Treating the hanging columella:No single technique prevails

Over the years, I have utilized a variety of techniques to correct the hanging columella region. These can be separated into management of the caudal septal area, middle crus of the alar cartilage, nasal spine, and columellar tissue. I do not use the open rhinoplasty approach to treat the isolated hanging columella in most cases. I have found that the combination of resection of the caudal septum and two fixation sutures (4-0 PDS) to pull up the hanging columella generally solves the problem. In situations where there is excessive caudal septal tissue, I will resect this to raise the columella. If the caudal septum is twisted, it should be straightened. My early hanging columella cases had a significant incidence of recurrence because I failed to coapt the columella to the caudal septum with sutures. Infrequently, I have found it necessary to resect the cephalic (superior) edge of the middle crus to correct a hanging columella. But I prefer to stay away from the medial and middle crus area unless I cannot correct the problem otherwise. Sometimes I find it necessary to remove excess tissue in the membranous portion of the septum. If the middle crura is unusually large, it is reduced by resecting some of the cephalic (superior) aspect. If the patient has a hanging columella with an acute col-umella-labial angle, resection of the caudal septum with rotation of the tip cartilages may not correct the deformity. I have used augmentation of the anterior nasal spine with a cartilage graft in such a situation. Nasal spine augmentation has been a useful technique in Asian-Americans or African-Americans where there may be a combination of hanging columella and nasal spine deficiency. Ronald P. Gruber, MD, Oakland, CA, is a board-certified plastic surgeon and an ASAPS member. The combination of resection of the caudal septum and two fixation sutures (4-0 PDS) to pull up the hanging columella generally solves the problem. My approach to the hanging columella is first to determine its cause. It is important to differentiate between a true hanging columella, retracted alar cartilages, or a combination of the two. In most situations, patients have a hanging columella without alar cartilage retraction. For patients with retracted alar cartilages, a composite graft or batten graft between the upper and lower lateral cartilages is required. Whether the open or closed rhinoplasty technique is used, I use a transfixion incision to shorten the columella by the amount estimated to correct the deformity. The full length of the caudal septum is not shortened, only a portion where the “excess” is located. In the open approach, a 4-0 PDS suture is passed between the leaves of the middle crura and back through the caudal septum. The needle is then passed back between the leaves of the middle/medial crura, where the knot is tied. In the closed approach, the middle/medial crura are also sutured to the caudal septum. The needle does not actually pick up the crura, but instead is passed through the fibrous septum that connects them. The needle is then passed through the caudal septum, and the knot is tied. Preferably, two such sutures are used. The hanging columella deformity is easily correctable in most situations with the techniques that I have described. If there has been previous surgery and scarring, the anticipated correction may not be as satisfactory.