The Management of Alar–Columellar Disproportion

The Ideal Alar–Columellar Relationship and the Aging Nose

Normal columellar show is classically defined as between 2 and 4 mm of visible columella below the alar margin on profile view ( Figure 21-1 ). However, this definition fails to differentiate between relative positions of the ala and the columella. Tardy qualitatively described the ideal appearance of the ala and columella on frontal view as a gentle “gull-in-flight” configuration where the columella represents the body of the gull and the alar margin represents the wings of the gull. On profile view, the alar margin resembles a gentle S-shaped configuration. Gunter quantified the alar–columellar relationship by drawing horizontal lines through the tip-defining point, the alar rim, and the columellar–alar–facial junction. This divided alar–columellar disproportion into six categories, depending on if whether the position of the ala or columella (or both) were contributing to the problem. Perhaps an all-encompassing method of analysis is to consider all the factors that contribute to a pleasing alar–columellar relationship: width of columellar show, long axis of the nostril, shape of the nostril, shape of the alar margin, presence of a double break in the columella, length of the upper lip, columella-to-lip ratio, columella-labial angle, and the configuration of the lateral crus. With respect to the nostril shape, an oval shape is desirable.

The anatomic components ( Figure 21-2 ) that determine the position and shape of the columella include the cartilaginous caudal septum, membranous septum, and intermediate and medial crus of the lower lateral cartilages. Their contributions may vary. Typically, the caudal-cephalic dimension of the medial crus is 4 mm, which we refer to as the medial crural width. The position and shape of the ala are established by the width and orientation of the lateral crus of the lower lateral cartilages and the insertion and resilience of the fibroadipose component of the nasal ala.

Aging has a significant effect on these structures. Weakening of fibroelastic attachments in the scroll region as well as suspensory ligaments between the medial crura lead to tip ptosis, divergence of the medial crural footplates, and subsequent lengthening of the membranous septum. Also, with aging there is bone recession in the premaxillary region. In sum, these changes give the appearance of narrowing of the nasolabial angle and shortening of the columella, with a hanging columella anteriorly and a retraction posteriorly.

Alteration of the tip rotation and projection in this case, in concert with adjunctive procedures, may itself correct the hanging columella defect. Numerous methods have been developed that define the ideal proportions and angles of the nose and nasal tip projection. An approach to create an ideal alar–columellar relationship can only be undertaken after the desired tip projection and rotation are set.

The Hanging Columella Deformity

The hanging columella deformity is a common cause of alar–columellar disproportion. A retracted ala or alar notching can give the appearance of a hanging columella and must be differentiated, because the etiology and surgical repair are different. The anatomic configurations that make up the hanging columella deformity include overdevelopment of the caudal septal cartilage, which pushes down the medial crura, and/or the redundant membranous septum ( Figure 21-3 ). Additionally, the medial and intermediate crura can be too wide, excessively curved and convex, or vertically inclined. The long medial crus, with an excessive C-shaped curvature, has been cited as a prominent cause of the hanging columella deformity. Adamson cited a broad vestibular vault and ptosis of the medial crura as additional causes. In the senior author's experience, a large nasal spine is rarely the etiology because it is usually the septum that projects more forward and caudally than ever does the spine.

A hanging columella can result from previous rhinoplasty. Loss of tip projection and rotation causes loss of tip support and relative redundancy of the columella with apparent columellar show. Forward or caudal placement of a columellar strut or caudal septal extension graft can be the culprit. Suturing together previously bifid and lateralized medial crura can make the columella more caudally prominent. A tip graft that is too thick or a plumping graft that is too large can create the same problem.

