Thank you for the opportunity to respond to the commentary put forth by Pitak-Arnnop et al in their Letter to the Editor entitled “Aging rhinoplasty alone fails to create a youthful appearance of the lateral face, but secondary cleft rhinoplasty rejuvenates the nose,” a direct comparison and criticism of our article entitled “The efficacy of rhinoplasty alone in facial rejuvenation.”

We applaud the efforts of Pausch et al in their description of secondary cleft rhinoplasty and the beneficial effects their reconstructive rhinoplasty achieved in the appearance of the nose. Although the results in the aforementioned study demonstrate more youthful and aesthetically pleasing noses, there are important fundamental differences in the research objectives and study design between our 2 research efforts. It is these differences that best emphasize our research interest in determining the relative impact of various facial operations in rejuvenating the aging face.

Pausch et al evaluated the rejuvenating effects of rhinoplasty in 8 patients with cleft lip nasal deformity aged between 16 and 20 years (with the exception of one 48-year-old patient), whereas our investigation concerned the effects of cosmetic rhinoplasty on the aging face in 48 study patients drawn from a population (white women older than 55 years) that would typically explore options for facial rejuvenation. Pausch et al presented panelists with black and white photographs that were cropped to reveal only the nose, whereas our layperson evaluators were presented with color photographs of the lateral view of the entire face and neck. Our experimental design introduces a method of evaluating the relative importance of isolated features of the face by using computer-simulated imaging. In this study design, a single morphed feature is the only variable in the presented images, whereas the remainder of the face is held constant, thereby testing only a single variable. Our evaluators were presented with either a natural photograph or a photograph in which only the nose had been morphed with computer software, and all evaluators received the same instruction: “please estimate the patient’s age.”

Panelists in the Pausch et al study were presented with views of their patients’ noses alone. It is not surprising that their panelists determined the postoperative noses to be more attractive than the preoperative cleft lip nasal deformity state and that the estimated ages of the postoperative noses more closely approximated their patients’ young ages. An analogous study of lower eyelid deformities would be to provide panelists with photographs of ectropion patients that are cropped to reveal only the periorbital region and ask panelists both to estimate the age of the eyelids and if the preoperative state is more attractive than the postoperative result.

Whereas their efforts address the nose alone in the absence of the face, our endeavor was to understand the relative importance of nasal appearance on the aging face. We agree that the lateral view of the face may place proportionately greater emphasis on the jawline morphology; however, this is valuable information for the older patient seeking facial rejuvenation, as a cervicofacial rhytidectomy may deliver comparatively greater degrees of perceived youthfulness even in the presence of a dorsal hump and ptotic nasal tip. This knowledge assists patients and physicians in selecting operations that will maximally rejuvenate the face.

The eye of the beholder is an important component in this study, and Pausch et al rightly make note of the differences between the panel compositions in our research. Patients seeking facial rejuvenation do so for a variety of reasons; but common to all is the expectation that their appearance will, in general, be appreciated by the average layperson as more youthful. We sought to find evaluators who were representative of those laypersons a typical patient would encounter in the patient’s routine activities. We developed 2 cohorts of layperson evaluators (18-25 and 45-75 years old) to determine if age played a role in the ability to estimate age or appreciate the role of a simulated cosmetic rhinoplasty. We accept the criticism that finer degrees of description of our evaluators could improve this study, especially with regard to sex.

The field of study regarding age estimation is well developed within psychology, but is surprisingly less robustly studied among those surgeons dedicated to the art and science of facial rejuvenation. Our research efforts, and those of Pausch et al, are both early steps by surgeons seeking objective data with which to better educate our patients and guide our practice of facial rejuvenation. It is our hope that the study method we used can be enhanced by the criticisms of Pausch et al and used by other researchers to expand this field of inquiry, as we seek to provide improved counseling and superior overall results for patients seeking rejuvenation of the aging face.