different surgical approaches due to the morphological and structural changes affecting the nose over time.

OBJECTIVES

In this study, the authors aimed to evaluate the age-related cellular and architectural changes of nasal cartilages and soft tissue attachments.

METHODS

This prospective study included 80 patients who underwent rhinoplasty. Patients were divided into 2 groups according to age. Group I included 40 patients ranging in age from 19 to 39 years. Group II included 40 patients aged at least 40 years. Samples from nasal cartilages (upper lateral, lower lateral, and septum) and nasal attachments (interdomal, inter-cartilaginous, and septo-crural) were taken. All specimens were evaluated histologically to detect age-related changes. A modified version of the Mankin grading scale was used to score each nasal cartilage sample. All attachment samples were examined by image analysis for quantitative assessment. The results were correlated to preoperative anthropometric measurements of nasolabial angle and nasal projection.

RESULTS

Histologically, in group II, the cartilage matrix showed fibrinoid degeneration with a significant decrease in the number of chondrocytes and increased perichondrial fibrosis compared with group I. Attachments in group II showed a lower number of blood vessels and decreased percentage of collagen bundles. Modified Mankin scores were significantly higher in group II, indicating weak cartilages compared with group I. There was negative correlation and significance between projection, nasolabial angle, cartilages, and attachments in study groups. The linear regression model revealed that the lower lateral cartilage is the cartilage that is most affected by the aging process.

CONCLUSIONS

These findings not only enhance our current understanding of the natural changes that occur in the nose during aging but may also affect surgical decision-making when grafting or suturing are considered during rhinoplasty.

Level of Evidence: 2.

Facial aging trajectories: A common shape pattern in male and female faces is disrupted after menopause

OBJECTIVES

Despite variation in lifestyle and environment, first signs of human facial aging show between the ages of 20-30 years. It is a cumulative process of changes in the skin, soft tissue, and skeleton of the face. As quantifications of facial aging in living humans are still scarce, we set out to study age-related changes in three-dimensional facial shape using geometric morphometrics.

MATERIALS AND METHODS

We collected surface scans of 88 human faces (aged 26-90 years) from the coastal town Split (Croatia) and neighboring islands. Based on a geometric morphometric analysis of 585 measurement points (landmarks and semilandmarks), we modeled sex-specific trajectories of average facial aging.

RESULTS

Age-related facial shape change was similar in both sexes until around age 50, at which time the female aging trajectory turned sharply. The overall magnitude of facial shape change (aging rate) was higher in women than men, especially in early postmenopause. Aging was generally associated with a flatter face, sagged soft tissue ("broken" jawline), deeper nasolabial folds, smaller visible areas of the eyes, thinner lips, and longer nose and ears. In postmenopausal women, facial aging was best predicted by the years since last menstruation and mainly attributable to bone resorption in the mandible.

DISCUSSION

With high spatial and temporal resolution, we were able to extract a shared facial aging pattern in women and men, and its divergence after menopause. This fully quantitative three-dimensional analysis of human facial aging may not only find applications in forensic and ancient human facial reconstructions, but shall include lifestyle and endocrinological measures, and also reach out to studies of social perception.

Facial Plastic Surgery in the Geriatric Population

Greater life expectancy with advancements in technology and medicine has led to an increasing interest in facial rejuvenation. Facial aging is an inevitable process that largely results from soft tissue descent and volumetric deflation. However, a comprehensive knowledge of the aging process and precise assessment of the exact pathologies yielding the patient's senescent appearance is essential to produce the best cosmetic outcome. The surgeon must evaluate each region independently and the aging face as a whole to ensure a pleasing, natural appearance.

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.

Association of Increasing Nasal Tip Projection With Lip Position in Primary Rhinoplasty

Importance

The effects of rhinoplasty maneuvers on adjacent facial features are an important component in preoperative planning and patient counseling. Tip projection modifications are commonly performed in both cosmetic and reconstructive rhinoplasty.

Objective

To evaluate the subsequent change in lip projection that results from increasing nasal tip projection.

