Aesthetic treatment of retracted and hanging nasal columellas

This study discusses approaches for aesthetic correction of nasal columellas, i.e. retracted and hanging columellas, most commonly observed in clinical practice. We describe a chondral-mucoperichondrial nasal septal flap and direct or indirect approaches described by Randall as our preferred procedures to correct retracted and mild to moderate hanging columella, respectively. A combination of procedures is used in more severe cases, in addition to modified Armstrong and Joseph’s approaches. These treatment options are compared to other literature reports on this specialty.

Keywords:
Nose Surgery; Rhinoplaty Methods; Columella Aesthetics

Authorship

LIACYR RIBEIRO Corresponding author: Liacyr Ribeiro Rua Visconde Silva, 52, salas 903/904. Botafogo, Rio de Janeiro. - CEP: 22271-092. Tel: (21) 2539-4893.

Former BSPS and ILAFPS President; Honorary Member of BSPS and ILAFPS; Member of ASAPS, ASPS, ISAPS; Member of the Academy. Fluminense of MedicineFormer BSPS and ILAFPS President; Honorary Member of BSPS and ILAFPS; Member of ASAPS, ASPS, ISAPS; Member of the Academy. Fluminense of MedicineFormer BSPS and ILAFPS President; Honorary Member of BSPS and ILAFPS; Member of ASAPS, ASPS, ISAPS; Member of the Academy. Fluminense of Medicine

MARCELO CASTRO MARÇAL PESSOA

Member of BSPS, ISAPS - Plastic surgeryMember of BSPS, ISAPS - Plastic surgeryMember of BSPS, ISAPS - Plastic surgery

RENATO MONTEIRO DE ANDRADE

Member of BSPS - Plastic surgeryMember of BSPS - Plastic surgeryMember of BSPS - Plastic surgery

Corresponding author: Liacyr Ribeiro Rua Visconde Silva, 52, salas 903/904. Botafogo, Rio de Janeiro. - CEP: 22271-092. Tel: (21) 2539-4893.

SCIMAGO INSTITUTIONS RANKINGS

Member of BSPS, ISAPS - Plastic surgeryMember of BSPS, ISAPS - Plastic surgeryMember of BSPS, ISAPS - Plastic surgery

Member of BSPS - Plastic surgeryMember of BSPS - Plastic surgeryMember of BSPS - Plastic surgery

Figures

Figures (13)

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Figure 1
A normal columella Schematic representation of the ideal alar-columellar relationship

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Figure 2
The Gunter classification of alar-columellar relationships The Gunter classification includes five subtypes. Type I, II, IV and V refer to primary deformities. Types III and VI refer to a combination of alterations observed in Types I and II, and Types IV and V, respectively.

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Figure 3
Hidden columella Schematic representation of hidden columella, known as retracted columella or Type V columella, according to the Gunter classification. It normally occurs in elderly patients with acute columellar-labial angles.

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Figure 4
Treatment options for correcting hidden columella (A) Schematic representation of hidden columella. (B) Chondral-mucoperichondrial nasal septal flap is our preferred choice. (C) Cartilage graft on the anterior nasal spine. (D) Structural graft, “STRUT” type, in the crux medialis.

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Figure 5
A chondral-mucoperichondrial nasal septal flap Schematic representation of a chondral-mucoperichondrial nasal septal flap positioned on the anterior nasal spine, according to nasal topography, restoring the columellar-lip angle within the standards established by treating hidden columellas.

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FIGURE 6
Surgical sequence of the chondral-mucoperichondrial flap (A) Demarcation of excess quadrangular cartilage portion. (B) The excess segment is cut up to the attachment of the maxillary crest. (C) The distal segment mucosa is carefully decorticated while maintaining perichondrium integrity. (D) Partial-thickness relaxing incisions are made on the cranial segment of the flap to facilitate its folding. (E) Once folded, the flap is molded with 5-0 nylon sutures. (F) Finally, the flap is positioned on the anterior nasal spine according to nasal topography and stabilized with externally fixed 6-0 nylon thread that is maintained for 7 days.

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Figure 7
External fixation of a chondral-mucoperichondrial nasal septal flap The flap is stabilized using an external fixation suture with 6-0 nylon, externalized to the level of columellar-labial angle, and maintained for 7 days.

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FIGURE 8
Pre and post-operative aspect of a patient treated with chondral-mucoperichondrial flap. Negroid nose with hidden columella was corrected with chondral-mucoperichondrial flap.

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Figure 9
Pre and post-operative aspect of a patient treated with chondral-mucoperichondrial flap. Long nose with acute columellar-labial angle and subsequent hidden columella. Patient operated by open approach with chondral-mucoperichondrial flap, lowering the osteocartilaginous dorsum, columellar strut, and resection of the cephalic portion of the lower lateral cartilages.

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Figure 10
Schematic representation of a hanging columella A hanging columella classified as Type I according to the Gunter classification.

