Kỹ Thuật Nâng Mũi Hiện Đại: Góc Nhìn Từ Các Bậc Thầy Hàn Quốc (Man Koon Suh, 2021)

144
Fig. 28  (a–c) Preop view of 25-year-old female, Type IV
long nose. She had a weir excision for wide alar base and
silicone implantation to correct of columellar-labial angle a
year ago by a different surgeon. (d, e) lumpiness when smil-
ing (red arrow) and impending exposure of implant (black
arrow) because of inappropriate implant size and location.
(f) The procedure is as follows. Removing subcutaneous fat
and layer of nasal SMAS for bulbous tip, Dorsal augmenta-
tion with silicone implant, Dermocartilagenous tissue with
depressor septi nasi muscle rolling down to fill dead space
after removing implant, fixed strut graft with conchal carti-
lage and transdormal suture and tip up-rotation with rein
flap and shield graft for tip definition. For wide nasal dor-
sum, in-fracture of the nasal bone was performed. (g–j)
Postoperative 8 month view
a
b
c
d
S. G. Park

145
e
f
g
h
Fig. 28  (continued)
Nasal Tip Technique (3): Tip Shortening

146
and medial crus is done to elevate the subcutane-
ous fat and layer of nasal SMAS. Another method
is unrooping the thick nasal skin by dissecting it
with a layer of supra-perichondrial plan of lateral
crus and medial crus and removing fat and nasal
SMAS attached to the skin with Metzenbaum
scissor. The former method can be used to elevate
lower columellar pedicled or supra-tip pedicled
nasal SMAS flaps and dermocarilagenous with
DSN muscle flap (Fig. 29). For nasal tip circula-
tion subdermal plexus should be preserved, it
should have thick enough skin to maintain
circulation.
In most of these cases, the alar base is wide;
therefore it is better to perform alar base reduc-
tion (weir excision) simultaneously or wait after
a month if poor tip circulation is suspected. When
there is a redundant skin after redraping the tip
and columella skin, trim the redundant skin to
tighten columella (Fig. 27).
i
j
Fig. 28  (continued)
S. G. Park

147
Further Reading
Anderson JR. A reasoned approach the nasal base surgery.
Arch Otolaryngol. 1984;110:349–58.
Arregui JS, Elejalde MV, Regalado J, et  al. Dynamic
rhino-plasty for the plunging nasal tip: functional
unity of the inferior third of the nose. Plast Reconstr
Surg. 2000;106:1624–9.
Boccieri A. Mini spreader grafts: a new technique asso-
ciated with reshaping of the nasal tip. Plast Reconstr
Surg. 2005;116:1525–34.
Byrd HS, Hobar PC. Rhinoplasty: a practical guide for sur-
gical planning. Plast Reconstr Surg. 1993;91:642–54.
Cobo R.  Mestizo rhinoplasty. Facial Plast Surg.
2003;19(3):257–68.
Foda HM. Management of the droopy tip: a comparison
of three alar cartilage modifying techniques. Plast
Reconstr Surg. 2003;112:1408–17.
Gunter JP, Landecker A, Cochran CS.  Frequently used
grafts in rhinoplasty: nomenclature and analysis. Plast
Reconstr Surg. 2006;118:14–29.
Gunter JP, Rohrich RJ, Adams WP Jr. Dallas rhinoplasty.
St. Louis: Quality Medical Publishing; 2002.
Guyuron B, Behmand R. Nasal tip sutures. Part II: The
interplays. Plast Reconstr Surg. 2003;112:1130–45.
Hwang K, Kim DJ, Hwang G.  Relationship between
depressor septi nasi muscle and dermocartilagenous
ligament; anatomic study and clinical application. J
Craniofac Surg. 2006;17:286–90.
Jeong JY, Oh SH, Lee SR, et  al. Muscular system of
depressor septi nasi: anatomical study and clini-
cal application. J Korean Soc Aesthetic Plast Surg.
2009;15:49–54.
Ko BM, Kang SY, Yoo YC, et  al. Anatomical nasal tip
plasty with autogenous cartilage graft. J Korean Soc
Plast Reconstr Surg. 2002;29:17–22.
Park SG, Jeong H, Ye CH. Multifactoral approach for cor-
rection of drooping tip of ling nose in Easr Asian. Arch
Plast Surg. 2014;41(6):630–7.
Pearlman SJ. Surgical treatment of nasolabial angle in bal-
anced rhinoplasty. Facial Plast surg. 2006;22(2):28–35.
Pitanguy I, et al. The surgical importance of the dermocar-
tilaginous ligament of the nose. Plast Reconstr Surg.
1995;95(5):790–4.
Rohrich RJ, Huynh B, Muzaffar AR, et al. Importance of
the depressor septi nasi muscle in rhinoplasty: ana-
tomic study and clinical application. Plast Reconstr
Surg. 2000;105:376–83.
Suh MK. Atlas of Asian rhinoplasty. Singapore: Springer
Nature; 2018.
Tardy ME Jr. Rhinoplasty the art and the science.
Philadelpia: Saunders; 1997.
Tebbetts JB. Shaping and positioning the nasal tip with-
out structural disruption: a new, systematic approach.
Plast Reconstr Surg. 1994;94:61–77.
Tezel E, Numanoglu A. Septocolumella suture in closed
rhinoplasty. Ann Plast Surg. 2007;59:268–72.
a
b
Fig. 29  (a) Subcutaneous dissection of tip through open
rhinoplasty incision. (b) And then peeling with a layer of
supra-perichondrial plan of lateral crus and medial crus to
elevate the subcutaneous fat, layer of nasal SMAS, and
dermocartilagenous ligament with DSN muscle
Nasal Tip Technique (3): Tip Shortening

