Atlas of Asian Rhinoplasty

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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Correction of Alar-Columellar
Disproportion
In the past, the alar-columellar complex has received relatively
little attention from Asian rhinoplasty surgeons. More recently,
increasing number of patients have voiced desire to correct pri-
mary alar-columellar disproportion as well as secondary dispro-
portion due to nasal tip plasty. Because of this, Asian rhinoplasty
surgeons have begun paying more attention to alar-columellar
relation, with advancements in operative technique.
According to Gunter, alar-columellar disproportions can
be quantified by comparing the long axis of the nostril with
the perpendicular alar-columellar distance. From the profile
view, the nostril has a symmetric oval shape, with the long
axis (anterior-posterior) dividing the nostril into cephalic and
caudal halves. Thus, the normal distance between the alar
rim to the long axis should be equal to the distance between
the axis and the columella rim (Fig. 13.1). Ideally, AC dis-
tance in Fig.  13.1 (columellar show) should measure
2–4  mm. Increased distance for the cephalic nostril half
(>2  mm) indicates the alar retraction, while increased
distance for the caudal nostril half distance (>2 mm) indi-
cates hanging columella. In converse, decreased cephalic
half implies hanging ala, while decreased caudal nostril half
can be an indication of retracted columella. Alar-columellar
disproportions exist in variations (Fig. 13.2).
For ideal alar-columellar relationship, all corrective pro-
cedures must be performed only upon completing the nasal
tip plasty.
13
Fig. 13.1 Alar-columellar relationship. The long axis of the nostril connects the most anterior and posterior points of the nostril. This long axis
divides the oval shape of nostril into cephalic and caudal halves. The distances between long axis and the alar rim, “AB,” and between long axis
and the columella rim, “BC,” should roughly be equal for a normal nostril shape

590
Type I: hanging columella
Type II: retracted ala
Type III: combination of I & II
Type IV: hanging ala
Type V: retracted columella
Type VI: combination of IV & V
Fig. 13.2 The Gunter classification of alar-columellar relationships. This classification most clearly describes the alar-columellar relationship in
six subtypes. Types I, II, IV, and V are primary deformities. Types III and VI refer to a combination of deformities observed in types I and II, and
types IV and V, respectively
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Retracted Ala
Retracted ala is widely recognized as a stigma of incorrectly performed rhinoplasty and is a common cause for secondary
rhinoplasty. However, primary alar retraction is not rare among patients without prior history of rhinoplasty. Retracted ala is
characterized by retracted alar rim, weak lateral crura, and excessive nostril show, and can accompany external valve
insufficiency.
Causes of Alar Retraction
Alar retraction has a wide variety of congenital and acquired causes.
Congenital
1. Hypoplasia of lower lateral cartilages
2. Cephalically positioned lateral crura of lower lateral cartilages
Normally, the lateral crura should be directed towards lateral canthus. If pointed towards the medial canthus, the lateral
crura are positioned too cephalically (Fig. 13.3). The position of lateral crura should be evaluated by tracing the lateral crura
prior to making the rhinoplasty incision. Upon making the open rhinoplasty incision and retraction of skin flap, the lateral
crura will have been retracted with the skin flap, which is observed to be cephalically rotated compared to the original
position.
Fig. 13.3 Cephalically positioned lateral crura of lower lateral cartilages
Retracted Ala

592
Fig. 13.4 Caudal
repositioning of lateral crura
Acquired
1. Inadequately performed transdomal and lateral crural spanning sutures
2. Over-resection of cephalic portion of lateral crura of lower lateral cartilages
3. Scar contracture of the scroll area or vestibular mucosa
The above three problems induce cephalic malpositioning of the lateral crura, which causes alar retraction.
4. After projection of a very low tip with multilayered cartilage onlay graft or shield graft in Asians, tight closure of the
inframarginal incision may cause pinched tip and alar retraction, because, after disproportional projection of the tip/ala
skin to the vestibular skin (too high infratip lobule compared to the nostril apex height), the inframarginal wound closure
can pull the alar rim posteriorly and cephalically and predispose to the alar retraction and pinching.
Correction of Alar Retraction
For Mild Alar Retraction
Repositioning of Lateral Crura Caudally
This technique can be used for mild alar retraction without much tissue deficiency. The lateral crus is dissected from the
underlying internal lining and detached from accessory ligament. The lateral crus is repositioned caudally (Fig. 13.4). The
repositioned lateral crus is fixated to the underlying vestibular skin with absorbable suture. This technique is fairly limited
and can often be very ineffective for small and weak lower lateral cartilage in Asian patients. The effect of this technique can
be increased by the addition of lateral crural strut graft. In addition, the technique can be useful in addressing mild alar retrac-
tion, when combined with septal extension graft and derotation graft for correction of low tip or short nose (Fig. 13.5).
13 Correction of Alar-Columellar Disproportion

