Adolescent and aging nose

Two-sentence lead. Surgery on the growing nose no longer appears to stunt facial growth when cartilage-sparing techniques are used, though long-term growth data remain thin, and childhood nasal obstruction is treated to prevent mouth breathing, malocclusion, and sleep apnea. In older adults the nose shows tissue atrophy, brittle bone, tip droop, inelastic skin and valve collapse; functional nasal procedures are rising in the Medicare population, skin excision at the radix has been used past age 50, and skin thickness measured by pinch test and ultrasound (dermis 0.3 to 0.9 mm at the keystone) now guides soft-tissue planning at any age.

Key points

• Pediatric functional rhinoplasty: historically deferred to skeletal maturity at 18; studies of facial growth "to date" show no effect and surgery is safe with cartilage-sparing and preservation techniques; untreated obstruction leads to mouth breathing, snoring, malocclusion, obstructive sleep apnea [37619608]
• Older-adult review, 9 articles: aging nose shows soft tissue atrophy, bony fragility and resorption, tip ptosis, internal and external valve collapse, worsening dorsal hump [33739380]
• 27 older-adult cases: indication posttraumatic in 17 (63%), obstruction in 10 (37%); tip grafts 70%, caudal septal extension grafts 67%, columellar struts 26%; septoplasty 96%, turbinate ablation 85%, spreader grafts 70% [33739380]
• Medicare Part B 2000-2019: rising use of CPT 30465, 30410, 30420, 30520, 30140; falling 30400; per 100,000 enrollees 30465 and 30140 rose while 30520 fell [33847511]
• Rhinoplasty decision, 256 participants (106 had surgery, 46 considering, 104 not): neuroticism raised likelihood 16.3% (29.3% with a family member who had rhinoplasty); extraversion 24.4% (30.9%); psychoticism 15.4% (19.1% without family history); physical neglect 17.9% (22% without family history); emotional abuse via neuroticism 5.4% (17.7% with family history) [39285056]
• Acellular human dermis camouflage graft, 91 patients over 20 years (2000-2020), mean follow-up 3.8 years: 70 (77%) were revisions to thicken thinned skin; contour problems 1%; resorption 3%; infection 4%, all cleared with one oral antibiotic course [36637866]
• 3D simulation vs actual result, 40 patients (VECTRA), blinded panel 1-5: preoperative mean 1.7 (67.5% poor); simulation 2.9 (good in 60%); actual 3.4 (82.5% good to excellent); panel preferred actual over simulation in 77.5% vs 22.5% (P<0.001); actual tip more projected than simulated; rotation no different [29789868]
• 3D imaging in Asian rib rhinoplasty, 44 patients randomized: postoperative result matched simulation; outcome satisfaction unchanged; doctor-patient communication satisfaction higher [33432387]
• Computer morphing at consult lets the surgeon postpone or cancel surgery in patients dissatisfied with the proposed change; imaging moving from 2D to 3D [26862968]; 3D surface imaging measures shape and volume change after surgery [26862969]
• Piezoelectric bony vault algorithm, 165 cases (Dec 2016-Jul 2018), fully open approach, 5 treatment groups by asymmetry; rhinosculpture used alone and with osteotomies to keep bony side walls stable [31157882]
• Revision defined as return to surgery to correct a functional or aesthetic concern from the original operation [29857339]; revision rate 5% to 15%; PGS (problem, graft, prior surgeries) staging plus E for expectations proposed [27149684]
• Pediatric nasal surgery review: most often after trauma; safe in selected children with a plan that spares growth centers; long-term growth outcomes described as still elusive [28340652]
• Aging nose review (Toriumi): sun damage, hormones, lost elasticity, bone resorption and gravity produce the classic changes; surgery must resist ongoing remodeling forces [26862965]
• Lenticular skin excision at the radix during rhinoplasty in 12 patients over 50 with thin inelastic skin, long nose and drooping tip: up to 1.6 cm of skin removed; minimal scar, no complication at 1 year or more [26579338]
• Skin pinch test validated by ultrasound in 75 primary patients: keystone dermis 0.3 mm (thin), 0.5 mm (normal), 0.9 mm (thick); nasolabial fold dermis 0.7, 1.1, 1.4 mm; oily skin thicker at every site; non-Caucasian patients more often had thick subdermal soft tissue; Level 4 [27965218]
• Salvaging the compromised skin-soft tissue envelope in revision rhinoplasty: reduced vascularity and scarring after prior surgery; algorithm for prevention, early recognition and intervention [42091325]
• Alar flare classified into three types by rim shape on basal view; excision pattern tailored to type to narrow the lower third without an operated look; Level V [29068925]
• Digital imaging in 40 secondary rhinoplasties (Rohrich, 2000-2013; 87.5% women): agreement between imaging and result rated 2.36 dorsum, 2.65 midvault, 2.27 tip, 2.63 alae, 2.99 base; tip and dorsum hardest to predict [27219263]
• Computer imaging survey, 238 of 1,200 AAFPRS surgeons (19.8% response; 83% board certified): 63% use imaging at consultation; 92% morph the images themselves; about two-thirds give patients a printout [28432415]
• 3D-printed splints vs taping for 12 weeks after primary rhinoplasty, 36 vs 34 randomized: volume reduction 15.1% vs 10.6% at 1 year and 14.9% vs 10.3% at 6 months (P<=0.05); tip and dorsum reductions held at 1 year [37744773]
• Leukocyte- and platelet-rich fibrin membrane for camouflage and dead-space filling, 23 patients (19 with diced cartilage): no early or late complication; all patients satisfied [32983802]

