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The Hanging Columella

Often in revision rhinoplasty, there can be alar-columellar disproportion that persists or was created by the original surgeon. It is of paramount importance to distinguish the etiology of the disproportion. In this section, we will discuss management of the hanging columella, describe the normal anatomy of the alar-columellar relationship, illustrate how to distinguish a hanging columella from a retracted ala or pseudo hanging columella, and describe how maneuvers in primary rhinoplasty can alter the normal alar-columellar relationship.

Pertinent anatomy and etiology

Classic descriptions in texts describe the normal alar-columellar relationship as being between 2mm and 4mm of visible columella below the alar margin on profile view. This definition fails to describe the appropriate position of the alar margin as it pertains to the alar-columellar relationship. A retracted ala can give the appearance of a hanging columella and must therefore be differentiated from it because they are managed differently. Excessive nostril show with a droopy tip, short upper lip, a long lateral crus, and a strong lateral crus with no apparent notching is suggestive of a hanging columella. In contradistinction, the presence of alar notching, weak or deficient lateral crura, retraction of the alar margin, or an alar margin with excessive curvature are suggestive of alar retraction or a pseudo hanging columella.

A hanging columella can be pre-existing and go unrecognized by the previous surgeon or it can be a result of previous surgery. In the evaluation of a hanging columella, the important anatomic structures to consider are the caudal cartilaginous septum, the membranous septum, and medial and intermediate crus. Anatomic deformities that make up the hanging columella deformity include an excessively long caudal cartilaginous septum, a redundant membranous septum, and a wide, curved, convex or vertically oriented medial/ intermediate crura. Other causes include a the long medial crus with bowing or a C-shaped curvature, or a broad vestibular vault and medial crural ptosis. Other causes particular to previous rhinoplasty include a columellar strut or a caudal septal extension graft that protrudes caudally. Suturing biphid medial crura can make the columella more prominent. Also, a shield graft that is too thick or excessive plumping grafts can also contribute to the hanging columella. The loss of tip projection and rotation from previous rhinoplasty can also result in relative excessive columellar show.

Surgical evaluation and management

Management of the hanging columella, like most maneuvers in rhinoplasty, is based upon identifying the etiology. For the excessive cartilaginous caudal septum or redundant membranous septum, it is typically excised via a transfixion incision. This can be achieved entirely via an endonasal approach. If increased rotation is desired, a triangular wedge of caudal septum is removed with the base of the triangle oriented dorsally. If counter rotation is desired, the base of the triangle is oriented toward the nasal spine. If no rotation is desired, a straight piece is removed. As always, at least 1 to 1.5 cm of caudal septum is preserved to maintain tip support.

When excising membranous septum, an ellipse of membranous septum is removed with the widest portion of the ellipse being positioned over the area of greatest columellar protrusion. The transfixion incision is then closed followed by the placement of septocolumellar sutures with 4.0 PDS to maintain tip projection and rotation. On occasion, an overly prominent nasal spine will have to be reduced if it is a significant part of the hanging columella, but this is not very common.

For an overly bowed or wide medial crura, shaving of the medial crura at the junction of the medial and intermediate crura is performed and the medial crura are then sutured together. For excessively long or curved medial crura, some have espoused a medial crural overlay technique followed by placement of a columellar strut. As described earlier in this chapter, with excessively long lower lateral cartilages, a lateral crural overlay technique can be used. Other options such as the tongue-in-groove technique have been advocated by Kridel to set the medial crura back over the septum. An algorithm for use of this technique in the management of the hanging columella has also been previously described by Kridel. Finally, in revision cases where the cause of the hanging columella is caused by previous graft placement, the responsible graft (shield graft, columellar strut, caudal septal extension graft, or plumping grafts) is removed or modified.