593
a
b
c
d
e
f
g
h
i
j
k
l
Fig. 13.5 Correction of retracted ala by realignment of lateral crura caudally. (a–d) This female patient has a retracted ala. (e) The lateral crura
oriented in cephalic direction. (f) Left lateral crus is elevated from the underlying vestibular skin. (g) Both lateral crura are elevated from vestibular
skin and reoriented caudally. (h) Septal extension graft has been performed to project the tip, and caudally reoriented lateral crura are well main-
tained. (i–l) Postoperatively, the retracted ala has been corrected
Retracted Ala

594
Alar Rim Graft
This technique places auricular or septal cartilage graft along the alar rim. It is relatively easy to perform and is effective
(Fig. 13.6). The graft allows for about 2 mm of alar rim movement.
The alar rim graft can be placed via a closed approach through a small incision. Two incisions are made at the medial and
lateral sides of the vestibular roof. The medial incision is parallel to the graft direction along the caudal margin of the lateral
crus, while lateral incision is vertical to the direction of the graft. Through these incisions, the graft pocket is created using
a pair of iris scissors (Fig. 13.7).
For open rhinoplasty incision, the medial side incision can be used to create the pocket. The pocket should be parallel to
and made as close to the alar rim as possible.
For strengthening a weak ala, the alar rim graft does not need to be wide, with 1.8–2 mm being adequate in most cases.
For alar retraction, however, the graft should be at least 2–3 mm (Fig. 13.8). The graft length is between 10 and 15 mm. The
graft should be the widest where the alar retraction is the most severe. Once inserted within the pocket, the graft does not
need fixation suture. However, the graft end can be fixated to the neighboring soft tissue, if graft migration is a concern.
After alar rim graft, bolster suture or soft silicone sheet can be applied to compress the dead space and to stabilize the graft
within the pocket (Fig. 13.9).
Alar rim graft is effective for correction of mild alar retraction (Fig. 13.10). The technique is not as effective for retraction
in the lateral portion of the alar rim, which is addressed more effectively using extended alar rim graft (alar extension graft)
with/or without vestibular V-Y advancement.
Alar rim graft and repositioning of lateral crura can be performed simultaneously (Fig. 13.11).
Fig. 13.6 Alar rim graft
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a
b
c
d
Fig. 13.7 Alar rim graft through closed approach
Fig. 13.8 For correction of alar retraction, the graft
should be prepared to be 2–3 mm wide and
10–15 mm long
Retracted Ala

596
a
b
Fig. 13.9 Silicone sheets are used to compress the alar rim graft
a
b
c
d
Fig. 13.10 Correction of retracted ala
using alar rim graft. (a, b) This patient
with mild bilateral alar retraction
underwent alar rim graft (septal
cartilage). (c, d) Postoperative
photograph demonstrated improved
alar rim profile
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a
b
c
d
e
f
g
h
Fig. 13.11 Repositioning of lateral crura and alar rim graft for correction of retraced ala. (a–c) This patient has retraced ala on both sides. (d) The
lateral crura are cephalically positioned. (e) The alar retraction was addressed with columellar strut graft (conchal cartilage) and repositioning of
lateral crura caudally. Alar rim graft was also placed (not shown). (f–h) Postoperative photographs demonstrate improved alar retraction
Retracted Ala