Techniques and terms named

cartilage-sparing / preservation technique [37619608], tip graft [33739380], columellar strut [33739380], caudal septal extension graft [33739380], septoplasty / turbinate ablation / spreader graft [33739380], CPT 30400 / 30410 / 30420 / 30465 / 30520 / 30801 / 30802 / 30130 / 30140 / 30930 [33847511], acellular human dermis (AHD) camouflage graft [36637866], computer imaging / morphing [26862968], 3D surface imaging [26862969], VECTRA (Canfield) [29789868], 3D computer simulation [33432387], piezoelectric instruments / rhinosculpture [31157882], PGS staging [27149684], Eysenck Personality Questionnaire Revised Short Form / Childhood Trauma Questionnaire [39285056], soft tissue envelope [28052908], growth center preservation [28340652], aging nose remodeling forces [26862965], lenticular radix skin excision [26579338], skin pinch test and ultrasound dermal thickness [27965218], compromised skin-soft tissue envelope [42091325], alar flare types I-III [29068925], digital imaging in secondary rhinoplasty [27219263], computer imaging practice survey [28432415], 3D-printed nasal splint [37744773], leukocyte- and platelet-rich fibrin (L-PRF) membrane [32983802]

Numbers to remember

• 63% of older-adult rhinoplasties were posttraumatic; septoplasty in 96%, spreader grafts in 70% (n=27) [33739380]
• AHD graft: 4% infection, 3% resorption, 1% contour problems over mean 3.8 years (n=91) [36637866]
• Panel preferred the actual result over the 3D simulation in 77.5% of 40 cases [29789868]
• Neuroticism raised rhinoplasty likelihood 16.3%, extraversion 24.4% (n=256) [39285056]
• 165 piezoelectric bony-vault cases in 18 months [31157882]
• Revision rate 5% to 15% [27149684]
• Keystone dermis 0.3, 0.5, 0.9 mm for thin, normal, thick skin by pinch test, n=75 [27965218]
• Skin excision up to 1.6 cm in 12 patients over 50; 0 complications at 1 year [26579338]
• Imaging used by 63% of 238 responding facial plastic surgeons [28432415]
• Edema volume down 15.1% with 3D splints vs 10.6% with tape at 1 year, n=70 [37744773]
• Imaging-to-result agreement lowest at tip (2.27) and dorsum (2.36), n=40 secondary cases [27219263]

Numbers

What is still contested or missing

• Aesthetic rhinoplasty in children and adolescents is addressed only by a title-only commentary on file [36048532]; the pediatric review notes minor external variations "potentially can grow to a cosmetic deformity" [37619608]
• 3D simulation under-projects the tip relative to actual results [29789868] and did not change outcome satisfaction in a randomized trial [33432387]
• Surgeon prediction accuracy for dorsal height [35506909], the AHD commentary [36637870], and the soft-tissue envelope commentary [28052908] are title-only on file [35506909, 36637870, 28052908]
• Long-term growth effects of pediatric nasal surgery are called elusive by one review and absent by another [28340652, 37619608]
• Skin excision in older patients rests on 12 cases; L-PRF camouflage on 23 [26579338, 32983802]
• The imaging survey had a 19.8% response rate [28432415]
• Alar flare classification and aging-nose management are expert descriptions without outcome data [29068925, 26862965]

