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

Supplemental Digital Content is available in the text.


R
hinoplasty is now being increasingly performed in the middle-aged and elderly population. Approximately 20% of all rhinoplasty procedures in the United States are performed on patients who are older than 55 years. 1 In older patients, rhinoplasty presents a very different challenge compared with that in the younger individuals. 2 It is very important to characterize the anatomic and viscoelastic changes in the nose while planning rhinoplasty in the aging population. [3][4][5][6][7][8][9] There is relative lengthening of the nose with drooping of the nasal tip and increased prominence of dorsal hump in elderly patients. [3][4][5][6] In a younger individual, the nasal skin shrinks and adapts over the reduced nasal skeleton because of its natural elasticity. With aging, the skin loses its elasticity. 7,8 As such, a combination of nasal skeletal reduction with overlying inelastic skin provides a setup for redundancy and poor postoperative outcome. Multiple techniques have been described to overcome these problems including supratip advancement sutures, postoperative triamcinolone, and defatting. 9-12 Nasal skin resection for rhinoplasty has also been described. [13][14][15][16][17][18] In our study, we describe a lenticular nasal root skin removal as a part of rhinoplasty in middle-aged and elderly patients. Excision of nasal skin in these selected patients will decrease the potential for nasal tip ptosis and result in improved aesthetic outcomes.
Summary: 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.

Cosmetic
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SURGICAL TECHNIQUE
We reserved external skin excision technique for patients who were at least 50 years old. Among this patient cohort, the operating surgeon used his discretion to identify the patients with skin redundancy, after trimming of nasal skeletal components, who would benefit from this technique. In general, if the patient had more than 1 cm of vertical redundancy of skin, it was considered an indication for skin resection. Twelve patients were operated on using this technique. Most of these patients had either a very large nose or drooping tip or a dorsal hump.
An open rhinoplasty approach with wide nasal skin undermining was performed. Tip and dorsum manipulation, dissection of caudal septum, osteotomies, and sometimes, alar base resection were done as needed. A lenticular horizontal excision was then performed along the level of nasal radix (Supplemental Digital Content 1, which shows lenticular skin excision at the nasal root as a part of rhinoplasty in a representative patient, http://links.lww.com/ PRSGO/A132). The flap was pulled up till the skin had been tightened. A full thickness skin excision down to nasalis muscle was then performed after confirming the extent of the excision. Skin up to 1.6 cm in width was excised. The incision was then closed in 2 layers with a 5-0 monocryl and 6-0 nylon.

RESULTS
We have performed this technique on 12 patients with at least 1 year of follow-up for each patient. All our patients had a good aesthetic outcome with no skin redundancy and decreased nasal tip ptosis. We have included a representative preoperative and postoperative picture of rhinoplasty with skin excision showing portrait views and lateral views (Figs. 1,  2). The wound from the skin resection healed in all the patients with minimal scar. The mean Vancouver scar scale of our patients was 0.5 at 1 year follow-up, which indicates very good healing. 19

DISCUSSION
Rhinoplasty in elderly patients presents a unique challenge to the operating surgeon. 2 The nasal dorsum also assumes a more convex character with aging because of downward rotation of the lobule and columellar retraction. 6 There is an increased density of sebaceous glands in the nasal tip and alae, resulting in a fuller appearance of the nasal tip complex. 16 The nasal tip also becomes "droopy" (ptotic) with aging mainly because of weakened fibroelastic attachments between the upper and lower lateral cartilages, resulting in downward migration of the lateral crura. 3,5 With aging, the skin loses elasticity along with thinning of dermis and decreased dermal collagen content. 7,8 Skin excision in rhinoplasty has been described in few previous studies. However, the techniques and indications in these limited studies have significant variations from our described study. Joseph 13 listed 43 operations where he only performed external skin excisions. In such extreme cases, he described   15 However, there is increased risk of scar because of increased tension in this region compared with the root of the nose. Lemperle and Biewener 16 advocated vertical skin excision for sebaceous nose with supratip deformity. Even though this technique resulted in removal of sebaceous skin, it caused a visible scar that required dermabrasion. 16 Kabaker 17 demonstrated improvement in nasal tip ptosis and dorsal hump with skin excision across the bridge of the nose.
In younger patients, correction of tip ptosis benefits from the development of wound contraction and scar tissue, which pulls the trimmed lower lateral cartilages upward. 17 The overlying skin contracts to fit the smaller nose, and skin resection is not needed. In elderly patients undergoing rhinoplasty, the relatively longer nose with a dorsal hump and droopy tip coupled with lax skin with poor elasticity can result in poor aesthetic outcomes. [3][4][5][6][7][8] As such, resection of excessive skin can prevent redundancy and decrease postoperative tip ptosis. Because of abundance of sebaceous cyst in the lower portion of the nose, any incision in this region would likely result in a conspicuous scar. The thin skin around the root of the nose will heal with minimal scar. Based on these factors, our skin excision is located at the root of the nose.
With this technique, we demonstrated very good postoperative outcome with lenticular nasal skin excisions. In our experience, all the wounds from the skin resection healed with minimal scar, and the resulting smaller soft-tissue envelope provided a better coverage to the underlying osseocartilaginous framework.

CONCLUSIONS
In elderly patients with inelastic skin and long nose with a drooping tip, standard rhinoplasty techniques might result in skin redundancy. Lenticular skin excision along the root of the nose in such patients can improve the aesthetic outcome by decreasing the redundancy and preventing nasal tip ptosis.