598
For Moderate Alar Retraction
Alar Spreader Graft
Alar spreader graft is a spanning graft placed between the domes of lower lateral cartilages to spread out the cephalically
positioned lateral crura (Fig. 13.12).
The septal or auricular cartilage is fashioned as either a bar or a triangle shape and placed between the lower lateral car-
tilages to lateralize the lateral crura (Fig. 13.13).
Fig. 13.12 Alar spreader graft
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599
a
b
c
d
e
f
Fig. 13.13 Alar spreader
graft for correction of
retracted ala. (a, b) A
patient with moderate alar
retraction. (c) Intraoperative
photograph prior to alar
spreader graft. (d) The ala
spreader graft (conchal
cartilage) has been placed.
(e–f) The alar retraction is
improved
Retracted Ala

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Derotation Graft
Derotation graft can be a very effective technique for retracted ala with short nose. The graft can serve to push the lower
lateral cartilage caudally for tip lengthening while also serving as an alar spreader graft (Fig. 13.14). For this purpose, the
caudal half of graft is sutured to spread out the lateral crura. Fig. 13.15 shows the other example of this technique.
Derotation graft can be performed alone or combined with other techniques to correct more severe alar retractions
(Fig. 13.16).
a
b
c
d
e
f
g
h
i
j
k
Fig. 13.14 Derotation graft for the correction of retraced ala. (a–d) A patient with upturned nasal tip and retracted ala. (e) Prior to derotation graft.
(f, g) The derotation graft has pushed the lower lateral cartilage caudally and also spreads out the lateral crura. (h–k) Photograph after 3 months
13 Correction of Alar-Columellar Disproportion

601
a
b
c
d
Fig. 13.15 Derotation graft for retracted ala. (a, b) This patient with alar retraction underwent implant exchange, alar base reduction, and derota-
tion graft. (c, d) Postoperative photographs demonstrate improved alar retraction
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602
a
b
c
d
e
g
f
h
Fig. 13.16 Derotation graft and alar rim graft for moderate-to-severe alar retraction. (a–c) A patient with severe alar retraction. (d, e) The derota-
tion graft (conchal cartilage) was used to rotate the dome caudally and to spread out the lateral crura. Alar rim graft was also placed (not shown).
(f–h) Photographs after 3 months
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Lateral Crural Strut Graft
This technique can correct alar retraction by repositioning the lateral crura caudally (Fig. 13.17). This can be effective for
alar retraction due to cephalically positioned lateral crura, and is described in Chap. 9.
The preferred cartilage for this graft is the septal cartilage. Costal cartilage, auricular cartilage, and allograft cartilage can
also be used.
The lateral crura are dissected and elevated completely from the underlying nasal lining. The carved cartilage grafts are
then inserted under the lateral crura and sutured to the lateral crura above with 5-0 PDS. The graft and lateral crura are moved
caudally, and the posterior end of graft is placed in the pocket formed at the level of pyriform aperture edge.
Fig. 13.17 Lateral crural
strut graft for caudal
repositioning of lateral crura
Retracted Ala

604
For Severe Alar Retraction
Alar Extension Graft and V-Y Advancement of Vestibular Skin
This technique was first described by Kim et al. and was modified by this author and Song et al. A septal or conchal cartilage
graft is fixed to either the alar dome or the caudal margin of lateral crus (Fig. 13.18). Lateral end of this alar extension graft
can be tucked into the vestibular skin pocket for increased stability. The vestibular skin is advanced in the form of V-Y
advancement flap. This graft can be considered as a type of extended alar rim graft that is fixed to the lateral crura or alar
dome. This technique is effective even for retraction of lateral ala with tight skin.
a
b
Fig. 13.18 Alar extension
graft. (a) Alar extension graft.
(b) Alar extension graft and
V-Y advancement flap
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605
a
b
c
d
e
Fig. 13.19 Alar extension graft and V-Y advancement of vestibular skin. (a) V-Y advancement flap. (b) The flap is being elevated. (c) The pocket
is created for distal end of graft. (d) Alar extension graft is placed. Proximal end is sutured at the alar dome, and the distal end is placed in the
subcutaneous pocket. (e) The V-Y advancement flap is advanced and repaired. (f, g) Preoperative photographs. (h–i) Postoperative photographs
The technique consists of the following steps (Fig. 13.19):
1. V-Y advancement flap is created on the vestibular lining along the alar rim.
2. The anterior end of graft is fixated to the alar dome, caudal margin of the dome, or lateral crura. The posterior end of graft
is inserted into the soft-tissue pocket created within the alar rim. The posterior end should extend beyond the lateralmost
point of retraction, as much as possible.
Retracted Ala