149
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. K. SUH (ed.), State of the Art Rhinoplasty Techniques,

Surgery of Columella, Alar Rim
and Alar Base
Moo Hyun Paik and Lo Shui Chu
The ideal alar columellar relationship is an essen-
tial element of the esthetic harmony in the lower
one-third of the nose. However, each factor con-
tributing to the balance of ala and columella is
closely correlated and influenced by changes
around the tip of the nose. A comprehensive eval-
uation of adjacent anatomical features and proper
choice among many correction methods is imper-
ative to obtain an appropriate alar columellar
proportion.
Hanging Columella
Anatomic Causes of Hanging
Columella
Hanging columella is a deformity with the caudal
excess of the central portion of the lower third of
the nose. The shape of the caudal margin of the
medial crura, the position of the medial crura,
and the length of the caudal septum are mainly
responsible for the anatomical status of the colu-
mella. The caudal bowing of the medial crura,
caudal malposition of the medial crura, and long
caudal septum are the common component of
hanging columella. To successfully correct the
hanging columella, it is essential to understand
each of these elements before surgery and deal
with the cause individually.
Since the condition of the columella signifi-
cantly affects the columella labial angle in pro-
file, it also should be addressed. Even in the same
tip position, the nasal tip looks more upturned in
patients with hanging columella, especially in the
columella base (Fig. 1). A comprehensive plan is
required by predicting the change in tip position
and columella labial angle to correct hanging
columella. In particular, the length of the caudal
septum or the presence of caudal septal deviation
must be inspected and palpated in preoperative
evaluation.
Other combined alar columellar disproportion
must be taken into account. In the case of hang-
ing columella combined with retracted ala, both
hanging columella and retracted ala may appear
more exaggerated, and that should be closely
observed in preoperative evaluations (Fig. 2). If
the silicone implant is extended to the nasal tip,
the medial crura can be bowed and cause hanging
columella by compressing the alar cartridge
(Fig. 3). The silicone implant should not place on
the tip, and the autogenous cartilage is used for
tip plasty accompanied by correction of hanging
columella.
M. H. Paik (*)
Department of Plastic and Reconstructive Surgery,
Ulaanbaatar Agape Christian Hospital,
Ulaanbaatar, Mongolia
L. S. Chu
Gok Saem Aesthetic Plastic Surgery Clinic,
Seoul, South Korea

150
a
b
Fig. 1  (a) Even in the same tip position, the nasal tip looks more upturned in patients with hanging columella, espe-
cially in the columella base. (b) After correction of hanging columella
Correction of Hanging Columella
The hanging columella is corrected by reducing
the caudal excess at the center of the lower one-­
third of the nose, including cephalic reposition of
medial crura, reduction of the caudal septum, and
caudal trimming of medial crura.
Columellar Septal Suture
This is a suture between the caudal septum and
the columellar complex for the cephalic reposi-
tion of medical crura to deal with the hanging
columella. The caudal margin of the septum is
exposed and identified, separating the medial
crura for the passage of the suture needle
(Fig. 4a). If the caudal septal resection or devia-
tion correction is indicated, it must be addressed
before the suture placement. Generally, tip aug-
mentation is often necessary for East Asian popu-
lations. My preference is to use a columellar strut
for tip support or projection.
Before the columellar strut and medical crura
fixation, a 5-0 Nylon suture is passed through the
selected point of the caudal septum and tempo-
rarily tape to both cheeks to prevent interference
with the remaining surgical procedures (Fig. 4b).
The tightening of the suture is performed after
the fixation between the columellar strut and
medial crura (Fig. 4c, d). An appropriate amount
of tightening of the columellar septal suture may
vary depending on the multiple grafts or sutures
on the nasal tip. One of the noticeable advantages
of this maneuver is to correct the hanging colu-
mella incrementally at the end of the surgery just
before wound closure. If the need for columellar
septal suture is not sure, it can be placed and
taped temporarily and removed promptly at the
end of the operation if it is not necessary.
M. H. Paik and L. S. Chu

