See how a hanging columella and alar retraction can lead to excessive columellar show. Also learn what revision rhinoplasty techniques can be used to correct this significant problem.

In my last few rhinoplasty blog posts I've been going over a detailed analysis of a revision rhinoplasty patient of mine. So far we've looked at repairing a pinched tip and middle third narrowing. Today let's explore the patient's increased columellar show.

What is columella show?

From the profile view it is normal to be able to see 2 to 4 mm of the columellar sidewall. A hanging columella refers to a columella in which more than this amount is visible.

You can see how our patient has quite a significant amount of excessive columellar show. Too much of her caudal septal skin lining is visible.

How a hanging columella causes excess columellar show

Two separate factors can lead to excessive columellar show. The first is a hanging columella. This means that the columella extends too far down. This can be due to a naturally long septum that pushes the columella along with it. Alternatively, it can also result from prior rhinoplasty surgery in which scar or other grafts push the columella downward.

How alar retraction can lead to increased columellar show

Another factor that can lead to the problem of excessive columellar show is that of alar retraction. The ala are the nostril rims or margins and can retract upward as a result of cartilage resection during prior rhinoplasty. Some people naturally have alar retraction as a result of their nasal tip cartilage orientation.

How to fix a combined hanging columella and alar retraction

The patient that we're discussing has both causes of excessive columella show. There are a few ways to treat a hanging columella. One technique merely resects some of the long septal cartilage and then sutures the columella up to the new septum edge. In patients like ours who have a long, straight septum a maneuver called a tongue in groove setback is my preferred method of repair. This "tongue in groove" terminology is borrowed from the world of carpentry.

The tongue in groove setback may include trimming some excess septal cartilage (depending on how long the septum is), but the main technique involves separating the two medial crural cartilages that make up the columella, advancing them in the proper upward position, and then overlapping the medial crura over the long septum which acts as a great columellar strut. Sutures secure the columella cartilages in place where they maintain a nicely stabilized position.

Fixing alar retraction

There are several ways to treat alar retraction. For mild cases an alar rim graft will often be sufficient. Our patient's retraction is more severe so rim grafts alone probably wouldn't do. I these situations I find the best course of action to be lower lateral cartilage repositioning. As I previously discussed, since our patient has such severe tip pinching in her supra-alar crease added support is needed. We ended up rebuilding her lower lateral cartilages with a lower lateral cartilage strut graft. Once the grafts were in place we then fully freed the LLCs from the surrounding tissue, repositioned them downward and then inserted the strut grafts tips in a new pocket to keep the grafts and tip cartilages in place. This new, lower tip complex acts to push the nostril margin downward while at the same time reinforcing the collapsed supra-alar crease.

In the above set of photos you can see how this combination of maneuvers produces a much more pleasing  nostril appearance. The eye is no longer drawn to the nostril area at all and instead is directed up toward the eyes where it belongs.

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