Papers used

• Lekakis G et al.. Evolution of Preoperative Rhinoplasty Consult by Computer Imaging. Facial Plast Surg 2016. PMID 26862968. DOI 10.1055/s-0035-1570125
• Lekakis G et al.. Three-Dimensional Surface Imaging and the Continuous Evolution of Preoperative and Postoperative Assessment in Rhinoplasty. Facial Plast Surg 2016. PMID 26862969. DOI 10.1055/s-0035-1570122
• Rodman R, Kridel R. A Staging System for Revision Rhinoplasty: A Review. JAMA Facial Plast Surg 2016. PMID 27149684. DOI 10.1001/jamafacial.2016.0249
• Yılmaz Y et al.. Childhood Traumas and Personality Traits' Impact on Rhinoplasty Decision. Aesthetic Plast Surg 2024. PMID 39285056. DOI 10.1007/s00266-024-04339-w
• Shave S et al.. Pediatric Functional Rhinoplasty. Facial Plast Surg 2023. PMID 37619608. DOI 10.1055/s-0043-1772576
• Harounian J et al.. Accuracy of Surgeon Predictions in Rhinoplasty Outcomes Using Computer Imaging: A Quantitative Analysis of Dorsal Height. Facial Plast Surg Aesthet Med 2023. PMID 35506909. DOI 10.1089/fpsam.2022.0020 (title only)
• Sharma JM, Sherris DA. Commentary on: "The Use of Acellular Human Dermis as a Dorsal Camouflaging Graft in Rhinoplasty" by Melancon et al. Facial Plast Surg Aesthet Med 2023. PMID 36637870. DOI 10.1089/fpsam.2022.0266 (title only)
• House AE et al.. Consideration of Aesthetic Rhinoplasty in Children and Adolescents. Facial Plast Surg Aesthet Med 2023. PMID 36048532. DOI 10.1089/fpsam.2022.0098 (title only)
• Melancon CC et al.. The Use of Acellular Human Dermis as a Dorsal Camouflaging Graft in Rhinoplasty. Facial Plast Surg Aesthet Med 2023. PMID 36637866. DOI 10.1089/fpsam.2021.0399
• Geelan-Hansen K et al.. Use of Functional Rhinoplasty in the Aging Nose: Medicare Database Analysis. Facial Plast Surg Aesthet Med 2022. PMID 33847511. DOI 10.1089/fpsam.2020.0536
• Khetpal S et al.. Rhinoplasty in the Older Adult. Aesthet Surg J 2021. PMID 33739380. DOI 10.1093/asj/sjab140
• Li W et al.. Application of Three-Dimensional Imaging in Asian Rhinoplasty with Costal Cartilage. Aesthetic Plast Surg 2021. PMID 33432387. DOI 10.1007/s00266-020-02088-0
• Zholtikov V et al.. Rhinoplasty: A Sequential Approach to Managing the Bony Vault. Aesthet Surg J 2020. PMID 31157882. DOI 10.1093/asj/sjz158
• Persing S et al.. Three-Dimensional Imaging in Rhinoplasty: A Comparison of the Simulated versus Actual Result. Aesthetic Plast Surg 2018. PMID 29789868. DOI 10.1007/s00266-018-1151-9
• Marcus BC. The Revision Rhinoplasty Consult: The Art of Managing Expectations. Facial Plast Surg 2018. PMID 29857339. DOI 10.1055/s-0038-1655734
• Gruber RP et al.. Commentary on: Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery. Aesthet Surg J 2017. PMID 28052908. DOI 10.1093/asj/sjw206 (title only)
• Johnson MD. Management of Pediatric Nasal Surgery (Rhinoplasty). Facial Plast Surg Clin North Am 2017. PMID 28340652. DOI 10.1016/j.fsc.2016.12.006
• Toriumi DM, Rosenberger E. Rhinoplasty of the Aging Nose. Facial Plast Surg 2016. PMID 26862965. DOI 10.1055/s-0035-1570126
• Caterson SA et al.. Skin Excision as an Adjunctive Technique to Rhinoplasty in Middle-Aged and Elderly Patients. Plast Reconstr Surg Glob Open 2015. PMID 26579338. DOI 10.1097/GOX.0000000000000509
• Kosins AM, Obagi ZE. Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery. Aesthet Surg J 2017. PMID 27965218. DOI 10.1093/asj/sjw160
• Deot N, Nassif PS. Salvaging the Compromised Soft-Tissue Envelope in Revision Rhinoplasty. Facial Plast Surg Clin North Am 2026. PMID 42091325. DOI 10.1016/j.fsc.2026.01.005
• Rohrich RJ et al.. Managing Alar Flare in Rhinoplasty. Plast Reconstr Surg 2017. PMID 29068925. DOI 10.1097/PRS.0000000000003786
• Lehrman CR et al.. Digital Imaging in Secondary Rhinoplasty. Plast Reconstr Surg 2016. PMID 27219263. DOI 10.1097/01.prs.0000481836.06127.d5
• Singh P, Pearlman S. Use of Computer Imaging in Rhinoplasty: A Survey of the Practices of Facial Plastic Surgeons. Aesthetic Plast Surg 2017. PMID 28432415. DOI 10.1007/s00266-017-0858-3
• Patel A et al.. Comparing Postoperative Taping vs Customized 3D Splints for Managing Nasal Edema after Rhinoplasty. Plast Reconstr Surg Glob Open 2023. PMID 37744773. DOI 10.1097/GOX.0000000000005285
• da S Neto MP et al.. Use of the Autologous Membrane in Structured Rhinoplasty: An Alternative to Camouflaging and Filling. Plast Reconstr Surg Glob Open 2020. PMID 32983802. DOI 10.1097/GOX.0000000000003056