151
Even if the columellar strut is not used, it can
be used as a medial crural septal suture that
passes through the cephalic margin of the medial
crura and caudal septum in the same manner. As
an additional benefit, this suture also supports the
tip and corrects the tip drooping depending on the
suture point at the caudal septum (Fig. 5). When
moving the columellar complex to cephalad with
the columellar septal suture, usually one suture is
sufficient, but more than one suture is required
based on the deformity.
After columellar septal suture, redundant tis-
sue from the membranous septum may be
bunched behind the medial crura. In most cases,
redraping of the redundancy with an extensive
dissection of the septal area and using through-­
and-­through mattress sutures are sufficient. In
East Asians, resection of the redundant membra-
nous septum and nasal mucosa is rarely
indicated.
Caudal Septal Reduction
In managing the hanging columella, it is crucial
to evaluate the caudal septum condition before
surgery. Although the hanging columella caused
by long caudal septum is improved only with
caudal septal trimming, it is difficult to finely
control the amount of cephalic reposition of the
medial crura due to the influence of membranous
septum, and the columellar septal suture is mainly
used for precise adjustment. If the extent of
cephalic reposition of the columella is limited by
excess caudal septal length, the septal reduction
is required before columellar septal suture.
By minimizing the reduction of the excess
caudal septum, the medial crura or the columellar
strut can be directly fixed to the septum end to
end, and the tongue in groove technique can be
applied to overlap the medial crura and the sep-
tum. However, it has the drawback of creating a
fixed nasal tip inevitably. As previously men-
tioned in chapter “Nasal Tip Techniques (1): Tip
Augmentation Techniques”, we try to maintain
the mobility of the tip of the nose as much as pos-
sible in the tip plasty. Even though there is enough
space for the columella to move in cephalad to
control the hanging columella, the loss of unique
function of the membranous septum leads to dis-
comfort with a fixed nasal tip or click during ani-
mation. To maintain the gap between columella
and septum for preserving the function of the
membranous septum, the additional resection of
the caudal septum is done even the distance is
enough for columella to be repositioned. When
the caudal septal deviation exists, columellar sep-
tal suture causes columellar deviation, tip devia-
tion, and nostril asymmetry. The length of the
caudal septum and the presence of the deviation
of the caudal septum must be addressed before
columellar septal suture placement to achieve
good results (Fig. 6).
If the intrinsic tortuosity and deviation of the
caudal septum cannot be completely corrected,
the suture point of the septum should be located
Fig. 2  In hanging columella combined with retracted ala,
both hanging columella and retracted ala may appear
more exaggerated
Surgery of Columella, Alar Rim and Alar Base

152
a
b
c
Fig. 3  (a) If the silicone implant is extended to the nasal tip, the medial crura can be bowed and cause hanging colu-
mella by compressing the alar cartridge. Before (b) and after (c) the correction of hanging columella
M. H. Paik and L. S. Chu

153
in the midline. Some papers also mentioned
reductions of the anterior nasal spine, but since
the overdevelopment of ANS in East Asians is
not common, it is infrequent where the reduction
of the ANS is required.
Caudal Margin Trimming of Medial
Crura
The trimming of bowing or excess of the most
caudal aspect of the medial crura must be treated
carefully on account of frequently weak and nar-
row medial crura (Fig. 7). Excessive trimming of
medial crura causes narrowing and weakening of
medial crura and difficulty stabilizing the colu-
mellar strut, resulting in columnar deviation and
inadequate tip projection. If the medial crura are
narrow and bowed, rather than reducing the cau-
dal margin of the medial crura, it is desirable to
use the columellar septal suture to move the
entire columellar unit in a cephalic direction,
and the insufficient columellar base is aug-
mented by using a columellar strut or an addi-
tional graft (Fig. 8). Since caudal protrusion of
medial crura is often improved or changed
in location and amount by columella strut or sep-
tal extension graft for tip projection, caudal
excess should not be excised in advance.
However, it must be trimmed incrementally and
minimally after tip projection procedures for
more accurate results.
Latrogenic Hanging Columella
Due to numerous projection and lengthening pro-
cedures applied on the tip or septum, the preop-
erative normal alar columellar proportion may be
deformed, leading to a hanging columella.
a
b
c
d
Fig. 4  (a–d) Intraoperative views of columellar septal suture
Surgery of Columella, Alar Rim and Alar Base

154
a
b
c
d
Fig. 5  Columellar septal suture for managing tip drooping. Before (a) and after (b) the suture. (c, d) Intraoperative view
M. H. Paik and L. S. Chu

155
Fig. 6  A patient presents with hanging columella.
Preoperative (a, c, e, g) and postoperative (b, d, f, h)
views. (i, j) Caudal septal reduction. (k, l) Septal devia-
tion correction. (m, n) Tip plasty using columellar strut,
derotation graft, and columellar septal suture
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base