606
f
g
h
i
FIG. 13.19 (continued)
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3. Elevated vestibular flap is advanced caudally as the V-Y pattern to lengthen the vestibular lining and facilitate alar rim
advancement. This V-Y advancement enables enough space for the extension graft and tension-free caudal advancement
of the alar rim, which permits a more stable correction.
For small and weak lower lateral cartilage, alar retraction can occur over time after an alar extension graft because of the
cephalic mobilization of the alar cartilage. Therefore, it is important to support an alar extension graft with adjunctive pro-
cedures such as derotation suture, alar spreader graft, derotation graft, or septal extension graft.
Composite Graft
If the techniques described above do not adequately stretch the soft tissue of ala rim, the composite graft should be consid-
ered, especially for significant retractions (>3 mm).
Chondrocutaneous composite graft can be harvested from three sites along the auricle (Fig. 13.20). Among the options,
the anterolateral surface of conchal fossa is the most commonly harvested. For a given recipient alar rim, the best donor site
is the cymba concha of the contralateral ear, as this will most closely match the shape and concavity of the inner surface of
alar rim. However, the graft can also be harvested from the cavum concha. The triangular fossa provides the advantage of
thin skin. Primary closure is possible if the donor defect is small. If the graft is large, the defect can be closed using full-
thickness skin graft or local flap. The skin graft can be taken from the postauricular area, and the local flap can be taken from
a postauricular island flap.
Fig. 13.20 Donor sites in the auricle for composite graft. Cymba concha, cavum concha, and triangular fossa are potential donor sites for the
composite graft
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608
Composite graft is placed between the alar rim and caudal margin of the lateral crura to help pull the rim caudally. In
closed approach, the vestibular incision is made 2 mm posterior to the alar rim (Fig. 13.21). The incision is dissected with
sharp scissors, and the alar rim is pulled caudally to create the pocket for the composite graft being inset. During the surgery,
beveled incisions are performed to increase the contact surface of the recipient site for the graft, and a bipolar electrocoagula-
tor is used to minimize the thermal damage to the tissue. Harvested graft is placed in position and sutured meticulously with
6-0 absorbable sutures (Figs. 13.22 and 13.23).
In open approach, the composite graft is sutured to the caudal margin of lateral crura on the vestibular side (Fig. 13.24).
To compensate for graft contraction, the alar retraction should be overcorrected.
External and internal splints are used for 2 days to apply light compression against the graft.
The composite graft technique can be performed in combination with other techniques.
Fig. 13.21 Composite graft
to correct alar retraction
a
b
c
Fig. 13.22 Composite graft to nasal vestibule through the closed approach
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a
b
c
Fig. 13.23 Composite graft for correction of alar retraction. (a) Preoperative photograph. (b) Composite graft was taken from cymba concha. (c)
Postoperative photograph
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a
b
c
d
e
f
g
h
i
Fig. 13.24 Derotation graft and composite graft for correction of upturned tip with alar retraction. (a–c) This patient has an upturned nasal tip
with retracted ala on the left side. (d) Columellar strut graft and derotation graft (cymba conchal cartilage) are used to rotate the tip caudally. (e–f)
Chondrocutaneous graft is harvested from the triangular fossa and grafted to the inframarginal incision on left side. (g–i) Photograph after
3 months
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Hanging Ala
Hanging ala can occasionally be caused by malpositioned lower lateral cartilage but is more commonly due to soft- tissue
excess of the alar rim. Hanging ala is more frequent on the lateral side.
Mild hanging ala can be addressed by simple excision of the internal nasal lining and subcutaneous tissues, in a long
elliptical shape (Figs. 13.25 and 13.26). The incision should not incorporate any of the external skin. However, the excision
of internal lining will most likely be insufficient for severe hanging ala or in patients with thick skin. In such cases, the alar
rim will roll inward after wound repair, which will blunt the definition of alar rim, and it would be better to excise both the
external skin and internal lining (Fig. 13.27).
One must be careful in evaluating a patient with retracted ala, for which a normal lateral alar rim can appear to be a hang-
ing ala. These are considered pseudohanging ala due to the retracted portion of medial ala, and should be managed by
addressing the real problem in the medial ala.
a
b
c
Fig. 13.25 Correction of hanging ala by elliptical excision of nasal lining and subcutaneous tissue
Hanging Ala

