Columellar strut graft vs. septal extension graft—which should I choose for lowering the columella?

Surgery to lengthen the nasal columella (the pillar between the nostrils) primarily uses two methods: placing a cartilage strut between the feet of the nasal tip cartilage (medial crura), and fixing and extending cartilage to the oral side (caudal aspect) of the nasal wall (nasal septum)[1]The strut method involves simpler steps, while the extension method provides stronger support; however, the accuracy of the fixed position is directly reflected in the final appearance[2].

What's the difference? Fixation vs. no fixation

Columellar strut graft (placing cartilage between the medial crura) lifts the nasal tip mass. The columella lengthens, the top of the nostril rises, and the angle below the nose opens.[1]However, in methods where the nasal tip cartilage (alar cartilage) is not sutured, the nasal tip mass remains floating at the lower end[3]On the other hand, septal extension graft is directly fixed to the oral side (caudal aspect) of the septum and the bridge side (nasal dorsum). This makes the nasal tip support integral with the skeletal framework, allowing the projection amount and direction to be determined together.[1].

When is columellar strut graft the right choice?

A short columella with a retracted base and an acute (pointed) angle below the nose is a case well suited for strut graft.[1]In people with a longer nose and weak medial crura, it is also used to create a downward rotation of the nasal tip and maintain that direction.[1]Combining a columellar strut graft with a rotation-correction graft can sometimes allow the nasal tip and columella to be advanced inferiorly without adding bone to the nasal base or performing septal extension graft.[1].

When is septal extension graft the right choice?

When columellar retraction is severe, a rectangular septal extension graft or a broadly constructed replacement graft (replacement graft) is selected[4]In people with thick skin and a short columella, septal extension graft or a firmly fixed type of columellar strut graft serves as a strong support.[1]In Asians, nasal septal cartilage can be thin and weak. Therefore, longer and wider rectangular grafts are reportedly used to correct subtle columellar deformities.[4].

How do postoperative complications differ?

It has been reported that in septal extension graft, if the graft shifts, the columella may appear drooped[5]If surgery is performed with weak septal support, the grafted cartilage itself may tilt, resulting in asymmetry of the nasal tip, columella, and nostrils.[1]Because columellar strut graft is not fixed, the risk of displacement is reduced. However, it is noted that in maintaining the nasal tip height at the intended position and preventing postoperative descent, it falls slightly short of extension graft[6]In other words, it is a relationship where you accept either the "risk of shifting" or the "risk of loosening."

Years after surgery—which is superior long-term?

In people with straight and sturdy medial crura, combining a firm columellar strut graft or septal extension graft tends to preserve nasal tip position longer.[1]However, there is still limited long-term follow-up data directly comparing the two methods, and it is noted that which is superior in the long term has not been clearly determined.[2]In other words, superiority is not determined by the surgery name alone. Which to choose ultimately comes down to that individual's nasal anatomy.[2].

Filling in the uncertain parts through examination

Asian noses may have weak nasal septal cartilage and thick skin. Therefore, it is argued that columellar strut graft alone or septal extension graft alone may not maintain nasal tip height long-term[7]The choice between the two is determined by the nasal anatomy. The three key factors are: how much usable cartilage remains in the nasal septum, how thick the skin is, and whether the medial crura are sturdy.[7]During examination, these three factors and the details of any previous surgery are confirmed, and you will work with your physician to decide which support method to use.[1].