Treatment of the hanging columella deformity is based on the underlying etiology. Previous descriptions of surgical repairs have been separated into indirect and direct. The direct repairs involve resection of the caudal margin of the medial crura, whereas the indirect repairs involve trimming the caudal septum or the membranous septum. In the senior author's experience, the tongue-in-groove (TIG) technique is very effective in correcting the hanging columella deformity in many cases, including defects caused by long, convex medial and intermediate crura, vertical inclination of the intermediate crura, or overdevelopment of the caudal quadrangular cartilage. The TIG technique does not burn any bridges. In brief, mucoperichondrial flaps are developed on both sides of the caudal septum, a pocket is developed between the medial crura, and the caudal septum is positioned into the developed pocket. After assessment of the appropriate relationship, excess membranous septum is trimmed bilaterally on the septal (cephalic) side of the incision, allowing for the greatest excision in the area where the columella hangs the most. After closure of the transfixion incision, septocolumellar sutures are used to add strength or to affect change in the tip height. In select cases where the hanging columella defect still exists after the TIG procedure due to an overdeveloped caudal quadrangular cartilage, conservative excision of the caudal end of the cartilaginous septum is carried out. In contrast to some authors who have found a frequent need to reduce the maxillary spine, the senior author rarely finds the need to trim the nasal spine to correct the hanging columella defect. Occasionally, the medial crura may be too caudally projecting, and conservative trimming of the caudal edge of the medial crura is performed and the medial crura are sutured together. In the treatment of excessively curved and long medial crura, division of the alar cartilages at the angle of the medial and lateral crura has been advocated with placement of a columellar strut to restore strength and tip support. When the lower lateral cartilages are too long and are overdeveloped, a lateral crural overlay (LCO) can be used to shorten the lateral crura and rotate the tip, in concert with a TIG procedure to correct the hanging columella deformity by setting the medial crura back over the septum. Last, in revision cases where previous graft placement is the causative factor for the hanging columella defect, the offending graft, whether it is a tip graft, columellar strut, or caudal septal extension graft, is removed, replaced, or trimmed.

Treatment Algorithm for the Hanging Columella

Algorithms in rhinoplasty can only be guidelines since patients and noses are different and each treatment must be individualized. However, algorithms can help organize an approach to the problem. An algorithm has been developed to manage the hanging columella deformity in a systematic approach ( Figure 21-4 ). Once alar–columellar disproportion has been identified, the presence of a hanging columella is assessed. If a hanging columella is not present, the surgeon is directed to the diagnosis and treatment of alar retraction or notching with grafting. The next step is the palpation of the caudal septum at the columella to determine any contribution to the problem. At this point, the treatment algorithm diverges. If the caudal septum is normal, the surgical procedure to correct the hanging columella defect begins by performing a TIG procedure. Most cases of hanging columella with a normal caudal septum position will be resolved by a TIG procedure with trimming of the membranous septum. Conversely, if there is significant caudal septal excess, the caudal septum is trimmed first, followed by a TIG procedure. After reevaluation for persistent hanging columella, further conservative trim of the caudal septum may be performed, making sure to preserve an adequate caudal septal strut when septoplasty is also performed. If the hanging columella deformity persists, a TIG procedure involving medial crural setback on the caudal septum is considered and performed. Consideration is also given to the occasional presence of a prominent maxillary spine, with attendant reduction. We then proceed with external rhinoplasty to identify additional causes for any residual persistent hanging columella. Any cartilage grafts previously placed that are contributing to a hanging columella, including a columellar strut graft, tip graft, caudal septal replacement graft, caudal septal extension graft, or columellar batten grafts, are removed. If a hanging columella is still present, trimming of the caudal medial crura is performed, and consideration is given to a medial crural overlay (MCO) technique in cases of long intermediate or convex intermediate crura, or an LCO technique in cases of excessively long lower lateral cartilages.

The Retracted Ala

A retracted ala is usually encountered after previous rhinoplasty, but it can be secondary to a previously unrecognized disproportion. Familial variants contributing to a retracted ala include a highly arched alar lobule margin with high insertion into the cheek laterally or a plunging nasal tip with high-arched ala. Vertically oriented lower lateral cartilages may significantly contribute to bilateral retracted alae.

