Rhinoplasty Dr Bashar Bizrah Article on: PostRhinoplasty Probleins and Revision Surgery Part 4: Hanging columella

4. Hanging columella:

Cause:

1. Loss of tip support.
   The postoperative dropped and underprojected tip cause the hanging columella
2. Reduction of very large noses.
3. Redundant of septocolumellar soft tissue due to poor septocolumellar closure.
4. Undertrimming of caudal septum.
5. Wide medial crura.
6. Long tip graft:
   Increases columella show giving false impression of hanging columella.

Prevention:

1. The use of columellar strut will prevent 80% of hanging columellas.
2. Properly positioned septocolumellar sutures will prevent redundant septocolumellar soft tissue.
3. As indicated limited trimming of the caudal septum. (Figs. 8 – 33,39)

Treatment:

Assess the cause and treat accordingly:

1. Columellar strut:
   Deliver the alar: a columellar strut is sutured like a sandwich to the medial crura and the use of tip grafts should be considered.
2. Trimming of the caudal septum.
3. Excision of redundant septocolumellar soft tissue and correct closure.
4. Trimming of caudal edge of wide crura and consideration of columellar strut.
5. Remove the long tip graft, reshape it and put it back.

5. Colurnellar retraction:

Causes:

1. Excessive trimming of the caudal septum. (Fig. 13 -12)
2. Overcorrection of the caudal dislocation.
3. Submucous resection of the nasal septum.
4. Congenital or a result of nasal trauma.

Prevention and treatment:
The use of columellar strut through a precise pocket or revision of alar delivery and suturing the columellar strut between the two medial crura.

6. Supratip collapse:

Causes:

1. Submucous resection of the nasal septum. (Figs. 13 -11,12)
2. Poor septoplasty technique:
   Mainly when dislocating the dorsum osteo-cartilagenous junction due to the pulling of the septum at the SMR operation.

Fig. 13 - 10. Assessment of alar columellar relationship (Gunter and Rohrich)

3. Cartilagenous hump over-removal:
   
   • Overtrimming of upper lateral cartilages.
   • Overtrimming of the dorsum septum and superior septal angle.
4. Poorly performed osteotomies which dislocate the osteocartilagenous junction
   due to aggressive mobilization of the nasal bones.

Treatment:

1. Minor supratip collapse: (Fig. 9 – 8)
   Precise pocket supratip grafts.
2. Moderate supratip collapse:
   Multiple layers of supratip grafts. (Fig. 17 – 21)
3. Major supratip collapse:
   This is usually combined with bony dorsum collapse. The treatment is to fully redo rhinoplasty with consideration of alar delivery, columellar strut, tip grafts and supratip grafts. The supratip grafts are sutured to the domal apex underlined by a long dorsum graft placed on the bony dorsum and supratip (Fig. 17 -21). Lateral osteotomies are performed to raise the dorsum profile line and narrow the bony pyramid.

7. Saddling:

This usually indicates a very poor technique by an inexperienced surgeon:
Causes:

1. Cartilagenous and bony hump over-resection. (Fig. 13 – 9)
2. Poorly performed septal surgery.
3. Poor tip plasty technique.
4. Aggressive osteotomies.

Treatment:

This problem usually causes psychic disturbance to Arab patients. Because there are many Chinese living in the Gulf area, the patient is usually very upset and says, “I have changed from an Arabic face to a Chinese face”.

Steps of correction:

1. Tip plasty:
   Alar delivery, new dome creation, scoring, suture fixation, columellar strut, tip grafts. (Figs. 17 – 12,16)

Fig. 13 - I I. (A,B,C) Post SMR cartilagenous collapse. In septa/ correction always leave an adequate caudal and dorsum margin and do not pull the septum in order to avoid dislocation of the bony cartilagenous junction. This case was managed by new dome creation, scoring, suture fixation, columellar strut, tip graft and double supratip grafts with medial and lateral osteotomies.

2. Lateral osteotomies:
   It will slightly raise the dorsum profile line, narrow the root of the bony pyramid and close the open roof deformity. (Fig. 17 – 18)
3. Supratip and dorsum grafting:
   This is discussed in detail in the chapter on saddling. In principle the author uses conchal autografts in multiple layers for supratip and bony dorsum augmentation. Because all these patients have poor septorhinoplasty possibly resulting in large septal perforation, the author personally prefers to use multiple layer supratip grafts which are sutured to the apex of the dome, then underlined by long dorsum grafts (Fig. 17 – 21). Little postoperative supratip fullness is appreciated by most of his patients in particular compared with the preoperative saddling.