Design, Setting, and Participants

In this case series, 20 patients underwent primary rhinoplasty with the objective of increasing tip projection during the period from October 1, 2014, to September 25, 2015. Preoperative and postoperative photographs were evaluated.

Main Outcomes and Measures

The increased tip projection was verified using the Goode ratio. Upper lip projection was calculated by the Z angle, which is based on the intersection between the Frankfort horizontal plane and the profile line. Vermilion height was also assessed.

Results

Of the 20 patients in the study (19 females and 1 male; mean [SD] age, 26.8 [10.2] years; range, 16-52 years) 18 (90%) demonstrated an increase in upper lip projection when the tip projection was increased by either a columellar strut or tongue-in-groove maneuver. The Z angle demonstrated a statistically significant decrease of 2.7° (95% CI, 1.5°-3.9°; P < .001). Although the vermilion height did not change a significant amount, there was a trend toward an increase in mean height of 0.051 (95% CI, -0.00515 to -0.10685; P = .09).

Conclusions and Relevance

Increasing nasal tip projection causes a measurable increase in upper lip projection. This new causal association has been applied to our filler injection armamentarium as an alternative way to achieve the desired result of a more youthful upper lip.

Level of Evidence

4.

Incidence and Preoperative Risk Factors for Major Complications in Aesthetic Rhinoplasty: Analysis of 4978 Patients

Background

Rhinoplasty remains one of the most common aesthetic procedures performed in the United States. Current literature on rhinoplasty complications is inconclusive and is based on retrospective reviews and small cohorts.

Objectives

The purpose of this study was to examine the incidence and identify predictive risk factors for major complications following rhinoplasty alone or in combination with other aesthetic operations in a large, prospective, multicenter database study.

Methods

A prospective cohort of patients undergoing rhinoplasty between May 2008 and May 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring an emergency room visit, hospital admission, or a reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, and combined procedures.

Results

A total of 129,007 patients were identified, of which 4978 (3.9%) underwent a rhinoplasty. The overall complication rate was 0.7% (n = 37). Hematoma was the most common complication (0.2%), followed by infection (0.2%), and pulmonary complications (0.1%). Age ≥40 years was found to be an independent risk factor for developing complications. Age ≥40 years was found to have a relative risk of 2.05 (P = 0.04) for any major complication. Complications increased from 0.58% in rhinoplasty alone cases to 1.02% (P < 0.05) with the addition of 1 other body region to 2.09% with the addition of 2 other body regions (P < 0.05). The risk of pulmonary complications increased from 0.1% to 1% (P < 0.05) with the addition of rhinoplasty with 2 other body regions. Gender, type of facility, smoking status, and BMI ≥25 did not appear to significantly impact the risk for major complications.

Conclusions

The major complication rate following rhinoplasty remains low. The risk is increased with age ≥40 years and with the addition of other cosmetic procedures. Pulmonary complications, although rare, do occur, and also increase when combining rhinoplasty with other aesthetic surgery. These findings are important to consider when planning rhinoplasty and educating patients on the safety of combined aesthetic surgeries.

Level of Evidence

2.

A Practical Approach to Rhinoplasty

Rhinoplasty continues to be one of the most commonly performed aesthetic surgical procedures. Over the past 25 years, the open approach has increased in popularity and is the focus of this article. The principles for successful rhinoplasty include comprehensive clinical analysis and defining rhinoplasty goals, preoperative consultation and planning, precise operative execution, postoperative management, and critical analysis of one's results. Systematic nasal analysis is critical to establish the goals of surgery. Techniques to address the nasal dorsum, nasal airway, tip complex, alar rims, and bony vault that provide consistent results are discussed.

Aesthetic Motivation of Geriatric Rhinoplasty The Surgical Outcome

BACKGROUND

Rhinoplasty in the elderly population has recently emerged as an issue in terms of rejuvenation. There, however, is a paucity of published data on geriatric rhinoplasty in Asian patients. The aims of this study were to investigate the motivation of aged Korean patients to undergo the procedure, and to demonstrate our experience of rhinoplasty in patients of 60 years of age and older.

