Rhinoplasty in the older patient

Rhinoplasty is often indicated in the older patient, either as an isolated procedure or in continuous or staged combination with other facial rejuvenative operations. The operations must be tempered with conservatism and artistic judgment. The nose of an older person should look natural and inconspicuous and fit the patient's face. Because of possible coronary or hypertensive problems, epinephrine in the local anesthetic solution should be used in lesser concentrations, requiring a longer wait for its full vasoconstrictive effect. Nasal cartilage is tougher, and the nasal bone more brittle in the older patient. In addition to the usual complete rhinoplasty, the partial rhinoplasty is a useful operation for the older individual.     

Knee arthroscopy in the older patient

With seniors living longer, more active, healthier lives, arthroscopy in the senior knee has become a commonlyperformed orthopaedic procedure., Because of the favorable risk-benefit ratio of arthroscopy when compared with more invasive procedures such as arthroplasty or osteotomy, the procedure is often offered as a temporizing measure to patients in whom it may be of only short-term benefit. Appropriate patient selection is imperative to a successful outcome. Based on currently available data, the following patient variables can be associated with favorable postoperative outcomes: normal roentgenographic limb alignment, history of mechanical symptoms, minimal or no roentgenographic signs of degeneration, short duration of symptoms, and no previous surgery. With minimal associated morbidity, it appears that arthroscopic lavage may be considered as a palliative treatment option for osteoarthritic knees; however, results deteriorate over time. Preexisting degenerative articular changes, not age, have often been reported as the most important predicting factor for the outcome following arthroscopic partial meniscectomy in the elderly. Although the results of arthroscopic partial meniscectomy are poorer in patients with significant degenerative joint disease, the results appear to be acceptable in the short term. In active seniors with mild degenerative knee arthritis, conservative arthroscopic debridement is the initial procedure of choice after a nonoperative regimen has failed. Because of its unpredictability, high failure rate, and prolonged rehabilitation phase, abrasion arthroplasty has fallen out of favor as a primary treatment for degenerative arthritis of the knee in the older, active patient.     

Suction-assisted lipectomy in the older patient

A retrospective study of 158 suction-assisted lipectomy patients ranging in age from 50 to 81 years was completed in order to determine the success of the technique in this subset of older patients. These were primarily cosmetic procedures of the trunk and extremities. The patients presented with a typical wide spectrum of systemic medical disorders as one would expect in this age group. The study revealed no mortalities and limited suboptimal aesthetic results consisting of insufficient fat removal, requiring secondary suctioning, and waviness or asymmetry. We feel that with adequate preoperative explanation and planning suction-assisted lipectomy can be a rewarding procedure in patients of all ages.     

Suction-assisted lipectomy in the older patient

A retrospective study of 158 suction-assisted lipectomy patients ranging in age from 50 to 81 years was completed in order to determine the success of the technique in this subset of older patients. These were primarily cosmetic procedures of the trunk and extremities. The patients presented with a typical wide spectrum of systemic medical disorders as one would expect in this age group. The study revealed no mortalities and limited suboptimal aesthetic results consisting of insufficient fat removal, requiring secondary suctioning, and waviness or asymmetry. We feel that with adequate preoperative explanation and planning suction-assisted lipectomy can be a rewarding procedure in patients of all ages.     

Surgical considerations in the geriatric patient

The geriatric patient has a high incidence of foot deformities and may be considered a good surgical candidate if healthy and psychologically ready for the surgical procedure. Foot problems in the geriatric population that may require surgical intervention can be grouped into approximately five categories, including (1) localized orthopedic disorders (ie, bunions, hammer toes, and so on); (2) skin and nail problems (ie, onychomycosis); (3) degenerative and inflammatory arthritis; (4) diabetic foot disorders; and (5) neuromuscular disease. However, age-related changes in cardiovascular, pulmonary, and renal function increase the risk of perioperative complications. The higher rates of complications seen in the older surgical patients result in part from existing comorbidity and age-associated changes in organ function. Extensive procedures depending on good bone healing for success should usually not be attempted on older patients. Office surgery for the geriatric patient should involve only the simplest procedures and should be kept to a minimum because of the increased possibility of postoperative complications. In the hospital there is better preoperative evaluation, operating room conditions, and postoperative care.     

Advances in analgesia in the older patient

The average age of the world's population is increasing rapidly, with those over 80 years of age the fastest growing subsection of older persons. Consequently, a higher proportion of those presenting for surgery in the future will be older, including greater numbers aged over 100 years. Management of postoperative pain in these patients can be complicated by factors such as age and disease-related changes in physiology, and disease-drug and drug-drug interactions. There are also variations in pain perception and ways in which pain should be assessed, including in patients with cognitive impairment. Alterations in pharmacokinetics and pharmacodynamics may influence drugs and techniques used for pain relief. The evidence-base for postoperative pain management in the older population remains limited. However, most commonly used analgesic regimens are suitable for older patients if adapted and titrated appropriately.     

Assessing onychial disorders in the older patient

Disorders and diseases of the toenails (onychial) in the older patient are often the focus of the primary foot complaints. They may be a result of the aging process, the end result of repetitive microtrauma or historical major trauma, a complication or related clinical change associated with a multiple system disease or condition, or a localized foot problem. This article details the symptoms of and problems associated with onychial disorders in the elderly.     

