Columella drooping and prominent nostrils? Changes visible with columella elevation surgery

Columella elevation surgery is a procedure that corrects a state where the septum dividing the left and right nostrils appears to protrude downward[1]. The structure causing the depression is often located deeper than the columella itself, and after examining the width of the caudal nasal septum or membranous septum and the shape of the medial crura, we determine where to shorten[1][2].

What is the real cause of columella drooping?

When viewed from the side, a state where the columella appears to drop below the edge of the nostrils is called columella ptosis. Textbooks identify an excessively wide membranous septum as the anatomical cause[1], and the protruding caudal nasal septum is also recognized as a contributing factor[2]. While what is visible is the columella, the structure that needs correction is often the deeper septal structure[2].

Which area needs to be addressed to elevate the columella?

In most cases, a single procedure is not sufficient. Textbooks describe that a combination of techniques—shortening the nasal septum, reshaping the medial crura, and securing the position with sutures—can be used to address the issue[1]. When the protruding caudal nasal septum is the cause, it is corrected either by excision, reorientation, or both[2]. Regarding the management of the caudal nasal septum, there are North American surgeon surveys and systematic reviews that organize the range of techniques and their outcomes[3].

Who is a suitable candidate? The columella issue is often not isolated

When the nose is long, the medial crura are weak, and the nasal tip points downward, raising only the columella will not result in a well-balanced appearance[1]. For this type, a sequence is recommended: shortening the caudal nasal septum, refining the cephalic portion, shortening the lateral crura, excising the membranous septum, and then augmenting the columella with support cartilage[1]. A deviated caudal nasal septum can be the source of columella deviation and asymmetry of the nostrils, so it should be evaluated before revision surgery[1]. A framework for classifying the deviation pattern of the septum—such as C-shaped or reverse C-shaped—has been established and is used as a common language for evaluation[4].

Is there a specific numerical standard for normal appearance?

A numerical standard for how much visibility is considered normal was not found in the resources reviewed. It is said that when viewed from the side, a state where the columella appears slightly below the edge of the nostrils appears balanced, but no source supporting this with numerical data was identified within the scope of this review[1]. Rather than determining by numbers, assessing the direction of the nasal tip and the angle with the upper lip together provides a more realistic clinical judgment[2].

Important considerations: relapse and loss of support

The important concern is loss of support. Even when support cartilage is placed in the columella, if the foundation support of the nose is insufficient, the nasal tip support and height may be lost postoperatively, and the tip often descends[5]. The role and application of support grafts are organized in reviews, and raising the columella and supporting the nasal tip cannot be separated[6]. If too much of the membranous septum is excised, the columella may appear retracted instead, so careful judgment regarding the amount of tissue to remove is necessary[1].

Points to confirm during consultation

During consultation, we distinguish whether what appears drooped is the columella itself, a protruding caudal nasal septum, or nasal tip ptosis[1][2]. By taking lateral photographs and viewing them together with the angle with the upper lip and the direction of the nasal tip, it becomes clear where should be shortened for balance[2]. If previous nasal surgery has been performed, the amount of remaining septal cartilage determines which techniques can be used, so this is confirmed first[1]. How much to elevate is determined individually by the surgeon based on the overall balance of the nose.