METHODS

A total of 20 patients, 11 men and 9 women, underwent rhinoplasty between December 2003 and September 2012 at the Asan Medical Center. Anthropometric measurements were performed preoperatively and postoperatively. Two independent ENT surgeons viewed photographs to assess the surgical outcomes. Patient satisfaction was graded using a visual analogue scale (from 1 = dissatisfied, to 4 = satisfied) by telephone interview.

RESULTS

The rhinoplasty performed in our patient cohort aimed to address deviated nose (30%), postinfectious deformed nose (15%), flat nose (15%), saddle nose (10%), and additional cosmetic rhinoplasty for planned septoplasty (10%). Anthropometric measurements showed statistically significant improvements in nasal tip projection, nasal length, dorsal height, and radix height. The mean satisfaction scores were 2.9 for physicians and 2.5 for patients. Three patients (15%) experienced incomplete improvement of nasal obstruction, and 7 patients (35%) expressed aesthetic dissatisfaction about tip shape or dorsal deviation after rhinoplasty. Three patients (15%) underwent revision rhinoplasty.

CONCLUSIONS

The aged patients in this study received rhinoplasty to resolve their long-cherished desires. If elderly patients have no risk of general condition, surgeons do not need to discourage a patient's wish to improve their appearance.

Sublabial Autologous Ear Cartilage Grafting for Increasing the Nasolabial Angle

Background

The loss of nasal tip support is caused by many factors and eventually results in the collapse and eventual dropping of the nasal tip. This reduces the nasolabial (NL) angle and negatively affects respiratory functions and one's appearance.

Methods

The aim of this retrospective study, which was conducted on 52 patients, was to present and popularize a simple and effective method for the reconstruction of a weakened columella by inserting an autologous ear cartilage graft using a sublabial approach.

Results

Of all the patients, three patients experienced transplant rejection. The period of follow-up observation was one to five years (mean, 27 months). The results were objectively evaluated by measuring the NL angle in standardized photos before and after the procedure at different time intervals over the follow-up period. We observed a significant increase of the NL angle (mean, 20°), and found these results to be durable over the long term. Of the 52 patients included in this study observed patients, three were dissatisfied (due to immediate infection and shifting of the strut), 28 were satisfied, and 21 were very satisfied.

Conclusions

The surgical method described here is simple and can be learned quickly. It has very good results with few complications, and is our method of choice for complex and serious cases seen in everyday rhinosurgical practice.

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.

Skin Excision as an Adjunctive Technique to Rhinoplasty in Middle-Aged and Elderly Patients

Supplemental Digital Content is available in the text.

Rhinoplasty in middle-aged and elderly patients comes with its own set of challenges. There is relative lengthening of the nose with drooping of the nasal tip. With aging, the skin loses its elasticity, and the combination of nasal skeletal reduction along with overlying inelastic skin provides a setup for skin redundancy and poor postoperative outcome. We describe a surgical technique involving lenticular skin excision as a part of rhinoplasty in 12 patients older than 50 years to improve the aesthetic outcome. Skin width up to 1.6 cm was excised. Included is a literature review of skin excision in rhinoplasty. In elderly patients with thin, inelastic skin and long nose with a drooping tip, a reduction rhinoplasty technique might result in skin redundancy. Lenticular skin excision along the radix of the nose in these 12 patients improved the aesthetic outcome by decreasing the redundancy and preventing nasal tip ptosis. The wound from the skin resection healed in all the patients with minimal scar, and no complication was noted after at least 1 year of follow-up for each patient.

Fat Grafting to the Forehead/Glabella/Radix Complex and Pyriform Aperture: Aesthetic and Anti-Aging Implications

BACKGROUND

Optimal aesthetic outcomes from rhinoplasty are heavily influenced by structures adjacent to the nose. Although the importance of the chin has been emphasized since the inception of rhinoplasty, little attention has been given to the forehead. The forehead/glabella/radix complex represents a vital triad in rhinoplasty, from which the nasofrontal angle is derived. In the present study, the authors sought to determine whether fat grafting to the forehead/glabella/radix complex and pyriform aperture can favorably impact the nasofrontal and nasolabial angles, respectively.

