|
 |
EARLY CONCERNS
"One must really listen to these patients, as most do not want to make as significant changes as younger patients. Less is indeed more in the mature rhinoplasty patient. Often, the rhinoplasty is done in conjunction with other operative procedures, so it is indeed a subtle change that is needed or implied by the patient," says Rod Rohrich, M.D., F.A.C.S., professor and chairman of the Department of Plastic Surgery at UT Southwestern Medical Center.
As noted by Dr. Rohrich and colleagues in a paper published in Plastic and Reconstructive Surgery, "Aging patients usually have different expectations and motivations than their younger counterparts; therefore, open communication and frank discussions are paramount to define realistic goals."1And communicating early in the process, for example, during the pre-operative interview, about other issues including concurrent medical problems, medications they may be taking and their goals and expectations for the surgery is also important.
"I usually find these [older] patients to be very grateful with very reasonable expectations that are usually centered around just breathing better. In general, this patient population has a better idea of what can and cannot be accomplished with surgery alone, and they are less concerned about some cosmetic issues that might bother the younger patient population. But, every patient must be treated individually, of course," says Marcus W. Moody, M.D., director of the Division of Rhinology and assistant professor in the Department of Otolaryngology/Head and Neck Surgery at the University of Arkansas for Medical Sciences.
According to Dr. Moody, "If a patient presents primarily for breathing issues, avoid any drastic and unnecessary cosmetic changes unless specifically having addressed these with the patient beforehand. Often, the surgeon may have an aesthetic ideal in mind that is compatible with the goal of breathing better, but the older patient may be very disappointed to have the appearance of the nose changed beyond minimal adjustments," he explains.
In their paper, Dr. Moody and colleague also point out that the pre-operative exam should also include a comprehensive head and neck evaluation because older patients can have undiagnosed abnormalities that need to be identified pre-operatively.2
SURGICAL TECHNIQUE
Many older patients have functional disorders that have worsened with age, and surgery requires special care as these patients' tissues are more delicate than younger patients' and potential donor sites are fewer, according to experts.1-3
Additionally, the authors note, anatomic changes in skin, cartilage, underlying bony framework and nasal airways require special consideration to achieve optimal outcomes.2 "The effects of age on the skin, ligaments, and cartilage of the nose conspire with the relentless pull of gravity to create a ptotic tip and collapsing nasal sidewalls."2
Therefore, when performing rhinoplasty, "a firm structure is always important, but in the older patient it is doubly important. Cartilage is weakened or thinned. Connective tissue is lax. The surgeon must anticipate the need for grafting materials and reconstruction of the support of the nose in every case. Weakening of existing structure is to be discouraged," Dr. Moody says.
And according to Dr. Rohrich, "there are certain common goals in performing rhinoplasty in the older nose: perform tip derotation with tip refinement; increase tip projection and relative columellar lengthening; decrease the overall nasal length; correct the dorsal hump; address and support the internal nasal valves; and correct septal deviation and inferior turbinate hypertrophy, if present."1
