Columella strut graft vs. septal extension graft—which should I choose to lower the columella?

In surgery to lower the columella, the main approaches are placing a cartilage strut between the medial crura and securing a graft to the caudal septum[1]. The former has a lighter assembly, while the latter provides stronger support but the precision of fixation directly affects the outcome[2].

What's the difference? Whether or not to fix it

A columella strut graft lifts the nasal tip mass by placing cartilage between the medial crura, lengthening the columella, raising the apex of the nostril, and opening the angle below the nose[1]. However, in types without suturing to the alar cartilage, the nasal tip mass remains in a floating structure that sits independently below[3]. Caudal septal extension graft directly fixes to the caudal and nasal dorsal septum, so the nasal tip support becomes integrated with the nasal skeleton, allowing simultaneous control of projection and rotation[1].

When is a columella strut graft appropriate?

A short columella with a recessed base and an acute angle below the nose is a typical indication for columella strut graft[1]. In people with a longer nose and weak medial crura, it is also used to create and maintain a downward rotation of the nasal tip[1]. By combining a strut and a rotation-correcting graft, the nasal tip and columella can be advanced inferoanteriorly in some cases without augmenting the nasal base bone or adding septal extension graft[1].

When is a caudal septal extension graft appropriate?

For a columella with severe retrusion, a rectangular caudal septal extension graft or a replacement graft with width is selected[4]. In people with thick skin and a short columella, a caudal septal extension graft or a well-fixed strut graft serves as firm support[1]. In Asians, the septal cartilage may be thin and weak, and longer, wider rectangular grafts are reported to be used to correct hidden columellar deformity[4].

How do the complications differ?

It is reported that in caudal septal extension grafting, if the graft shifts, the columella may appear droopy[5]. If the septum is not adequately supported beforehand, the graft itself may tilt, causing asymmetry in the nasal tip, columella, and nostrils[1]. Columella strut graft carries less risk of shifting because it is not fixed, but in terms of determining the nasal tip height at the target position and minimizing postoperative descent, it is said to lag behind extension grafting[6]. In other words, the risk of shifting and the risk of loosening are traded off against each other.

Which has better long-term results?

When a firm strut graft or caudal septal extension graft is combined with a straight, sturdy medial crus, the nasal tip position tends to be maintained longer[1]. However, data comparing the two directly over the long term are limited, and there is no established consensus on which is superior long-term[2]. In other words, superiority is not determined by technique name alone; the choice comes down to the nasal anatomy.[2].

Fill in the gaps that can't be decided in the consultation

It is argued that in Asian noses, where the septal cartilage is weak and the skin is thick, neither columella strut graft nor caudal septal extension graft alone may be able to maintain nasal tip height long-term[7]. The choice is determined by nasal conditions: how much usable cartilage remains in the septum, how thick the skin is, and whether the medial crura are sturdy[7]. During consultation, the physician confirms these three points and the history of any previous surgery, then decides together with you which support method is appropriate[1].