Columellar lowering surgery brings forward and downward the column between the nostrils (nasal columella) that has recessed backward. It corrects the appearance of a short nasolabial distance and a downward-pointing nasal tip. The basic approach is to place a cartilage strut between the cartilages (medial crura) that support the nasal tip. When recession is severe, we switch to a graft fixed to the nasal septum (the partition in the middle of the nose).[1]The basic approach is to place a cartilage strut between the cartilages (medial crura) that support the nasal tip. When recession is severe, we switch to a graft fixed to the nasal septum (the partition in the middle of the nose).[2].
When the nasal columella is recessed, how does the appearance change?
When the nasal columella is recessed (columellar recession), the nasal columella appears shortened. The angle from the base of the nose to the nasal columella becomes steeper, and the nasal tip appears to point downward[1]When viewed from the side, the area below the nose appears compressed, and when viewed from the front, the appearance of the nostrils changes. This occurs more easily in people with a longer nose and weak medial crura support. It is often recorded as appearing together with changes in which the nasal tip droops.[1].
When you elevate the supporting cartilage strut, what moves?
When a cartilage strut is placed between the medial crura, five changes occur. The nasal tip becomes elevated and the columella lengthens, the uppermost part of the nostrils is lifted, the angle below the nose opens, and the base of the columella advances forward.[1]I think it becomes clearer when you consider the changes expected from columellar lowering surgery as these five changes occurring together.[1]The cartilage used for the strut is ideally a straight-shaped nasal septal cartilage (the cartilage dividing the nose), as the first choice. When there is insufficient cartilage, it is harvested from the ear or rib.[1].
Who is it suitable for? People for whom the strut alone is sufficient, and those for whom it is not
The columella is short, the base is recessed, and the angle below the nose is steep. This type of condition is typical for strut grafting suitability.[1]On the other hand, when the nose is quite long, the medial crura are weak, and the nasal tip is drooping, the strut alone will not be sufficient. The procedure becomes a staged assembly where techniques are sequentially added: shortening the caudal (lower) nasal septum, refining the upper cartilage, and shortening the lateral crura (cartilage forming the outer side of the nostrils).[1]When the recession is severe, a quadrangular-shaped caudal septal extension graft (extending the lower portion of the nasal septum) or a replacement graft with width is used.[3].
How is it different from grafting that is fixed to the nasal septum?
With a method that only places a strut, the nasal tip mass remains independent at the lower portion and is not connected to the nasal septum.[4]The caudal septal extension graft is fixed directly to the caudal and nasal dorsum (the upper line of the nose) of the nasal septum. Therefore, the direction of the nasal tip and the forward projection of the columella can be precisely controlled simultaneously.[1]In terms of determining the nasal tip height at a targeted position and suppressing postoperative height loss, caudal septal extension grafting, which connects end-to-end, is described as being more stable than a strut.[5].
Where do relapse and asymmetry appear?
When a firm strut or septal extension graft is combined with a straight and sturdy medial crura, the nasal tip position tends to be maintained longer. However, in exchange, the nasal tip becomes stiffer.[1]If septal extension grafting is performed while the nasal septal support is weak, the grafted cartilage may tilt. This can lead to asymmetry in the nasal tip, columella, or nostrils.[1]If a previous surgery involved placing a strut or suturing to shorten, resulting in the nasal tip pointing too upward, a separate procedure to reposition the tip downward may be necessary.[1].
What to confirm during consultation
The consultation examines three things: the degree of columellar retraction, how much nasal septal cartilage remains and its strength, and skin thickness.[1]In patients with thick skin and a short columella, a firmly fixed type of graft is more likely to be chosen as a firm support.[1]Long-term data directly comparing strut grafting and septal extension grafting is still limited. Which approach is suitable is determined in discussion with the surgeon while examining the actual nose.[2].
- 1Suh DH. Atlas of Asian Rhinoplasty. Springer, 2018（Retracted Columella／Cartilage Grafts of the Tip／Long-Term Stability of the Tip Projection／Preoperative Evaluation for Rhinoplasty chapters）.
- 2Nocini R, Magagnotto N, Chirumbolo S, Albanese M, Bertossi D. New Insights into the Role of Columellar Strut and Septal Extension Graft: A Comparative Review of Long-Term Outcomes. Diagnostics. 2025. doi:10.3390/diagnostics15162051
- 3Structure Rhinoplasty. Vol.2（Caudal septal extension and replacement graft, morphology in Asian Before-after cases）.
- 4Daniel RK. Rhinoplasty: An Atlas of Surgical Techniques.（septal reconstruction grafts／rib graft Before-after cases）.
- 5Structure Rhinoplasty. Vol.1（Caudal septal extension graft connecting end-to-end and determination of tip height）.