More often, the retracted ala is due to aggressive excisional surgery or as a result of normal scar contracture from prior surgery. The cephalic trim of the lower lateral cartilage is a commonly used technique in rhinoplasty to refine and narrow the tip and to cause rotation of the tip via scar contracture at the scroll area. The degree of scar contracture is difficult to predict, and varying amounts of cephalic trim of the lateral crus can cause the alar margin to retract and result in alar–columellar disproportion. Other excisional techniques that can predispose to this condition include excision of the lateral-cephalic portion of lateral crura and vertical interruption of the lower lateral cartilages. Often specific to the closed rhinoplasty approach and causing a more difficult situation is the possibility that the vestibular skin under the lower or upper lateral cartilages was inadvertently trimmed via an intercartilaginous, intracartilaginous, or transcartilaginous incision, which, coupled with a cephalic trim, can predispose to alar retraction. Additionally, a tightened lateral crural spanning suture may be yet another iatrogenic cause for alar retraction, which can be relieved with removal and repositioning. And, in the open technique, a tightened closure of the marginal incision may also predispose to such retraction.

In treating the retracted or notched ala, management depends first on the identification of any tissue deficiency. In cases of mild retraction with no tissue deficiency, the lateral crus can be detached after wide undermining of the scroll area, followed by repositioning of the lateral crus more inferiorly. A vertically oriented lower lateral cartilage can be repositioned inferiorly in this manner. If tip rotation is needed as well, the Boccieri modification of the Kridel LCO technique is an excellent way to address this problem. In the senior author's experience, double-dome sutures can solidify the position of the lower lateral cartilages and counteract the tendency for retraction, especially when the domes are brought together with a caudal rotation of the lower lateral cartilages. Retraction with high insertion of the lateral crus can also be treated with alar base resection and repositioning. Alar rim grafts can be used to treat mild to moderately retracted alae or as a preventive measure to counteract floppy alae or potential future scar contracture with later retraction. Alar rim grafts can be placed through a closed or open technique via a precise pocket created in the alar rim ( Figure 21-5 ). A properly sized graft is fashioned to fit the exact pocket, and the medial aspect is sewn to the alar rim soft tissue so as to prevent migration of the alar rim graft. If an alar base excision is to be carried out additionally, the rim graft may be inserted through that incision from lateral to medial. Alternatively, an alar batten onlay graft with an extension in the alar rim can be used effectively to treat a retracted ala. For the nose with a pinched nasal tip, an alar spreader graft can effectively treat the tip as well as the alar retraction.

In many revision cases, however, retraction is accompanied by scar contracture and lack of mobile tissue to reposition the ala more caudally. In these cases, extra tissue must be obtained to “push” the alar rim inferiorly. The mainstay for management is the composite auricular skin–cartilage graft. The auricular skin and cartilage are harvested as a composite graft from an anterior approach, using a well-camouflaged incision ( Figure 21-6 ). The composite auricular graft may be placed along the cephalic edge of the lateral crura, or scroll area, and can be sutured into the intercartilaginous incision through an endonasal approach ( Figure 21-7 ). Alternatively, in the open technique, it may be sutured directly to the caudal edge of the lower lateral cartilage on the vestibular side ( Figure 21-8 ). These composite grafts have a high take rate and are often necessary to correct a severely retracted or notched ala. One needs to allow for shrinkage of the grafts, but sometimes it is later necessary months down the line to intranasally trim any remaining bulk; however, it is preferable to overcorrect initially than to remain shy of the necessary correction. Alternatively, Guyuron has described using an internal lining V-Y advancement to lower the alar rim, in combination with structural cartilage reconstruction for any missing lateral crus. For very severe alar retraction, reconstruction using a cutaneous alar rotation flap and autogenous cartilage batten grafts was described.