612
a
b
Fig. 13.27 Correction of hanging ala with thick alar skin
a
b
Fig. 13.26 Before and after correction of hanging columella
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Correction of Thick Ala
Thick ala can be accompanied by hanging ala. For correction of thick ala, an elliptical incision is performed at the thick por-
tion of caudal surface of alar rim (Fig. 13.28). The excision incorporates the skin and the subcutaneous tissue within the
nostril wall (Fig. 13.29). Subcutaneous tissue should be excised deeply and widely for better result. The wound is closed with
6-0 nonabsorbable sutures. Soft silicone sheets are applied externally and internally to compress the dead space.
a
b
c
d
e
Fig. 13.28 Correction of thick
ala. (a) A nose with thick ala. (b)
Operative design for thick ala
correction and reduction of wide
alar base. (c, d) The skin and
subcutaneous tissue are excised
within the nostril wall. (e) Wound
is repaired
a
b
Fig. 13.29 Correction of thick ala
Correction of Thick Ala

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Correction of Thin Ala
Thin ala is not a common issue among Asians (Fig. 13.30). Functionally, it can be accompanied by external valve collapse.
Thin ala can be corrected using alar rim graft or lateral crural onlay graft. Though effective for external valve collapse that
accompanies thin alar rim, these grafts are quite limited in increasing the thickness of alar rim.
Fig. 13.30 Caucasian patient with thin ala
accompanying the external valve insufficiency
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615
Correction of Columellar Deformities
Hanging Columella
Hanging columella refers to a columella that is excessively caudal in relation to the alar rim. This makes a nose appear lon-
ger, with the inner portion of columella and membranous septum visible from lateral view.
True hanging columella should be distinguished from pseudohanging columella. The columella is created by the illusion
of hanging columella from retracted alar rim or notched alar. This requires a corrective method different from that used for
true hanging columella.
It is possible for hanging columella to coexist with retracted ala (Fig. 13.31).
a
b
Fig. 13.31 Hanging columella accompanying retracted ala
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616
Anatomic Causes of Hanging Columella
Anatomic structures related to columella position are medial crura of lower lateral cartilages, membranous septum, and
caudal septal cartilage. Anatomic configurations and iatrogenic causes of hanging columella are listed below (Fig. 13.32):
1. Excessively wide membranous septum
2. Long septal cartilage hanging down caudally, with or without caudally positioned ANS
3. Wide medial crura
4. Long medial crura with exaggerated curvature
5. Iatrogenic: hanging columella due to failed rhinoplasty
Another cause of hanging columella can be caudal placement of columella strut graft or septal extension graft. Suture
techniques like medialization of lateral crura, or tip onlay/shield graft, can also create for weak and convex medial crura that
bend and displace caudally.
Fig. 13.32 Primary hanging columella can be caused by wide membranous septum, long caudal septal cartilage, wide medial crura, and long
curved medial crura
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Correction of Hanging Columella
Hanging columella is corrected based on the underlying abnormality in anatomic configurations and iatrogenic causes.
Trimming of the Caudal Septum (Causal Septal Shortening)
For a hanging columella due to long caudal septal cartilage, the caudal septum should be shortened to create room for
cephalic repositioning of the medial crura. Caudal septal shortening should be performed in a conservative manner.
The strip resection of caudal septal cartilage can be performed in the following variations. First, the whole caudal septum
is shortened to correct the hanging columella and to rotate the tip in cephalic direction (Fig. 13.33). Second, the anterior
caudal septum is shortened for cephalic rotation of the nasal tip (Fig. 13.34). Third, the posterior caudal septum is shortened
to correct posterior hanging columella without any rotation of nasal tip (Fig. 13.35).
For small correction of the long septum, a resection of 2–3 mm width can be sufficient. Larger reductions require greater
