Who is a good candidate for columellar lift surgery? Is the columella drooping, or are the alae elevated?

Columellar lift surgery is most suitable for patients whose columella (the structure between the nostrils) appears to droop below the alae when viewed from the side, and where the cause lies in the shape of the nasal septal tip or the cartilage of the columella. If the alae are elevated and the columella simply appears more prominent as a result, columellar lift surgery may not be appropriate. For those who want a higher nasal tip, correcting the columellar droop first determines the final result.

Why does the columella appear drooped?

There is not a single cause. In research examining revision cases of nasal surgery, columellar descent was related to insufficient removal of the nasal septal tip, outward bulging of the cartilage inside the columella, and the shape of soft tissues[1].

After nasal septal extension (surgery to add cartilage that supports the nasal tip), the added cartilage can shift and cause columellar descent[2]. Because the correction method depends on the cause, it is first necessary to identify where the problem originates.

How do you distinguish between a columellar problem and an alar problem?

This is judged by observing the relationship between the alar rim and columellar position in a side view. During nasal examination, the relationship between the alar rim and columella, and the shape of the columella and nostrils, are confirmed from front, side, and inferior views[3]. There is a classification for this relationship in a side view, distinguishing whether the discrepancy is on the columellar side or the alar side[4].

When the alar rim is pulled upward, the columella can appear prominent even if it is not actually drooping. It is reported that when the ala is elevated, the appearance of the nasal tip worsens and the shape of the nostril becomes distorted[5]. In this case, rather than the columella, surgery to lower the alar side is a candidate[5].

What should someone consider if they also want a higher nasal tip?

It is important to correct columellar droop first. In textbooks on nasal surgery for Asian patients, correcting columellar descent is described as a prerequisite for sufficiently raising a low nasal tip[6].

Methods that only layer cartilage onto the nasal tip can paradoxically worsen columellar droop and result in loss of nasal tip height[6]. If you wish to raise the nasal tip, it is reassuring to have this planned together with the columellar correction.

Is columellar lift surgery suitable for someone with a short columella or one that is recessed?

Rather than columellar lift surgery, surgery to support and project the columella forward is a candidate. For a nasal tip with a short columella, a recessed columellar base, or an acute nasolabial angle, columellar strut grafting (placing a cartilage strut inside the columella) is considered appropriate[6].

Excessive cartilage removal in previous nasal surgery can also cause columellar recession[7]. Whether the columella is "drooping" or "recessed" determines opposite surgical goals.

What if someone has had previous nasal surgery?

Surgery is possible, but the effects of the previous procedure must first be assessed. Among people undergoing revision surgery after nasal surgery, literature reports show 5–15%, and a study of 732 subjects found 8.6%[1].

When a columellar strut or nasal septal extension projects the nasal tip too far, it can narrow the alar base[6]. Communicating what was done in the previous surgery and having the cartilage condition and any material deficit confirmed is the starting point[6][7].

Things to confirm before treatment

There are three reference points for decision-making. The first is whether the columella is drooping or the alae are elevated[4][5]. The second is whether the cause of droop is the nasal septal tip, cartilage shape, or soft tissue[1]. The third is whether you also want to change the nasal tip height[6].

The positional relationship between the columella and alae can be difficult to distinguish from photographs or articles alone. For your own nose, ask your doctor to confirm during examination whether the cause is columellar or alar by viewing your profile and inferior view.