Cancer chemotherapy in the older cancer patient

This article reviews the principles of systemic cancer treatment in older individuals. These include: assessment of physiologic age with a comprehensive geriatric assessment (CGA), adjustment of chemotherapy doses to the patient's renal function, and prevention of myelotoxicity with hemopoietic growth factors. Other complications that become more common with age include mucositis, peripheral neuropathy and cardiomyopathy. Two chronic complications of chemotherapy become more common with age, including myelodysplasia and chronic cardiomyopathy. The goal of systemic cancer treatment in the older person should include prolongation of active life-expectancy and compression of morbidity in addition to prolongation of survival and symptom management.     

Safety of face-lifts in the older patient

OBJECTIVE: To compare the surgical and anesthesia complications after rhytidectomy in patients 75 years and older vs those aged 45 to 61 years. DESIGN: Retrospective review of 107 patients of a single surgeon in private practice. All patients 75 and older who underwent rhytidectomy (using deep-plane and superficial musculoaponeurotic system plication techniques) from 1998 to 2002 were selected. This cohort was compared with a randomly selected group of rhytidectomy patients aged 45 to 61 from the same period. Complications related to the procedure or anesthesia were recorded, as well as American Society of Anesthesiologists (ASA) physical class, method of procedure, and patient age. RESULTS: The mean ages of the 2 groups were 79.0 years (33 patients) and 54.2 years (74 patients). Five patients in the older cohort had minor complications after surgery, compared with 7 in the younger group (P = .52). No major complications were reported. CONCLUSIONS: Patients 75 and older carry risks of postoperative complications from face-lift procedures that are similar to those of middle-aged patients, when matched for ASA class. Preoperative counseling should emphasize patient health status rather than age when considering the risk of postoperative complications. Face-lift surgery can be safely performed in patients 75 years and older with ASA class less than 3.     

Assessing hyperkeratotic lesions in the older patient

Hyperkeratotic lesions in the older patient create pain and deformity, limit ambulation, and may predispose the patient to ulceration. These lesions have multiple etiologies, particularly in the older patient, including the normal physiological changes of aging, disease, deformity, changes in balance, shoe last incompatibilities, and inappropriate footwear. This article outlines the signs, symptoms, and management of hyperkeratonic lesions.     

Surgical correction of muscular torticollis in the older child

Thirty-three children between 6 and 16 years of age who were treated for muscular torticollis were followed up from 2 to 10.5 years after surgery. All patients had a distal open release of the sternocleidomastoid muscle. Preoperative and postoperative assessment by a rigid scoring system showed that all patients improved in terms of function as well as cosmesis. Children less than 12 years of age showed the most improvement, with 71% excellent and good results. Late release of the sternomastoid in muscular torticollis can, therefore, give acceptable results.     

Perioperative management of the older patient

With an ageing population, anaesthetists have increasing importance in taking care of the elderly undergoing surgery. Physiological changes, comorbidities, frailty and cognitive dysfunction conduce to adverse outcomes, institutionalization and mortality. This article looks into the physiological changes and anaesthetic considerations in the older patients. Preoperative assessment including use of the Comprehensive Geriatric Assessment, frailty, nutritional and cognitive assessments will be discussed. Prehabilitation can potentially modify frailty, improve outcome and reduce length of hospitalization. Preoperative nutritional therapy, where indicated, can improve nutritional status and reduce complications.Two important complications to avoid in the elderly are perioperative neurocognitive disorder (PND) and postoperative acute kidney injury (PO-AKI). PND is a predictor of poor outcome including mortality. Intraoperative electroencephalogram monitoring may help to decrease the incidence of delirium. PO-AKI is a common morbidity in elderly and its incidence can be reduced by appropriate fluid therapy and drug choice.     

Tibial plateau fractures in the older patient.

The epidemiology and management of 151 tibial plateau fractures in patients aged over 60 years of age were reviewed. There were 115 females and 36 males. The usual mode of injury was a simple fall (88 fractures, 58%). The most common pattern of injury observed was the split depression variety, which accounted for 48 (32%) cases, followed by central depression fractures, which occurred in 31 (20%) cases. Non-operative management was used in 103 (68%) of fractures, open reduction and internal fixation in 40 (26%) fractures and external fixation in 8 (5%) fractures. Functional outcome in 67 patients assessed by the Hohl plateau evaluation score was similar in all 3 groups and was more closely related to initial fracture pattern. Forty-six (68%) of these 67 patients had evidence of osteoarthritic change on follow-up radiographs, but only 2 patients in the entire series went on to have a knee replacement. Degenerative change and a mediocre functional outcome are a common occurrence following tibial plateau fractures in patients over 60 years of age.     

Mechanical bowel preparation in the older surgical patient

A major risk of colon resection is contamination from the bowel. Poor cleansing of the colon has been associated with an increased incidence of wound infections and intra-abdominal abscesses. Despite controversy on the usefulness of colon cleansing methods, mechanical bowel preparation along with oral and intravenous antibiotics have become common preoperative practice. The population is aging, and surgeons and endoscopists are going to be increasingly involved in the care of older patients. This review focuses on various colon cleansing methods and examines specific issues in older patients.