METHODS

The authors reviewed pre- and postoperative images (obtained by an independent professional photographer) of patients who underwent autologous fat grafting to the forehead/glabella/radix region and the pyriform aperture, with or without concurrent rhinoplasty. Nasofrontal and nasolabial angles were measured on lateral images. Mean pre- and postoperative values were calculated and compared. A Wilcoxon rank-sum test was used for statistical analysis.

RESULTS

Twenty-six patients underwent fat grafting alone (FG group; mean follow-up, 3.3 years), and 19 had fat grafting plus rhinoplasty (FG + R group; mean follow-up, 5.2 years). The mean nasofrontal angle in the FG group decreased by 2.0° (P = 0.005), and the mean nasolabial angle increased by 2.3° (P = 0.006). The mean nasofrontal angle in the FG + R group decreased by 2.0° (P = 0.011), and the mean nasolabial angle increased by 6.0° (P = 0.026).

CONCLUSIONS

Autologous fat grafting to the forehead/glabella/radix complex and pyriform aperture is a reliable method to favorably influence the nasofrontal and nasolabial angles, respectively. Such treatment optimizes the interplay between the nose and the adjacent facial features, enhancing overall aesthetics.

The plunging tip: analysis and surgical treatment

BACKGROUND

The plunging tip refers to a deformity in which the nasal tip plunges on smiling.

OBJECTIVES

To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a focus on the anatomic changes of the nose on smiling.

METHODS

Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose.

RESULTS

Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively. Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip.

CONCLUSIONS

This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose. No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation.

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.

Analysis of the development of the nasal septum and measurement of the harvestable septal cartilage in koreans using three-dimensional facial bone computed tomography scanning

Background

The septal cartilage is the most useful donor site for autologous cartilage graft material in rhinoplasty. For successful nasal surgery, it is necessary to understand the developmental process of the nasal septum and to predict the amount of harvestable septal cartilage before surgery.

Methods

One hundred twenty-three Korean patients who underwent three-dimensional (3D) facial bone computed tomography (CT) were selected for evaluation of the midsagittal view of the nasal septum. Multiple parameters such as the area of each component of the nasal septum and the amount of harvestable septal cartilage were measured using Digimizer software.

Results

The area of the total nasal septum showed rapid growth until the teenage years, but thereafter no significant change throughout the lifetime. However, the development of the septal cartilage showed a gradual decline due to ossification changes with aging after puberty in spite of a lack of change in the total septal area. The area of harvestable septal cartilage in young adults was 549.84±151.26 mm² and decreased thereafter with age.

Conclusions

A 3D facial bone CT scan can provide valuable information on the septal cartilage graft before rhinoplasty. Considering the developmental process of the septal cartilage identified in this study, septal surgery should not be performed until puberty due to the risk of nasal growth impairment. Furthermore, in elderly patients who show a decreased cartilage area due to ossification changes, septal cartilage harvesting should be performed carefully due to the risk of saddle nose deformity.

Age-related histologic changes in human nasal cartilage

IMPORTANCE

Understanding age-related changes is important when considering cartilage-based implants or grafts during rhinoplasty and nasal reconstructive surgery.

OBJECTIVE

To characterize the cellular and architectural changes in human nasal cartilage with aging.

DESIGN

Laboratory study.

PARTICIPANTS

Nasal septal cartilage was harvested from 50 consecutive patients undergoing septoplasty, rhinoplasty, or septorhinoplasty.

INTERVENTION

Cartilage specimens were stained with hematoxylin-eosin (H&E) and safranin O for cartilage.

MAIN OUTCOME MEASURES

A modified Mankin histologic grading scale was used to analyze each cartilage sample for H&E findings and safranin O staining. Higher H&E scores indicated more degenerative changes, while higher safranin O scores indicated reductions in proteoglycan content within the cartilage matrix, representing decreased active chondrocyte activity. Correlation between H&E and safranin O scores and patient age was determined.