156
e
g
h
f
Fig. 6  (continued)
M. H. Paik and L. S. Chu

157
i
j
k
l
Fig. 6  (continued)
Surgery of Columella, Alar Rim and Alar Base

158
The columellar strut, septal extension graft,
manipulation of the septum can all induce caudal
malposition of columella by pushdown of the
columella and release of the membranous sep-
tum, causing, or worsening the hanging colu-
mella (Fig. 9).
To prevent postoperative hanging columella, it
is imperative to predict the position change of the
columella by each procedure, performing antici-
patory caudal septal reduction or columellar sep-
tal suture, which can be tied or removed at the
final adjustment of the surgery as necessary.
If the silicone implant is extended to the nasal
tip, the medial crura can be bowed and cause
hanging columella by compressing the alar car-
tridge. The silicone implant should not place on
the tip, and the autogenous cartilage is used for
tip plasty accompanied by correction of hanging
columella (Fig. 10).
Retracted Columella
Anatomic Causes of Retracted
Columella
The retracted columella is relatively common in
East Asians with weak nasal septum and alar car-
tilage development. The recent incidence and
severity of iatrogenic occurrence after cosmetic
rhinoplasty are increasing. The essential compo-
nents of retracted columella are medial crura,
caudal septum, and membranous septum. The
medial crura need to be moved caudally, and if
the length of the caudal septum is short, it needs
to be extended. The release of the membranous
septum and central nasal mucosa, which is the
critical element in the correction of the retracted
columella, is crucial for the caudal reposition of
the columella. The fundamental concepts and
m
n
Fig. 6  (continued)
M. H. Paik and L. S. Chu

159
Fig. 7  A patient with hanging columella corrected with
caudal margin trimming of medial crura. Before (a, c, e,
g) and after (b, d, f, h) the surgery. Before(i, k) and after
(j, l) caudal margin trimming of medial crura. Caudal sep-
tal reduction, columellar septal suture were also used to
treat hanging columella. (m) Augmentation was per-
formed using several tip grafts and a silicone implant on
the dorsum
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base

160
e
f
g
h
Fig. 7  (continued)
M. H. Paik and L. S. Chu

161
i
j
k
l
Fig. 7  (continued)
Surgery of Columella, Alar Rim and Alar Base

162
surgical procedures are almost identical to those
in short nose correction, such as columellar strut,
derotation graft, and various septal extension
grafts to fix the released columella in a new cau-
dal position.
Correction of Retracted Columella
Caudal Reposition of Medical Crura
The essence of retracted columella correction is
the caudal reposition of the medial crura, for
which the extensibility of the membranous sep-
tum is crucial. No matter how strong the grafts
method and materials are used, it is impossible to
extend the retruded columella beyond the amount
of expandability of the soft tissue envelope,
including the membranous septum and nasal
mucosa. Therefore, it should be noted that the
extent of soft tissue expansion is the limit of
retracted columellar that can be corrected in gen-
eral cosmetic rhinoplasty. Adding a visible graft
on the columella may help to some extent.
However, the caudal protrusion amount is quite
limited due to less redundant soft tissue envelop
around infratip lobule and columella in East
Asians.
In primary cases, it is possible to estimate
approximately how long the columella can be
extended by pulling the columella caudally dur-
ing preoperative evaluation due to the well-­
preserved extensibility of soft tissue without
tethering. In contrast, it is often unable to predict
in secondary cases because of several previously
m
Fig. 7  (continued)
Fig. 8  A
cartilage
graft
for
columellar
base
augmentation
M. H. Paik and L. S. Chu

163
Fig. 9  (a, c, e, g) A secondary case of hanging columella
due to previously used columellar strut. (b, d, f, h) After
the correction. (i, j, k) Silicone implant and columellar
strut were removed. (l) Caudal septal reduction. (m, n)
Septal deviation correction. (o) A new columellar strut
and columellar septal suture
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base

164
e
f
g
h
Fig. 9  (continued)
M. H. Paik and L. S. Chu

165
i
j
k
l
Fig. 9  (continued)
Surgery of Columella, Alar Rim and Alar Base

166
m
n
o
Fig. 9  (continued)
M. H. Paik and L. S. Chu

167
Fig. 10  A case of hanging columella caused by a silicone
implant on the nasal tip. Preoperative (a, c, e, g) and post-
operative (b, d, f, h) views. (g, h) After silicone implant
removal, tip plasty was performed using autogenous
grafts with a columellar septal suture
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base

