Avoiding regret with columellar advancement: cartilage foundation selection and the risk of deviation

Regret following columellar advancement often stems from the cartilage foundation inserted to project the columella becoming deviated, or the direction of the nasal tip shifting away from the intended angle. Research indicates that the type of deviation most likely to occur varies depending on which method is used to construct the foundation. Since few studies focus exclusively on this procedure name, data from similar surgeries will be organized here.

What does columellar advancement surgery accomplish?

It is a procedure to project the columella (the column separating the left and right nostrils) forward or downward when it appears retracted in profile. Textbooks describe methods such as grafting a rectangular cartilage extension to the tip of the nasal septum, or replacing it with cartilage of greater width.[1].

There is also a method of placing a cartilage strut to support the columella (columellar strut). This targets noses with a short columella, a retracted subnasal region, or an acute nasolabial angle, serving to lengthen the columella and advance the subnasal area.[2].

Does the method of constructing the foundation change which deviations are most likely?

Yes. In a study comparing short-nose surgery in Asian patients, the nasal septal extension method (287 cases) showed nasal tip and columellar deviation in 5.23%, while the method adding cartilage to lower the nasal tip (142 cases) showed 1.41%.[3].

Conversely, the change in which the nasal tip descended occurred in 4.53% with the nasal septal extension method and 8.45% with the other method. Fullness immediately above the nasal tip also showed a difference of 0% versus 2.82%.[3]Rather than determining which is superior, it is more practical to recognize that each method has characteristic shape changes to which it is prone.

This study targeted correction of short noses rather than columellar advancement itself. Nevertheless, the point of creating a cartilage foundation to project the columella is shared.

What if there is not enough of my own cartilage?

When septal or auricular cartilage is insufficient for support, rib cartilage (costal cartilage) is used.[4]A synthesis of 6 studies and 888 patients using costal cartilage for nasal surgery showed complication rates of 7% (or 8% depending on calculation method).[5].

Most were minor, centered on infection, cartilage warping, and position deviation.[5]Although satisfaction was high, large variation between studies was noted, with possible bias toward publication of better results.[5].

Does it last? Will there be regression?

Opinion remains divided on whether the columellar strut method preserves nasal tip height and direction long-term. Some reports suggest that the strut's effect on nasal tip height is modest.[4].

With a Y-shaped strut made from auricular cartilage, correction is possible without the foundation reaching the nasal root bone, and a shorter foundation may better suppress columellar inflammation.[6]Foundation length and fixation method are also factors influencing the final result.

If asymmetry between the sides is a concern?

A method of grafting cartilage only to the insufficient side of the columella has also been reported. In a study of 86 patients, the aesthetic score increased from 68.3 points preoperatively to 92.3 points at one year.[7].

However, the position of the nasal tip requires consideration of height, direction, and left-right balance together, and a plan tailored to each individual's skeletal anatomy is essential.[8].

Points to confirm during consultation

First, the method by which the foundation will be constructed and what changes are typical with that method.[3]Second, whether your own septal or auricular cartilage will suffice, or whether costal cartilage will likely be needed.[5][4]Third, whether the columellar retrusion differs between the left and right sides.[7].

How much advancement will harmonize with the overall face cannot be determined from an article alone. At an actual consultation, have the physician evaluate the nasolabial angle and nasal tip height in relation to your individual anatomy.