Treating the hanging columella:Accurate diagnosis is key

Treatment of the hanging columella must begin with accurate diagnosis of the problem. My surgical management is based on the anatomic “abnormalities” that cause the hanging columella. Pseudo-hanging columella is seen after an “overdone” rhinoplasty with elevated or notched lateral crura of the alar cartilage. Excessive bowing of the columella can be seen after Le Fort I osteotomy to shorten the vertical height of the maxilla. These presentations do not represent an actual hanging columella, are difficult to treat, and are beyond the scope of this discussion. True exaggerated bowing or excessively long medial crura of the alar cartilage is best treated with an open rhinoplasty technique. The medial crura are divided at their junction with the middle crura, straightened or shortened as indicated, then stabilized with sutures to a cartilage strut placed between the medial crura from the anterior nasal spine to the nasal tip. A flattened, unrolled middle crura of the alar cartilage also requires resection or reshaping with sutures via an open rhinoplasty technique. On occasion, a cartilage strut is needed to maintain tip support. A flattened, unrolled middle crura of the alar cartilage also requires resection or reshaping with sutures via an open rhinoplasty technique. On occasion, a cartilage strut is needed to maintain tip support. James W. Fox IV, MD, Philadelphia, PA, is a board-certified plastic surgeon and an ASAPS member. If the problem is a long caudal portion of the quadrilateral cartilage, I shorten the nasal septum under direct vision by use of either a closed or open rhinoplasty technique. Generally, I resect a triangular piece of cartilage from the dorsal tip of the septum that gets wider as the resection approaches the base of the septum at the anterior nasal spine in profile view. If the problem is redundant membranous septal soft tissue, resection of a portion of the membranous septum is easily accomplished. If a malpositioned or malformed anterior nasal spine is the culprit, rongeur reshaping or, if needed, removal of the spine is performed. Familial or soft tissue ptosis of the nasal tip position caused by aging requires dorso-cephalad rotation of the nasal tip. There is no one way to treat the hanging columella. The goal is to correct the anatomic variant. Sometimes this requires a combination of the above-described techniques.