RESULTS

There was positive correlation between safranin O staining scores and age, with higher scores seen with advancing age (P = .01). A linear regression best-fit equation was determined to calculate a potential safranin O staining score for a given age.

CONCLUSIONS AND RELEVANCE

We have quantitatively determined that advancing age is positively correlated with reductions in cartilage proteoglycan content and active cartilage growth. This finding not only enhances our current understanding of the natural changes that occur in cartilage with aging but may also affect surgical decision making when cartilage grafting is considered during functional, reconstructive, and aesthetic rhinoplasty.

LEVEL OF EVIDENCE

NR.

The plunging tip: illusion and reality

BACKGROUND

The plunging tip is defined as a nasal deformity where the nasal tip descends or "plunges" during smiling.

OBJECTIVE

The authors prospectively measure a series of 25 patients with a focus on the anatomic changes of the nose before and after the patient smiles.

METHODS

Twenty-five women who presented for cosmetic primary rhinoplasty and complained of a plunging tip were included in the study. Three angles were measured on lateral view (tip angle, nasolabial angle, and columella inclination angle), along with changes in tip, subnasale, and alar crease. The Simon tip rotation angle (STRA) measured tip position in relation to the static tragus. The alar rim angle measured the angle of the alar rim at the nostril. Changes in static and smiling positions were compared.

RESULTS

Tip, nasolabial, and the columella inclination angles decreased between static and smiling positions by 10.9, 11.8, and 11.9 degrees, respectively. Tip position dropped by 0.9 mm, while the subnasale and alar crease junction elevated by 1.3 and 3.7 mm, respectively. The STRA, an angle independent of alar base movement, decreased by less than 1 degree. The alar rim angle increased by 9.9 degrees.

CONCLUSIONS

Our data demonstrate that the nasal tip changes its position less than 1 mm with a full smile. The concept of a "plunging tip" is an optical illusion. In reality, the alar crease and subnasale elevate and the alar rim straightens, while the tip position changes minimally. Objectively, the tip moves less than 1 mm and less than 1 degree using the STRA.

Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation

In principle, to achieve the most natural and harmonious rejuvenation of the face, all changes that result from the aging process should be corrected. Traditionally, soft tissue lifting and redraping have constituted the cornerstone of most facial rejuvenation procedures. Changes in the facial skeleton that occur with aging and their impact on facial appearance have not been well appreciated. Accordingly, failure to address changes in the skeletal foundation of the face may limit the potential benefit of any rejuvenation procedure. Correction of the skeletal framework is increasingly viewed as the new frontier in facial rejuvenation. It currently is clear that certain areas of the facial skeleton undergo resorption with aging. Areas with a strong predisposition to resorption include the midface skeleton, particularly the maxilla including the pyriform region of the nose, the superomedial and inferolateral aspects of the orbital rim, and the prejowl area of the mandible. These areas resorb in a specific and predictable manner with aging. The resultant deficiencies of the skeletal foundation contribute to the stigmata of the aging face. In patients with a congenitally weak skeletal structure, the skeleton may be the primary cause for the manifestations of premature aging. These areas should be specifically examined in patients undergoing facial rejuvenation and addressed to obtain superior aesthetic results.

LEVEL OF EVIDENCE IV

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.

Rhinoplasty

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty.

SUMMARY

Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.

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.

Secondary cleft rhinoplasty rejuvenates the nose: a suggestion from a panel survey

BACKGROUND

Cleft-lip nasal deformity (CLND) affects the overall facial appearance and attractiveness. The CLND nose shares some features in part with the aging nose.

OBJECTIVES

This questionnaire survey examined: 1) the panel perceptions of the role of secondary cleft rhinoplasty in nasal rejuvenation; and 2) the influence of a medical background in cleft care, age and gender of the panel members on the estimated age of the CLND nose.

STUDY DESIGN

Using a cross-sectional study design, we enrolled a random sample of adult laypersons and health care providers. The predictor variables were secondary cleft rhinoplasty (before/after) and a medical background in cleft care (yes/no). The outcome variable was the estimated age of nose in photographs derived from 8 German nonsyndromic CLND patients. Other study variables included age, gender, and career of the assessors. Appropriate descriptive and univariate statistics were computed, and a P value of <.05 was considered to be statistically significant.

