Retracted columella and downward-pointing nasal tip? What Columella descent procedure can address

Columella descent procedure corrects a retracted columella by advancing it anteroinferiorly, addressing shortness below the nose and downward-pointing nasal tip.[1]The basic method involves placing a cartilage strut between the medial crura, but when recession is severe, grafting fixed to the nasal septum is used instead.[2].

When the columella is retracted, how does appearance change?

In columella retraction, the columella becomes shortened, the angle from below the nose to the columella becomes sharper, and the nasal tip appears to point downward.[1]In profile view, the area below the nose appears compressed, and from the front, the visibility of the nostrils changes. It is noted that this tends to occur in people with longer noses and weak medial crura support, and often appears together with changes in which the nasal tip droops.[1].

When the cartilage strut is erected, what moves?

When a cartilage strut is placed between the medial crura, the nasal tip height increases, the columella lengthens, the apex of the nostrils rises, the angle below the nose opens, and the base of the columella moves forward.[1]The changes expected from columellar lowering surgery become easier to understand when you recognize that these five effects occur as one unified outcome.[1]The cartilage used for the strut is ideally the nasal septal cartilage, which has a straight shape; when insufficient, cartilage is harvested from the ear or rib.[1].

Who is it suitable for? Those for whom a strut alone is sufficient, and those for whom it is not.

A short columella, recessed base, and acute angle below the nose are a typical case suited for strut grafting.[1]On the other hand, when the nose is quite long, the medial crura are weak, and the nasal tip droops, a strut alone is insufficient, and additional techniques are sequentially added—shortening the caudal nasal septum, refining the superior cartilage, and shortening the lateral crura.[1]When posterior rotation is severe, a quadrangular caudal septal extension graft or replacement graft with width is used.[3].

How is it different from a graft fixed to the nasal septum?

With a method that only places a support, the mass at the tip of the nose remains independent at the bottom and is not connected to the nasal septum[4]Because caudal septal extension grafts are directly fixed to the caudal and dorsal nasal septum, the direction of the nasal tip and the forward projection of the columella can be adjusted precisely at the same time[1]In terms of determining the height of the nasal tip at the target position and suppressing postoperative descent, caudal septal extension grafts that connect end-to-end are noted to be more stable than supports[5].

Where do relapses or asymmetries appear?

When a firm support or nasal septal extension graft is paired with a straight and strong medial crura, the position of the nasal tip tends to be maintained longer, but in exchange, the nasal tip becomes firmer[1]If a septal extension graft is performed with weak septal support, the graft may tilt, leading to asymmetry in the nasal tip, columella, or nostrils[1]If a previous surgery placed a support or used suture plication and the nasal tip became overrotated, a separate procedure to reorient it downward may be needed[1].

What to confirm during your consultation

During consultation, we examine three things: the degree of columellar retraction, how much nasal septal cartilage remains and its strength, and skin thickness[1]In people with thick skin and a short columella, a firmly fixed type of graft tends to be chosen as a rigid support[1]Long-term data directly comparing support grafts and nasal septal extension grafts is still limited, so which is more suitable is something to decide with your doctor while looking at your actual nose[2].