168
g
h
e
f
Fig. 10  (continued)
M. H. Paik and L. S. Chu

169
used grafts and scar adhesions. Meticulous sharp
dissection is performed, separating the medial
crura and membranous septum while pulling the
medial crura caudally. More extension can be
obtained with extensive dissection of the septal
region. Because perichondrium is less stretchable
than bare skin and mucosa, it is beneficial not to
include the perichondrium in the elevated flap for
the maximal extension, but more bleeding should
be considered. For adequate caudal shifting of
the entire alar cartilage, including the medial
crura, the release of the scroll area between the
alar cartilage and the upper lateral cartilage is
often necessary to correct retracted columella
effectively (Fig. 11).
In secondary cases, elevated flap, including
alar cartilage, is detached from surrounding
inelastic scar tissue and perichondrium (Fig. 12).
Dissection extended to the deep septal area, and
the underlying surface of the upper lateral carti-
lage is required for more release. Caution should
be taken not to perforate the inner lining with
meticulous sharp dissection, and repositioned
columella is fixed with cartilage graft or sutures
as needed.
Septal Extension Graft
Despite the drawback of creating a rigid nasal tip
obliterating the membranous septum, septal
extension graft is the most straightforward, effec-
tive, and most commonly used method for
retracted columella correction. Various septal
extension graft is used to fix caudal repositioned
alar cartilage, and tip projection can be obtained
simultaneously.
Columellar Strut with Derotation Graft
This technique is my preferred method in
retracted columella correction with the benefit of
preserving the function of the membranous sep-
tum as much as possible to maintain the mobility
of the nasal tip using elastic ear cartilage.
Recently, many surgeons are trying to preserve
tip mobility as much as possible by adjusting the
size and shape of the septal extension graft.
However, septal extension is basically a vertical
typed graft in the left and right mobility in the
horizontal direction can be maintained to some
extent, whereas the mobility in the cephalocaudal
direction is inevitably limited. On the other hand,
the use of columnar strut and derotation graft has
a
b
Fig. 11  Before (a) and after (b) alar cartilage release
Surgery of Columella, Alar Rim and Alar Base

170
the advantage of being significantly less restric-
tive in mobility in both vertical and horizontal
directions.
A successful result using columella strut and
derotation graft depends on how much tension-­
free release of the columella is performed suffi-
ciently
to
achieve
good
results
without
obliteration of the membranous septum like sep-
tal extension graft (Fig. 13). The basic concept of
the techniques required for caudal extension in
the short nose or retracted columella is based on
whether the soft tissue envelope and inner lining
are stretched without tension rather than large
and solid grafts.
The columellar strut is used for integrating
with the medial crura as one complex unit,
retracted columella correction, tip projection, and
cephalic rotation of the nasal tip. The deeper
pocket for the columellar strut is more effective
for retracted columellar base correction. When
the footplate of the medial crura is flared, gather-
ing the footplate around the columellar strut also
contributes to correct the retracted columellar
base.
The derotation graft is used to support and
reposition the released mobile columella while
bridging the gap between the mobile unit and fixed
unit, which is septum and upper lateral cartilage
(Fig. 14). Sometimes, when the lateral crura are
well developed with enough caudal septal length,
good results can be achieved by gathering both lat-
eral crus with lateral crural spanning suture or tip
extension suture without derotation graft.
Septal Extension with Derotation Graft
If the length of the caudal septum is too short,
retracted
columella
cannot
be
effectively
­corrected with only the columellar strut and the
derotation graft alone, in which case the length of
the short caudal septum must be extended with
various septal extension grafts and extended
spreader grafts.
a
b
Fig. 12  (a) Skin flap elevation. (b) Scar flap elevation
M. H. Paik and L. S. Chu

171
Fig. 13  A case of the retracted columella. Preoperative
(a, c, e) and postoperative (b, d, f) views. (g) Removal of
irradiated homologous costal cartilage used in the previ-
ous operation. (h, i) Alar cartilage release. (j, k) columel-
lar strut with double-layered derotation graft
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base

172
g
h
e
f
Fig. 13  (continued)
M. H. Paik and L. S. Chu

173
i
j
k
Fig. 13  (continued)
Surgery of Columella, Alar Rim and Alar Base

174
Fig. 14  A patient presents with the retracted columella,
retracted ala, and wide alar base. Preoperative (a, c, e, g, i)
and postoperative (b, d, f, h, j) views. (k) Silicone implant
removal with total capsulectomy. (l) Retracted columella
and ala were corrected using a derotation graft and colu-
mellar strut. (m) Dorsal augmentation with dermofat graft.
(n) The alar base reduction was performed because the
elongation of the nasal tip aggravates the wide alar base
a
b
c
d
M. H. Paik and L. S. Chu