RESULTS

The sample consisted of 507 lay volunteers and 51 medical experts (407 [72.9%] were female; mean age ± SD = 24.9 ± 8.2 y). The estimated age of the CLND noses was higher than their real age. The rhinoplasty decreased the estimated age to a statistically significant degree (P < .0001). A medical background, age, and gender of the participants were not individually associated with their votes (P > .05).

CONCLUSIONS

The results of this study suggest that CLND noses lack youthful appearance. Secondary cleft rhinoplasty rejuvenates the nose and makes it come close to the actual age of the patients.

Panel and patient perceptions of nasal aesthetics after secondary cleft rhinoplasty with versus without columellar grafting

BACKGROUND

Cleft-lip nasal deformity alters patient's self-image, as well as posing unique challenges for the rhinoplastic surgeon.

OBJECTIVES

The main purpose of this study was to compare the panel perceptions of nasal aesthetics following secondary cleft rhinoplasty with versus without caudal septal extension grafting (columella grafting). We also investigated whether patient's self-assessment and satisfaction correlated with 4 other variables: (1) rhinoplasty techniques; (2) patients' age; (3) patients' gender; and (4) panel perceptions.

METHODS

Using a cross-sectional study design, we enrolled a sample of adult laypersons and medical experts. The predictor variable was the rhinoplasty techniques (with/without columellar grafting). The outcome variable was the panel rankings of nasal aesthetics based on the photographs of 50 nonsyndromic cleft patients before and after the rhinoplasty. Other variables included the patient's subjective assessment and satisfaction, demographic and anatomic variables. Appropriate descriptive, uni- and bivariate statistics were calculated. The significance level was set at P≤0.05 and <0.05 for single- and two-tailed tests of hypothesis, respectively.

RESULTS

The sample consisted of 507 laypersons and 51 professionals who gave comparative ratings (P>0.05). Columellar grafting was associated with higher rankings of postoperative nasal aesthetics (P =0.04). Most of the patients (90%) rated positive outcomes. Surgical techniques, patients' age and gender, and panel perceptions were not individually significantly associated with subjective measures and satisfaction.

CONCLUSIONS

Our results suggest that caudal septal extension grafting improves the nasal aesthetics of the cleft patients, as judged by the panel. Patient's self-assessment seems unreliable to be used as an outcome measure.

Rhinoplasty using Nácul's suspensor system: a preliminary report

A minimally invasive procedure based on a "suspensory system" is presented for the aesthetic correction of the flat nose. A Goretex monofilament is inserted between the connective tissue and the perichondrium from the septal, upper lateral, and alar cartilages in a quadrangular fashion. When tightened, it shortens the nose and elevates the tip. The procedure is performed on an outpatient basis with the patient under local anesthesia. It offers the patient immediate evaluation of the result. No edema or bruises have been observed. At this writing, 8 months after an application of this procedure, no extrusions or collateral reactions have been found.

Clinical presentation and management of geriatric rhinitis

The population of Americans over 65 years of age is growing at an unprecedented rate. Rhinitis is a common and burdensome complaint in this group, and physicians should be aware of the diagnosis and management of the disease. Geriatric rhinitis is a nasal disorder of older persons that presents with a constellation of nasal symptoms. The etiologies of this condition include both inflammatory diseases and the effects of aging on physiology of the upper airway. Possible causes include allergic rhinitis, nonallergic rhinitis (vasomotor rhinitis and gustatory rhinitis), adverse effects of medications, hormonal changes, postnasal drip syndrome, chronic rhinosinusitis and atrophic rhinitis. Nasal symptoms in the older patient present a clinical challenge because of the physiologic effects of the aging nose, the unusual clinical presentation, the presence of multiple comorbidities and the problem of polypharmacy. A number of therapeutic options exist for this disorder, although definitive studies of effective regimens are needed.