than 3 mm of reduction. The anterior nasal spine (ANS) can be removed partially using a rongeur or osteotome.
Upon caudal septal shortening, redundant membranous septum can obscure cephalic repositioning of medial crura of
lower lateral cartilages and also cause external valve narrowing. Because of this, the redundant portion of membranous sep-
tum should be redraped in the cephalic direction or resected in a strip.
Fig. 13.33 Shortening of the whole caudal septal cartilage
a
b
Fig. 13.34 Shortening of anterior caudal septum
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Fig. 13.35 Shortening of posterior caudal septum. (a–c) A patient with a hanging columella. (d) The posterior caudal septum is resected. (e)
Columellar strut graft is secured. (f) Medial crural-septal suture repositions the medial crura cephalically. (g–i) Postoperative photographs
a
b
c
d
e
f
g
h
i
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Trimming and Reshaping of the Medial Crura
At times, the excessive width of medial crura can project too much in caudal direction, which will require trimming of the
caudal margin of medial crura. However, the medial crura should not be excised such that the medial crura are weakened
(Fig. 13.36). The trimmed medial crura are sutured together, or a columella strut graft is placed if the trimmed medial crura
are too weak.
Medial crura with long exaggerated curvature (congenital C-shaped medial crura) can be corrected by trimming the cau-
dal margin of medial crura and to resect the most convex point of medial crura (Fig. 13.37).
a
b
c
d
Fig. 13.36 Trimming of medial crura
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a
b
c
Fig. 13.37 Trimming of the caudal margin of medial crura and segmental resection at the most convex point of medial crura. (a) Illustration of
the technique. (b) This patient with hanging columella underwent trimming of medial crura. (c) Postoperative photograph after the operation
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621
Cephalic Repositioning of the Medial Crura with Medial Crural-Septal Suture
The medial crural-septal suture is placed through the medial crura and the caudal margin of septal cartilage, in order to sus-
pend the medial crura or push the medial crura cephalically (Fig. 13.38).
This suture technique can be used by itself to correct hanging columella or in combination with caudal septal shortening
and/or trimming of the medial crura.
Technical details regarding medial crural-septal suture are described in Chap. 9. The suture should be performed using
nonabsorbable material. The suture technique should be performed along with columella strut graft when the medial crura
are weak. The primary prerequisite condition for this suture is the presence of a straight caudal septum. For a nose with
caudal septal deviation, the suture should be placed only after the deviated caudal septum has been corrected.
Fig. 13.38 Medial crural- septal suture
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L-Shaped Columellar Strut Graft
In lieu of medial crural-septal suture, the L-shaped columellar strut graft described in Chap. 9 can be used to correct hanging
columella. This graft is a modification of fixed type of columellar strut graft (Fig. 13.39).
L-shaped columellar strut is fixed securely to the posterior caudal septum. The long limb of graft should be placed more
cephalically than the medial crura, which is then secured to the long limb (Fig. 13.40).
However, this is a unilateral graft and can induce caudal septal deviation and graft deviation, in patients with weak caudal
septum. To prevent this, a small batten graft should be placed on the side opposite to the strut graft.
Fig. 13.39 L-shaped columellar strut graft
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623
a
b
c
d
e
f
g
h
i
Fig. 13.40 L-shaped columellar strut graft for correction of hanging columella. (a–c) This patient has a hanging columella and bulbous tip. (d, e)
The long limb of L-shaped columella strut graft is placed more cephalic to the medial crura. (f) Medial crura are repositioned cephalically and
sutured to the long limb of L-shaped columellar strut graft. Spanning suture of lateral crura and conchal cartilage onlay graft were also performed
to correct the bulbous tip. (g–i) After 4 years, the hanging columella remains corrected, with slimmer nasal tip
Correction of Columellar Deformities