175
g
h
e
f
Fig. 14  (continued)
Surgery of Columella, Alar Rim and Alar Base

176
i
j
k
l
Fig. 14  (continued)
M. H. Paik and L. S. Chu

177
Try to avoid rigid nasal tip caused by direct
fixation of the fixed unit with mobile alar carti-
lage, and septal extension graft is merely used for
elongation of the short caudal septum. Using
columellar strut and derotation graft on the
extended septum corrects retracted columellar to
make the tip of the nose as less rigid as possible
(Fig. 15).
In patients with retracted columella who
underwent septal extension graft in previous sur-
gery, alar cartilage is released from the extended
septum for caudal reposition and fixed with a
columellar strut and derotation graft. The man-
agement of the previous septal extension graft
also varies depending on each situation. If the
previous septal extension graft is not needed or
redundant for the retracted columella correction,
it is removed or reduced to maximize the mobil-
ity of the nasal tip. When the remaining septum
after removal or reduction becomes too weak,
leave it intact without manipulation.
Despite the need for a large amount of septal
cartilage in East Asians with small and weak
septal cartilage often combined with the
retracted columella, it is hard to harvest enough
septum. Excessive harvesting of septal cartilage
may cause iatrogenic septal deviation and sad-
dle nose, whereas an insufficient amount of sep-
tal cartilage is not enough for proper correction
of retracted columella or other procedures for
tip plasty. This shortage of septal cartilage is
one of the causes of the recent increased rib car-
tilage use, even in primary tip cases of East
Asian tip plasty.
The combination of septal extension and dero-
tation graft is a good alternative for patients with
insufficient septal cartilage, using a septal exten-
sion to elongate the short caudal septum and
using derotation graft and columella strut with
ear cartilage for correction of residual deformity.
Rib Cartilage Graft
Tip plasty with rib cartilage graft should be
avoided as much as possible because the patients
have to live with the stiff nasal tip for the rest of
their life. Nevertheless, recently the use of rib
cartilages has been increasing due to the elevated
incidence of iatrogenic saddle nose and unavail-
m
n
Fig. 14  (continued)
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Fig. 15  A case of retracted columella corrected using a
septal extension graft combined with the derotation graft.
Preoperative (a, c, e, g) and postoperative (b, d, f, h)
views. (i) Intraoperative view of short caudal septum.
Septal cartilage is not available because already harvested
in the previous operation. (j) A septal extension graft
using ear cartilage (k) derotation graft
a
b
c
d
M. H. Paik and L. S. Chu

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g
h
e
f
Fig. 15  (continued)
Surgery of Columella, Alar Rim and Alar Base

180
i
j
k
Fig. 15  (continued)
M. H. Paik and L. S. Chu

181
able ears and septum cartilage after several
operations.
The causes of the increase in the iatrogenic
saddle nose are excessive septal harvesting, reck-
less use of many alloplastic materials such as
Medpore and absorbable mesh plate, and inap-
propriate coping with the postoperative inflam-
matory reaction. In cases with a shortage of septal
and ear cartilage or severe saddle nose deformity,
septal reconstruction with autologous rib carti-
lage is inevitable even with available ear cartilage
(Fig. 16).
Retracted Ala
Anatomic Causes of Retracted Ala
Retracted ala is a relatively common deformity
that is significantly more challenging than other
alar columellar disproportions and requires con-
sideration of many factors in the lower third of
the nose. Until now, the classification of the alar
columellar relationship in the lateral view estab-
lished by Gunter is most commonly used, but
sometimes it is difficult to apply in clinical analy-
sis, especially with retracted ala.
Most of the patients with retracted ala are dis-
satisfied with the amount and shape of the nostril
shown in the front view rather than in the profile.
The lateral view diagnosis does not always cor-
relate with the features of frontal appearance that
the retracted ala in frontal view often shows a
normal alar columellar relationship in lateral
view (Fig. 17). Even in some cases, it is impos-
sible to draw the nostril axis for assessment due
to the invisible nostril in the profile (Fig.  18).
Although there are many references and classifi-
cations that emphasize the importance of the
front view, the configuration of “wings of a
seagull in gentle flight” is clearly one of the most
reliable features yet.
These various diagnosis and classification
methods in the alar columellar relationship have
their limitations and drawbacks but cannot be
overlooked as a reference.
Eventually, retracted ala can be described as
an excessive nostril show on the frontal view, and
the main purpose of surgery is to reduce the
amount and change the shape of frontal too much
nostril show. The nostril show seen from the front
is greatly affected by various surrounding factors
and must be appropriately analyzed in preopera-
tive planning. Factors that can influence the fron-
tal nostril exposure include the location and
shape of the alar rim, the columellar labial angle,
the retracted or hanging columella, and the nasal
tip length. The relevant deformity adjacent to the
alar rim must be recognized and addressed.
The correction of the retracted ala is the exten-
sion of both lateral portions of the columella,
resulting in the caudal reposition of the alar rim.
The upturned nose with obtuse columellar labial
angle worsens the frontal nostril show and
retracted ala. When the upturned nose is length-
ened, the retracted ala is also improved by shift-
ing the alar rim caudally. When combined with
hanging columella, retracted ala looks more
aggravated and will be somewhat improved
merely by correction of the hanging columella. If
retracted columella is accompanied, retracted ala
appears to be less severe, so that the more correc-
tion amount of alar rim is necessary than it looks
when the retracted columella is normalized.
Correction of Retracted Ala
The techniques used for retracted ala correction
are classified into two types according to whether
or not the position of the alar cartilage caudal
margin is moved caudally. And these techniques
often tend to make the tip of the nose more bul-
bous and should be noted, especially when the
retraction is located in a more lateral side of the
nostril (Fig. 19).
Methods with Caudal Reposition
of Lateral Crura
In most cases of retracted ala, techniques using
graft on the cephalic side of the lateral crura after
caudal reposition of lateral crura is the most pre-
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182
Fig. 16  A patient presents with severely retracted colu-
mella due to postoperative infection caused by Medpore
implant on the septum. Preoperative (a, c, e, g, i) and post-
operative (b, d, f, h, j) views. (k) Rib cartilage was used
to reconstruct saddle nose deformity
a
b
c
d
M. H. Paik and L. S. Chu

