Avoiding regret with columellar lift surgery. Common misalignment issues with strut grafting

Columellar lift surgery often leads to regret when the underlying cause of a deviated nasal tip or columella is misdiagnosed and grafting is performed anyway. When the cause lies in septal deviation, placing a strut alone may leave the deviation unresolved. We clarify which patients are suited to this procedure and what key distinctions should be confirmed beforehand.

What is this surgery for, anyway?

Columellar lift surgery uses septal cartilage or similar tissue as a strut to refine the nasal tip projection, columellar length, nostril height, and nasolabial angle (the angle between nose and lip)[1]. It is indicated for patients with a short columella, recessed infranasal region, or an acute nasolabial angle[2].

A "hanging columella" should be corrected first

When a simple onlay graft is placed to match a low nasal tip without first addressing the hanging columella, the hanging columella may worsen and the nasal tip projection may be lost[3]. To achieve adequate nasal tip projection, correcting this hanging quality is a prerequisite[3].

Deviation of the nasal tip or columella may not be caused by the strut

In most cases, the primary cause of an apparently deviated nasal tip or columella is deviation of the septal wall itself. Before correcting strut or graft orientation, evaluating and treating the septal deviation first is considered essential[4]. A malpositioned strut graft or placing a graft directly over medial crura with asymmetric strength are also cited as causes of columellar deviation[5].

Over-elevation creates the opposite balance problem

Raising the nostril apex height excessively with a long strut or extension graft may create an incongruous nasal tip projection and result in an unnatural appearance[6]Raising it higher is not necessarily better; the decision must be based on balance with the overall face.

Some patients experience regret due to difficulty breathing after the procedure.

Causes of nasal congestion following extension grafting include septal deviation, excessive narrowing of the nasal bone, medial displacement of the inferior turbinate, and valve collapse or scarring inside the nose.[7]In addition to changes in appearance, the impact on breathing is an important point to confirm after surgery.

Reports on graft types and outcomes

In a systematic review covering tip grafts overall, differences in projection and stability have been documented depending on the graft type.[8]Reports on positioning of the nasal tip also note that how the length and projection of the columella are designed affects the final result.[9]There are also reports on correction of the nasal tip and columella in crooked nose cases, showing that asymmetric cases require more complex planning than usual.[10].

Points to confirm during consultation

The first is whether any curvature of the nasal tip or columella stems from a septal issue.[4]The second is whether the plan addresses correcting a drooping columella first, if present.[3]The third is whether the degree of elevation is determined based on balance with the overall face, and whether the impact on breathing has been considered.[6][7]Which category applies to your case should be confirmed individually during your actual consultation.