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Reconstructive Surgery American Board of Otolaryngology - ABO

The Hanging Columella

From a facial profile view, many people have nostrils that are substantially higher than the tissue that separates the two sides of the nose. This condition is known as a hanging columella, or “alar-columellar disproportion”—an aesthetic deformity that many people seek to change through reconstructive nose surgery. But fixing a hanging columella may require a different approach for each patient, depending on the etiology, or cause or origin, of the deformity. Hanging columellas often occur naturally in patients. In other cases, it may have resulted from a mistake in a previous surgery in which the alar and columella became misaligned. Revision rhinoplasty involves performing corrective secondary surgery on a patient, who has previously undergone reconstructive nose surgery.

The following section will describe:

- techniques for managing a hanging columella
- the anatomy of the alar-columellar relationship
- ways to differentiate between a hanging columella and a retracted ala or a pseudo hanging columella, and
- how actions taken in primary rhinoplasty can alter the normal alar-columellar relationship.

Pertinent anatomy and etiology

In classic textbook definitions, the standard alar-columellar relationship is characterized as being able to see 2mm to 4mm of columella below the alar margin when looking at the profile view of a person’s face. This description, however, does not adequately describe the appropriate position of the alar margin within the alar-columellar relationship. A patient may appear to have a hanging columella, when it is really the result of a retracted alar. It is imperative to understand the cause of the hanging columella, as this will dictate the appropriate corrective measures required. Other signs of a hanging columella include excessive nostril show with a droopy tip, a short upper lip, a long lateral crus, and a strong lateral crus with no apparent notching. By contrast, the presence of alar notching, weak or deficient lateral crura, retraction of the alar margin, or an alar margin with excessive curvature may suggest alar retraction or a pseudo-hanging columella.

A hanging columella can exist naturally in a person’s facial features, or it can develop as a direct result of a previous nasal surgery. The key nasal structures to consider when evaluating a hanging columella include the caudal cartilaginous septum, the membranous septum, and medial and intermediate crus. Anatomic deformities that contribute to the hanging columella may include:

- a caudal cartilaginous septum that is excessively long
- a redundant membranous septum,
- a wide, curved, convex or vertically oriented medial/ intermediate crura,
- a long medial crus with bowing or a C-shaped curvature, or
- a broad vestibular vault and medial crural ptosis.

When a hanging columella develops as a result of previous surgery, the causes may include:

- a columellar strut or a caudal septal extension graft that protrudes caudally
- a suturing biphid medial crura that highlights the columella
- a shield graft that is too thick or excessive plumping grafts
- the loss of tip projection and rotation from previous rhinoplasty.

Surgical evaluation and management

Like most maneuvers in rhinoplasty surgery, the most effective way to correct a hanging columella will depend on the etiology, or cause, of the condition. If the hanging columella is caused by an excessive cartilaginous caudal septum or redundant membranous septum, the tissue should be removed or cut using transfixion incision, which can be done endonasally. If you seek to increase rotation, however, a wedge of caudal septum should be removed in the shape of a triangle, with the triangle’s base oriented dorsally. If counter rotation is what you wish to achieve, the base should be oriented vertically toward the nasal spine. Achieving zero rotation will require removing a straight piece of cartilage. As a rule, always leave at least 1 to 1.5 cm of caudal septum to prevent the tip of the nose from collapsing.

For a membranous septum, an ellipse-shaped part of the septum should be excised, with the widest part of the ellipse where the columella protrudes most severely. The transfixion incision is then closed using septocolumellar sutures with 4.0 PDS to maintain tip projection and rotation. In rare instances, if a large nasal spine is contributing to the hanging columella, it may have to be reduced.

To address medial crura that is overly bowed or wide, the medial crura is shaved at the meeting point of the medial and intermediate crura. The medial crura are then sutured together. For excessively long or curved medial crura, some surgeons employ an overlay technique followed by placement of a columellar strut. As previously described, a lateral crural overlay technique is also effective for addressing lower lateral cartilages that are excessively long. Dr. Russel Kridel, a top plastic surgeon, also advocates other options such as the tongue-in-groove technique to set the medial crura back over the septum, for which an algorithm exists to manage hanging columella. Finally, in cases where the hanging columella is caused by graft placement in a previous surgery, the graft (whether it be a shield graft, columellar strut, caudal septal extension graft, or plumping grafts) is either excised or altered.

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