624
Membranous Septum Shortening
Mild redundancy of the membranous septum can be redraped cephalically and fixated with mattress sutures. However, exces-
sive redundancy will require an excision. The mucosal shortening is performed via transfixion incision. The excess tissue is
excised in a strip, and the resulting wound is closed primarily (Fig. 13.41). The membranous septum consists of mucous
membranous portion and vestibular skin portion. Only the mucous membranous portion should be excised while preserving
the vestibular skin. If the vestibular skin is excised, the mucous membrane can become exposed, which results in a persis-
tently weeping nose.
Shortening of membranous septum should be performed as the last procedure in the correction of a hanging columella.
Most cases of hanging columella can be addressed by a combination of operative techniques mentioned above (Fig. 13.42).
a
b
c
Fig. 13.41 Shortening of membranous septum
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a
b
c
d
e
f
g
Fig. 13.42 Correction of hanging columella via a combination of techniques. (a, b) A patient with hanging columella. (c) The wide medial crura
was trimmed. (d) The posterior caudal septum was shortened. (e) Columella strut graft and medial crural-septal suture. (f–g) Two weeks after
operation
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Hanging Columella Combined with Retracted Ala
When the hanging columella coexists with retracted ala, the columella show will be very severe. Both hanging columella and
alar retraction will appear to be more severe than had each problem existed in isolation (Fig. 13.43).
The correction of hanging columella will depend on the anatomic relationship between medial crura and caudal septum,
and this is readily apparent upon exploration. However, the correction of retracted ala can vary significantly depending on
the severity of retraction, with significant variations in operative outcomes. As such, the success of a combined operation
depends largely on accurate assessment of the severity of alar retraction.
In a patient with both of these issues, it is better to address the hanging columella first, before attempting to correct the
ala. Correction of hanging columella will allow for a more objective assessment of the alar retraction, which will subse-
quently determine the operative method to be employed (Fig. 13.44).
Fig. 13.43 A patient having a hanging columella and retracted ala
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627
a
b
c
e
d
Fig. 13.44 Correction of hanging columella and retracted ala. (a, b) In this patient, the hanging columella makes the alar retraction appear worse
than it really is. (c) The hanging columella was corrected with strip resection of wide medial crura and medial crural-septal suture. The alar retrac-
tion was possible with derotation suture, which pushed the lateral crura caudally and laterally. (d, e) Six months after operation
Correction of Columellar Deformities

628
Retracted Columella
The long axis of the nostril connects the most anterior and posterior points of the nostril. This long axis divides the oval shape
of nostril into cephalic and caudal halves (Fig. 13.1). Defining the distance between long axis and the alar rim as “AB” and
that between long axis and the columella rim as “BC,” these distances should roughly be equal for a normal nostril shape.
Ideally, the distance from alar rim to columella rim (“AC,” columella show) is 2–4 mm. A columella is considered to be
retracted if the distance BC is less than 2 mm (Fig. 13.2).
Retracted columella is very common among Asians. Short and retracted columella accompanying retruded maxilla is not
only common in East Asian patients but also among Southeast Asian patients (Fig. 13.45).
Fig. 13.45 A patient with retracted columella and retruded
maxilla
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629
Causes of Retracted Columella
Causes of retracted columella can be classified as congenital and iatrogenic.
Congenital
1. Congenital deficiency of caudal septum
2. Hypoplasia of premaxilla and ANS
3. Secondary cleft lip nose deformity
Iatrogenic
1. Over-resection of caudal septum
2. Excessive resection of membranous septum
3. Excessive resection of medial crura
4. Excessively tightened medial crural-septal suture
5. Improperly performed tongue-in-groove (TIG) technique for tip plasty
6. Scar contracture from previous operation or infection
Operative Techniques of Primary Retracted Columella
Approximation of the Footplates
Medial approximation of footplates can lead to subnasale augmentation. The footplates are accessed via a minimal incision
placed through the membranous septum at the posterior border of footplates.
This technique can be used for minimal retraction of lower columella area and can be combined with columella strut graft.
Cartilage Graft in Front of Medial Crura
If the medial crura are not weak, columella projection can be performed via a cartilage graft placed between the medial crura
and columella skin. Most commonly, the auricular cartilage and septal cartilage are used (Fig. 13.46).
Upon incision just inside the columella, a pocket is created between the medial crura and columellar skin, into which the
cartilage graft is placed. The pocket should be symmetrical and located in midline. The placed graft does not require fixation.
If the medial crura are weak or the columella skin is thick, the technique is not effective, especially for severely retracted
columella.
Retracted Columella

