Does Columellar Elevation Surgery Really Work? What Research Reveals About Healing and Recurrence Rates

Columellar elevation surgery (a procedure to raise a drooping columella) can address many cases through a combination of methods tailored to the underlying cause—shortening the tip of the nasal septum, reshaping the internal cartilage, and suturing—according to textbooks[1]. However, there are few studies tracking outcomes numerically; one of the few actual measurements reported that among 97 patients who underwent closed-technique nasal surgery, all 7 who had preoperative columellar drooping showed complete resolution 12 months postoperatively[2].

Where is the standard for "drooping"?

Columellar drooping has a measurement method viewed from the side profile. According to textbooks, the normal relationship is when a line passing through the long axis of the nostril bisects exactly the distance between the alar margin and the lower surface of the columella; if this distance increases, it indicates columellar drooping, and if it decreases, it indicates columellar retraction[3]. Numerically, if the distance of the lower half of the nostril increases by more than 2 mm, it indicates columellar drooping.[3].

Visual characteristics are also defined. Columellar drooping occurs when the columella hangs too far below the alar margin, making the nose appear longer, and when viewed from the side, the internal surface of the columella and the membranous septum (the soft wall between the nostrils) become visible.[1]。The concern of "seeing the inside of the nostrils from the side profile" often falls under this definition.

What is the cause, and what needs to be corrected?

There are mainly 3 causes, and the area to be corrected is determined by them. According to textbooks, sagging due to protrusion of the caudal nasal septum (the tip end of the nasal septum) can be corrected by excision, rotation, or both[4].[4]。Many cases can be addressed with a combination of nasal septal shortening, medial crura (the cartilage legs within the columella) trimming, and suturing techniques. Which approach to choose is determined by the relationship between the medial crura and caudal nasal septum, and this becomes clear during surgical observation.[1].

A study examining 732 closed-technique nasal surgeries found that columellar sagging was related to insufficient caudal nasal septum excision, convex-shaped medial crura, and soft tissue deformity.[5]In other words, even with the same concern of "appearing drooped," the area to be reduced differs from person to person.

Does it really lift? Research findings

Although limited in number, there are reports with photographic evidence of lifting. In a 2022 retrospective study of 97 patients who underwent closed-technique rhinoplasty, all patients underwent standard tip procedures, and none had membranous septal excision.[2]When standardized lateral profile photographs taken 12 months pre- and post-operatively were examined, the 7 patients who had columellar drooping preoperatively showed neither drooping nor retraction postoperatively.[2]The authors conclude that in appropriate cases, columellar drooping can be corrected with alternative techniques without cutting the membranous septum.[2].

There are also reports showing the effectiveness of the suture fixation method. In the aforementioned study of 732 patients, it is stated that after systematically performing sutures to attach the nasal tip cartilage to the caudal septum to create height and direction, columellar retraction has become rarely seen.[5]However, this is part of a description from a study examining factors in revision surgery, not a prospective study with columellar retraction as the primary evaluation parameter.[5].

Why does recurrence or reverse deformity occur?

The reason it reverts is that the treatment is insufficient for the underlying cause. If there is inadequate resection of the caudal septum or if the convex shape of the medial crus remains, retraction persists.[5]Conversely, if the distance is reduced too much, the columella becomes retracted, so the amount of tissue removed must be kept within the range of normal relationships.[3]The revision surgery rate is reported in the literature as 5% to 15%, and in this study it was 8.6%.[5].

Why it should be considered together with nasal tip surgery

Columellar retraction is a prerequisite for nasal tip surgery. Textbooks caution that to achieve sufficient height on a low nasal tip, correcting columellar retraction first is a prerequisite, and simply stacking cartilage on top can worsen retraction and lead to loss of nasal tip height.[6]When accompanied by alar ascension, the recommended sequence is to correct the columella first and then assess the true degree of alar ascension.[1].

Flap methods that simultaneously correct both columellar retraction and alar ascension have also been reported, but this is at the stage of demonstrating feasibility with a single patient case.[7]When simultaneous surgery is recommended, ask about the track record of that technique.

What to confirm during consultation

The first is how much the distance between the columella and alar margin has increased in profile view.[3]The second is identifying the cause—whether it is the nasal septum, medial crus, or soft tissue.[1][5]The third is whether there is a plan to simultaneously change the height of the nasal tip.[6]The fourth is whether there is alar ascension, and if so, in what sequence to correct it.[1]The fifth is the possibility that revision may be needed and how to address it.[5].

The design changes based on septal length, medial crus shape, skin thickness, and nasal tip height. Therefore, from an article alone, you cannot determine what needs to be corrected on your own nose. During consultation, have the distance measured in profile view, the inside of the nose examined, the condition of the nasal tip and alar margins assessed, and the areas to be cut and sutured clarified together.