Hanging colmnella may be present as a single deformity but more commonly combined with drooped tip, dropped tip, short columella, humpy-long nose or crooked noses. (Figs. 8 – 33,39,58)
Definition:
Excessive exposure of columella-vestibular skin due to protrusion of the columella too far inferiorly.
The best assessment has been provided by Gunter and Rohrich. They recommend using the long axis of the nostril on lateral view as a line of reference. The normal caudal columella margin should lie within two mm of this line. (Fig. 2 – 4 and Fig. 13 – 10)
Aetiology and Management:
It is important to assess the columella, the tip and the septum carefully, in order to establish the cause of the hanging columella and manage it accordingly. Usually the correction is part of a full septoplasty operation.
- Overdeveloped caudal septum:
Corrected by shortening of the caudal septum. Followed by new dome creation, suture fixation, scoring, columellar strut and tip graft, in order to achieve tip elevation, definition and refinement. (Fig. 5 – 8 and Figs. 17 -13,14,15,16) - Redundant membranous septum:
This is usually a postoperative sequella. Corrected by excision of the redundant tissue and applying septocolumellar sutures. Columellar strut may be required. - Wide medial crura:
Corrected by caudal trimming of the medial crus and new dome creation, suture fixation, scoring, columellar strut and triangular shield tip graft. - Broad-obtuse domal arch or ptosis of medial crura (long lateral crus and weak medial crura):
It causes drooping of medial crura and hanging columella, corrected by new dome creation, suture fixation, scoring, columellar strut, shield tip graft and lateral crura overlay technique. - Pseudo hanging columella: causes:
A. Alar rim retraction:
Most commonly from aggressive resection of lateral crus of the alar. Correction is best achieved by a small conchal graft pushed into a tissue pocket created in the alar rim. For severe retraction, a composite skin cartilage auricular graft is positioned into a tissue pocket created in the vestibular alar surface. The best management is prophylactic by avoiding lateral ems over-resection.
B. Alar facial junction is too high:
This can be natural or postoperative narrowing. Assessed by drawing a line from the base of the columella to the alar facial junction, an angle greater than 30° is considered to be excessive (Adamson). The deformity is corrected by excision of a wedge of skin inferior to the alar facial junction and mobilizing the alar insertion inferiorly. In more advanced cases, an alar wedged vestibular skin flap may be required.
C. Prominent anterior maxillary spine or bulky premaxillary soft tissue:
This prominence of the columella base may give a false impression of hanging columella. Correction is by a sublabial small incision permitting reduction of maxillary spine and bulky soft tissue.
Fig. 8-33. A case of w ide and drooping tip with hanging columella and nare asymmetry. The author used the technique of new dome creation, scoring, suture fixation, columellar strut, tip gralts and lateral crura overlay technique in order to reduce the supra-alar fullness and rotate the tip.