630
a
b
c
d
e
f
g
h
Fig. 13.46 Cartilage graft in the columella. (a–c) A patient with retracted columella. (d, e) A cartilage graft is placed in the columella. (f–h)
Postoperative photographs
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631
Implant Insertion
Implant augmentation is appropriate for hypoplasia of premaxilla or anterior nasal spine (ANS). Intraoral access is created
via incision made 4–5 mm above the upper gingivobuccal sulcus. Through this access, the ANS is exposed. The implant is
inserted into the pocket and fixated to the ANS or soft tissue of caudal septum using absorbable suture.
The ideal size of implant is 3–4 mm × 10–12 mm, with a thickness less than 6 mm. In patients with thin skin and soft
tissue, thick implants should be avoided because the implant can become visible through the skin. Implants probably should
not be used in patients with asymmetric or deviated ANS or caudal septum.
After this operation, the posterior columella becomes caudally projected, with increased columellolabial angle and
cephalic rotation of nasal tip.
Columellar Strut Graft
Columellar strut graft projects the nasal tip but is also highly effective at projecting the columella. The graft is especially
effective for a nose with tip drooping and acute columellolabial angle (Fig. 13.47).
For columella projection, the strut graft is more effective when performed in combination with footplate approximation.
Columellar strut graft should be made long enough to be able to be close to the ANS. Upon closure of columellar incision,
the membranous septum can be stabilized with quilting suture to prevent posterior retraction.
Retracted Columella

632
a
b
c
e
f
d
Fig. 13.47 Columellar strut graft for correction of
retracted columella and low tip. (a–c) This patient
has a low dorsum, low tip, and retracted columella
with acute columellolabial angle. The patient
underwent dorsal augmentation (silicone implant),
tip plasty, and columellar projection with columellar
strut graft (septal cartilage). (d–f) Postoperative
photographs demonstrate a more defined dorsum,
projected tip, and columella
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633
Modified Columellar Strut Graft
To increase the effectiveness of columellar strut graft, the following modification can be applied to columellar strut graft.
Caudal Septal Batten Graft with Columellar Strut Graft
For a retracted columella with short and sunken caudal septum, cartilage graft can be fixed to the caudal septum as a bilateral
batten graft, with the columellar strut graft placed anterior to this (Fig. 13.48). Acceptable donor sources for the batten graft
are septal cartilage and conchal cartilage. It is advantageous to leave soft tissue between the batten graft and strut. Between
the batten graft and columellar strut, the membranous septum is tightened with quilting suture, to stabilize the columella
projection and minimize deviation of the strut graft onto either side of the batten graft.
This technique does not have a great columellar projection effect but provides a more mobile tip compared to septal exten-
sion graft (Fig. 13.49).
a
b
c
d
Fig. 13.48 Caudal septal batten graft plus columellar strut graft. (a) Bilateral batten grafts are placed on both sides of the posterior caudal septum.
(b–d) Columellar strut graft is placed in front of the batten graft
Retracted Columella

634
a
d
c
b
d
Fig. 13.49 Correction of retracted columella using caudal septal batten graft and columellar strut graft. (a, b) Preoperative photographs. (c, d)
Postoperative photographs
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635
L-Shaped Columellar Strut Graft
Septal cartilage is made into L-shaped columellar strut. When fixating to the caudal septum, the long limb of graft is placed
caudal to the medial crura. This graft simultaneously projects the nasal tip and the columella (Fig. 13.50).
a
b
Fig. 13.50 L-shaped columellar strut graft for columella
projection
Retracted Columella

636
Reverse Rein-Shaped Columellar Strut Graft
In this technique, mini-batten grafts are placed on both sides of the posterior caudal septum, and the columellar strut graft is
then placed between the caudal ends of the batten graft (Fig. 13.51).
Fig. 13.51 Reverse rein-shaped columellar strut
graft
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637
Septal Extension Graft
Septal extension graft is required to address severely retracted columella with short and/or deficient caudal septum.
Indications of septal extension graft for retracted columella are as follows:
1. For extreme degree of columellar retraction
2. Weak medial crura with thick skin
3. Severe scar contracture from prior rhinoplasty operation
Septal extension graft is described in Chap. 9. Most commonly used cartilage is septal cartilage, but the graft can also use
costal cartilage. The caudal portion of graft should be made to reach the ANS as much as possible, to adequately project the
columellar base (Fig. 13.52).
Retracted Columella