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FIGURE 11
Treatment options for hanging columella (A) Schematic representation of hanging columella. (B) Diagram representing transcolumellar approaches described by Armstrong (aggressive) and Joseph (open rhinoplasty with reconstruction of the crux medialis through structural grafts stabilized by sutures). (C) “Indirect” and (D) “Direct” approaches described by Randall.

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Figure 12
Surgical sequence for hanging columella (A) Lifting of the cutaneous flap allows observation of the excess crux medialis portion. (B) Demarcation of the area to be resected. (C) A wedge resection of the crux medialis is performed to correct the cartilage hyperconvexity commonly observed in this deformity. (D) The anatomy of the crux medialis was re-established by suturing the corrected area. (E) Schematic representation and pre-operative aspects before and after treatment.

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Figure 13
Treatment outcome of a severe case of hanging columella Owing to the complexity of the case, treatment was based on the combination of procedures described above. “Direct and indirect” approaches described by Randall were used, and partial resection of the crux medialis was adapted with sutures to treat the convexity typical of hanging columella, modifying concepts described by Armstrong and Joseph.

Figure 1 A normal columella Schematic representation of the ideal alar-columellar relationship

Figure 2 The Gunter classification of alar-columellar relationships The Gunter classification includes five subtypes. Type I, II, IV and V refer to primary deformities. Types III and VI refer to a combination of alterations observed in Types I and II, and Types IV and V, respectively.

Figure 3 Hidden columella Schematic representation of hidden columella, known as retracted columella or Type V columella, according to the Gunter classification. It normally occurs in elderly patients with acute columellar-labial angles.

Figure 4 Treatment options for correcting hidden columella (A) Schematic representation of hidden columella. (B) Chondral-mucoperichondrial nasal septal flap is our preferred choice. (C) Cartilage graft on the anterior nasal spine. (D) Structural graft, “STRUT” type, in the crux medialis.

Figure 5 A chondral-mucoperichondrial nasal septal flap Schematic representation of a chondral-mucoperichondrial nasal septal flap positioned on the anterior nasal spine, according to nasal topography, restoring the columellar-lip angle within the standards established by treating hidden columellas.

FIGURE 6 Surgical sequence of the chondral-mucoperichondrial flap (A) Demarcation of excess quadrangular cartilage portion. (B) The excess segment is cut up to the attachment of the maxillary crest. (C) The distal segment mucosa is carefully decorticated while maintaining perichondrium integrity. (D) Partial-thickness relaxing incisions are made on the cranial segment of the flap to facilitate its folding. (E) Once folded, the flap is molded with 5-0 nylon sutures. (F) Finally, the flap is positioned on the anterior nasal spine according to nasal topography and stabilized with externally fixed 6-0 nylon thread that is maintained for 7 days.

Figure 7 External fixation of a chondral-mucoperichondrial nasal septal flap The flap is stabilized using an external fixation suture with 6-0 nylon, externalized to the level of columellar-labial angle, and maintained for 7 days.

FIGURE 8 Pre and post-operative aspect of a patient treated with chondral-mucoperichondrial flap. Negroid nose with hidden columella was corrected with chondral-mucoperichondrial flap.

Figure 9 Pre and post-operative aspect of a patient treated with chondral-mucoperichondrial flap. Long nose with acute columellar-labial angle and subsequent hidden columella. Patient operated by open approach with chondral-mucoperichondrial flap, lowering the osteocartilaginous dorsum, columellar strut, and resection of the cephalic portion of the lower lateral cartilages.

Figure 10 Schematic representation of a hanging columella A hanging columella classified as Type I according to the Gunter classification.

FIGURE 11 Treatment options for hanging columella (A) Schematic representation of hanging columella. (B) Diagram representing transcolumellar approaches described by Armstrong (aggressive) and Joseph (open rhinoplasty with reconstruction of the crux medialis through structural grafts stabilized by sutures). (C) “Indirect” and (D) “Direct” approaches described by Randall.

Figure 12 Surgical sequence for hanging columella (A) Lifting of the cutaneous flap allows observation of the excess crux medialis portion. (B) Demarcation of the area to be resected. (C) A wedge resection of the crux medialis is performed to correct the cartilage hyperconvexity commonly observed in this deformity. (D) The anatomy of the crux medialis was re-established by suturing the corrected area. (E) Schematic representation and pre-operative aspects before and after treatment.

Figure 13 Treatment outcome of a severe case of hanging columella Owing to the complexity of the case, treatment was based on the combination of procedures described above. “Direct and indirect” approaches described by Randall were used, and partial resection of the crux medialis was adapted with sutures to treat the convexity typical of hanging columella, modifying concepts described by Armstrong and Joseph.

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Aesthetic treatment of retracted and hanging nasal columellas

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Mensagem

[1] Corresponding author: Liacyr Ribeiro Rua Visconde Silva, 52, salas 903/904. Botafogo, Rio de Janeiro. - CEP: 22271-092. Tel: (21) 2539-4893.