The Hanging Columella Combined with a Retracted Ala

Often in revision rhinoplasty, the surgeon encounters concurrently the presence of a hanging columella defect with a retracted ala. In these cases, it is essential to arrive at the correct diagnosis and assess the relative contributions of each deformity. Only then can the correct techniques be selected to achieve an aesthetically pleasing alar–columellar relationship. Once again, attention is given to the shape of the nostril, the tip rotation, the presence of alar notching, the strength and volume of the lower lateral cartilages, the shape of the alar margin, the size of the quadrangular cartilage, and the relationship of the tip and columella to the upper lip. Excessive nostril show with a ptotic tip, rounding of the caudal nostril margin, short upper lip, long lateral crus, and relatively strong lateral crus with no apparent notching are all suggestive of a hanging columella etiology. Conversely, the presence of alar notching, weak lateral crura, retraction of the alar margin, and excessive curve to the alar rim margin are suggestive of alar retraction as the etiology for excessive columellar show. In revision rhinoplasty, significant contributions from both the hanging columella defect and alar retraction commonly result in very significant amounts of columellar show. Failure to address the hanging columella in the original surgery, coupled with overly aggressive excisional techniques of the lateral crus, can result in this predicament. In these cases, the hanging columella defect is usually addressed first using the TIG technique, trimming of the membranous septum, and possible trimming of the caudal cartilaginous septum. After addressing the hanging columella, the surgeon can better assess the severity of the alar retraction and the amount of correction needed to achieve a columellar show less than 3 mm. The mainstay of treating severe retraction is the composite auricular cartilage graft, but in some cases, alar rim grafts can also be effective. Using a full armamentarium of techniques available to address the hanging columella and alar retraction, one can achieve an aesthetically pleasing columellar relationship, even in cases of severe alar–columellar disproportion (see Case Examples 5 and 6 ).

The Hanging Ala

The hanging ala, or alar hooding, is a relatively more uncommon diagnosis and can represent a normal anatomic variant previously unrecognized. A prominent ala, including excessive alar flare, can contribute to a hanging ala. In correcting alar flare, improper insetting of the ala after alar wedge resection can cause a hanging ala deformity. Other causes of the hanging ala include improperly placed grafts along the alar rim. Simple repositioning of the ala with a deep stitch via a lateral alar-facial incision, as one might make for alar wedge reduction, may often solve the problem. The hanging ala also can be corrected by directly removing an ellipse of the alar rim or extra alar lining and underlying subcutaneous tissue. Alternatively, techniques that promote alar retraction, including cephalic trim, can in this case help correct a hanging ala.

The Retracted Columella

A retracted columella, in comparison, is commonly seen in primary or secondary rhinoplasty or posttraumatically. Etiologies unrelated to previous nasal surgery include normal anatomic variation and congenital causes. Patients with cleft lip and palate deformity can present with columellar retraction, secondary to an underdeveloped premaxilla. In addition, numerous processes that erode the cartilaginous septum or cause septal perforation may cause a columella to be retracted. A variety of rhinoplasty techniques can induce the columella to retract. Excessive resection of the caudal septum or medial crura causes columellar retraction, especially in the long term. Excessive resection of membranous septum, without cartilage manipulation, can result in the same predicament. The TIG maneuver is an effective technique to reposition a hanging columella. However, excessive setback of the medial crus on the caudal septum can cause columellar retraction. Failure to stabilize the medial crural relationship to the caudal septum can lead to columellar retraction onto the caudal septum.

Treatment of the retracted columella in revision rhinoplasty also depends on identifying the causative factor for the defect. In cases where the diagnosis of retracted columella was missed in the initial surgery and where it represents a natural anatomic variant, one can place a columellar batten graft or place a cartilage or crushed cartilage onlay in the columella. Where additional strength of tip support is also desired, an extended tip graft with a caudal component can be used to correct the retracted columella. Alternatively, a columellar strut can be fashioned to extend caudally beyond the caudal border of the medial crura ( Figure 21-9 ). The columellar strut should be fashioned so that the most caudal extent of the strut is positioned in the area of greatest retraction. In cases where the caudal septum is weak or missing, a septal extension graft or a caudal septal replacement graft can help improve tip support and correct the retracted columella ( Figure 21-10 ). A plumping graft will specifically augment retraction near the columellar-lip angle (see Case Example 3 ). If the etiology is an improperly positioned medial crura onto the caudal septum, the surgeon needs to reposition the medial crura through bilateral elevation of septal mucoperichondrial flaps to free up the membranous septum and then use suture techniques to recreate the fibrous attachments between the medial crura and the septum. Finally, cases of columellar retraction secondary to a large septal perforation repair may require cartilage augmentation of the columella.