Columella lifting surgery: cut the septum or use thread? Choose based on degree of descent

Columella lifting surgery (surgery to raise a drooping columella) involves shortening the lower end of the nasal septum, shaving the cartilage inside the columella (medial crura), or using thread to approximate the columella to the septum, with most cases managed by a combination of these approaches[1]. Which method to choose depends on whether the columella appears drooping due to septal projection, cartilage position, or simply because the alar base on the side is descended[2][3]. Textbooks note that the cause often becomes clear only during surgery[1].

A drooping columella may have more than one cause

The causes can be broadly divided into three categories: the lower end of the nasal septum (caudal septum) is projecting, the cartilage position inside the columella is displaced, and the alar rim (rather than the columella itself) is descended.[2][3]Textbooks state that the caudal septum influences columella position and whether it causes deviation, retrusion, or ptosis should be evaluated preoperatively[3].

A review of Southeast Asian noses notes that the alar rim insertion is often lower than the columella base—meaning the alar wing is descended and the columella appears retracted.[2]In this case, rather than raising the columella, the triangular tissue on the medial side of the alar wing is excised in a procedure called "sail excision" to refine the alar contour.[2].

Technique 1: Shorten the lower end of the nasal septum

If septal projection is the cause, septum-cutting becomes the main approach. Textbooks state that columella ptosis due to caudal septal projection can be corrected by excision, rotation, or both.[3].

Traditionally recommended was excision of the membranous septum—the membranous portion between the columella and septum.[4]. However, a 2024 report showed that in 97 closed-approach (endonasal incision only) rhinoplasties, the membranous septum was not cut in any case, and in all 7 patients who had preoperative columella ptosis, neither ptosis nor retrusion was observed at 12 months postoperatively[4]In appropriate Before-after cases, the membranous septum can be corrected without cutting it using other techniques.[4].

Technique 2: Shave cartilage and bring it together with sutures

When shortening the septum is insufficient or when cartilage positioning is the issue, we combine methods such as shaving the medial crura or suturing the columella to the septum with sutures.[1]Sutures connecting the medial crura and septum are used alone or in combination with septal shortening or medial crura shaving.[1].

The suture method has its advantages and disadvantages. It is effective for people with a low nasal tip and drooping columella, but textbooks caution that its effectiveness is limited in Asians with weak medial crura.[1]The strength of your own cartilage determines whether sutures alone are sufficient.[1].

What is the deciding factor? It is determined during surgery.

The key is the positional relationship between the medial crura and caudal septum.[1]Since this relationship often becomes clear only after opening during surgery, it may not be possible to definitively decide on one method before the procedure.[1]The explanation of "adjusting the combination based on circumstances" follows standard textbook practice.[1].

What we want to confirm during consultation

What we want to check is whether the columella is drooping or whether the ala is drooping and the columella appears recessed.[2]It becomes clearer when we look together at the positional relationship between the columella and the edge of the ala in a side-profile photo.[4].

The prominence of the caudal septum, the strength of the medial crura, and whether the closed technique can address it are determined by examination and intraoperative findings.[4][3][1]Confirm with your doctor whether the membranous septum will be cut or not, and where the possibility exists that the surgical plan might change intraoperatively.