183
e
f
g
h
Fig. 16  (continued)
Surgery of Columella, Alar Rim and Alar Base

184
i
j
k
Fig. 16  (continued)
M. H. Paik and L. S. Chu

185
ferred method. The main purpose of retracted ala
correction is to reduce the nostril exposure on the
frontal view with the caudal reposition of the alar
rim.
The basic principle of caudal expansion in the
nose for retracted ala correction is extending the
outer skin, inner lining and maintaining this
extended envelope with a graft, as in a short nose
or retracted columella. Each of these three com-
ponents is necessary to achieve satisfactory
results in retracted ala correction. The outer skin
extension is identical to that of the short nose cor-
rection, and a typical supraperichondrial flap
elevation is performed in primary cases.
In secondary cases, the skin elevation is per-
formed above previous scar tissue for maximal
expansion (Fig. 20). Inner lining expansion for
caudal reposition of lateral crura is the most
important step in retracted ala correction
(Fig. 21). Incomplete release of lateral crura from
upper lateral cartilage for vestibular skin expan-
sion is a common cause of unfavorable results,
increasing the demand for composite graft. The
lateral crura and the stretchable vestibular inner
lining are detached from inelastic scar tissue with
meticulous sharp dissection in secondary cases
for tension-free release. To obtain more release,
further dissection can be extended to the under-
surface of the upper lateral cartilage. If the selec-
tive release of the lateral crura is limited, the
dissection is extended to the septal region for the
entire release of alar cartilage, and the correction
procedures of hanging columella are required to
compensate for the consequently excessive colu-
mella show.
Derotation graft, alar spreader typed derota-
tion graft, and intercartilaginous graft is used for
support and fixation of caudally repositioned lat-
eral crura. In particular, the horizontal width,
shape, and size of the graft are critical in correct-
ing retracted ala. A large and wide graft is indi-
cated in cases of weak and narrow lateral crura,
a
b
Fig. 17  A patient with retracted ala in frontal view (a) shows a normal alar columellar relationship in lateral view (b)
Surgery of Columella, Alar Rim and Alar Base

186
excessive cephalic trimming in the previous
operation, severe, and laterally located retracted
ala. In comparison with many grafts directly on
the alar rim, the use of grafts on the cephalic side
of the lateral crura after release is often more pre-
cisely adjustable, wider in range of correction,
and more robust in the long term. The intercarti-
laginous graft has the advantage of selectively
pushing the lateral crus with less hanging colu-
mella induction, but the support is relatively
weak due to soft and thin upper lateral cartilage
and lateral region of lateral crura (Fig. 22). On
the other hand, the derotation graft in the form of
an alar spreader graft has the benefit of being able
to support the lateral crura more strongly because
it is fixed to the septum, which is a solid foothold
(Fig.  23). In retracted ala caused by the weak
support of the lateral crura, it can be corrected
only by derotation graft adjusting the graft width,
which is somewhat similar to the effect of the lat-
eral crural only graft and alar batten only graft
(Fig. 24). Even in secondary cases with scar con-
tracture around the alar rim, good results can be
obtained without composite graft in most cases
due to complete release through extensive and
sufficient dissection for caudal reposition of lat-
eral crura (Fig. 25). Septal extension graft is a
centrally oriented method restricted in supporting
and controlling pushdown of the lateral crura,
often in need of adjunctive procedures including
alar spreader graft or derotation graft.
Methods Without Caudal Reposition
of Lateral Crura
The graft directly on the alar rim without caudal
reposition of lateral crura such as alar rim graft,
alar contour graft, alar extension graft, and the
inner lining extension procedures like vestibular
skin undermining, V-Y advancement have vary-
ing effects in retracted ala case by case depend-
ing on the extensibility of the patient's soft tissue
envelope around the alar rim. It is often difficult
a
b
Fig. 18  (a, b) In this patient, it is impossible to draw the nostril axis due to the invisible nostril in the profile
M. H. Paik and L. S. Chu

187
Fig. 19  When the retracted ala is located in a more lateral side of the nostril, it tends to make the tip of the nose more
bulbous. Before (a, c, e) and after (b, d, f) the surgery
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base

188
to predict the outcome (Fig.  26). Among the
methods without caudal reposition of lateral
crura, the composite graft is the most reliable
choice for expanding the vestibular inner lining.
However, the composite graft may also have
problems such as a visible scar or graft bulging
on the vestibule, graft failure, and possible
shrinkage in the long term.
In correction of the retracted ala, it is desirable
to mainly use the graft on the cephalic portion of
the lateral crura after release for caudal reposi-
tion. The grafts on alar rim caudal to lateral crura,
including composite graft, are used as adjuvant
procedures (Fig. 22).
Latrogenic Retracted Ala
The main purpose of the East Asian tip plasty is
tip projection and tip narrowing. However, the
incidence of the iatrogenic retracted ala is also
increasing due to the development of various
techniques for tip projection and narrowing.
For tip projection, the method of elongating
the columella is often applied by using either a
columella strut or a septal extension graft.
Excessive greed for projection unconsciously
results in a lateral crural steal converting the hori-
zontal component, lateral crura, into medial
crura, the vertical element for tip projection
(Fig. 27). The pivot point from the middle to lat-
eral crura is shifted to the cephalic, and the cau-
dal margin of the lateral crura moves toward the
cephalomedial, causing retracted ala. The typical
clinical manifestations of retracted ala due to lat-
eral crural steal are excessively long columella
and elongated nostril (Fig. 28).
As to tip narrowing, Interdomal suture and lat-
eral crural spanning suture are most commonly
used, and the distance between the middle or lat-
eral crura becomes narrower. Consequently, these
sutures move the caudal margin of lateral crura in
a cephalomedial direction retracting the nostril,
causing retracted ala when it is overtightened,
e
f
Fig. 19  (continued)
M. H. Paik and L. S. Chu

189
especially with cephalic trimming of lateral crura
(Fig. 29).
The iatrogenic retracted ala resulting from
over-projection and over-narrowing is often
accompanied by a narrow, pinched tip. The
retracted ala derived from lateral crural steal can
be corrected by medial crural steal moving the
caudal margin of the lateral crura in a caudal and
lateral direction. In this way, the excessively long
columella is shortened, and over elongated nos-
trils turn into a more natural round shape
(Fig. 24). The reduced tip height after medial cru-
ral steal can be compensated by an additional
Onlay graft on the nasal tip. In the management
of the retracted ala due to excessive narrowing,
the alar spreader graft or alar spreader type of
derotation graft is an excellent solution, widening
the gap between both middle and later crura
(Fig. 30). After those procedures for correcting
iatrogenic retracted ala, the accompanying nar-
row and pinched tip deformity is recovered con-
sequently. During surgery, the distance between
the caudal margin of the lateral crura and the
columella is an important indicator (Fig. 31).
To prevent the postoperative retraction of the
ala rim, care should be taken not to steal the lat-
eral crura during tip projection, and a supplemen-
tary Onlay graft should be used for insufficient
tip height. Also, cephalic margin trimming of the
lateral crura should always be performed conser-
vatively (Fig. 32). In East Asians, since the bul-
bous tip is often soft tissue dominant rather than
cartilage dominant, excessive use and over-­
tightening of the tip narrowing suture should be
applied with caution considering the soft tissue
manipulation.
In addition to the reasons mentioned above, a
variety of postoperative complications, including
acute or chronic infection and inflammation,
improper use of alloplastic material, can lead to
damage, scar contracture, and reposition of alar
rim, causing iatrogenic retracted ala (Fig. 33).
a
b
Fig. 20  (a, b) Skin flap elevation for expansion
Surgery of Columella, Alar Rim and Alar Base

190
a
b
c
Fig. 21  (a, b) Alar cartilage release for retracted ala correction. (c) Inferior and lateral reposition of lateral crura is
important for retracted ala correction
M. H. Paik and L. S. Chu

191
Fig. 22  The intercartilaginous graft for retraced ala correction. Before (a, c, e) and after (b, d, f) the surgery. (g)
Intercartilaginous graft. (h) Alar rim graft as adjuvant procedure
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base

192
e
f
g
h
Fig. 22  (continued)
M. H. Paik and L. S. Chu

193
Fig. 23  A case of retracted ala corrected with alar
spreader typed derotation graft. Preoperative (a, c, e, g)
and postoperative (b, d, f, h) views. (i) Removal of sili-
cone implant. (j) Removal of irradiated homologous cos-
tal cartilage. (k) Alar spreader type derotation graft. (l)
Additional derotation graft. (m) Dorsal augmentation and
tip skin reinforcement using dermofat graft
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base