Cosmetic Surgery New Jersey

	Figure 1. The long axis of the nostril is used as a reference line to assess the alar-columellar complex ln patients with a hanging columella.

The high point of the alar rim and the most inferior aspect of the columella should each he less than 2 mm from the reference line. A hanging columella exists when the most inferior aspect of the nostril is greater than 2 mm from the reference line. Similiarly, a retracted ala is when the high point of the alar rim is more than 2 mm from the reference line. Excessive visibility of membranous septum or "columella show" results when there is more than 4 mm between the alar margin and columella at their greatest distance.

Analysis and correction of the deformity has been previously described.' Traditionally, the origin of the hanging columella has been thought to be due to an increased width of the medial crura, to an excessive caudal descent of the medial crura, or to a very prominent caudal end of the septum. The surgical techniques for correction have been classified as either in-direct or direct depending on their focus.

Figure 2. A, Normal mediat and lateral crurat orlentation. B. Exaggerated curvature of the media/ crura that causes a hanging columella.

The indirect repairs referred to trimming of the caudal septum or the adjacent cephalic edges of the medial crura, or eliptical excision of the membranous septum. The direct repairs required excision of a composite piece of skin and cartilage from the caudal margin of the medial crura.

When intermediate crura are noted to he vertically oriented, Gunter et al' suggested resection of a portion of intermediate crura with reapproximation. Adamson et al' stated a broad vestibular vault, ptosis of the medial crura, and inappropriate placement of a columellar strut were additional causes to consider.

We propose that the primary anomaly seen in the hanging columella are long C-shaped medial crura that are fixed in position by their continuity with the lateral crura (Figure 2).

	Figure 4. Note the C-shaped medial crurus with excessive posterocephalic return of the foot.

Appropriate correction of the hanging columella should be directed toward its underlying cause. This requires straightening the excessively curved medial crura. which repositions their most dependent portion, resulting in a reduction of the distance between the most caudal portion of the columella and the most cephalic portion of the alar rim. Transection of the medial and lateral crura at their angles allows for appropriate reorientation.

In our 10 consecutive patients, we found the primary cause to he long and excessively curved medial crura resulting in increased alar rim to caudal columella distance. We oh-served C-shaped medial crura with normal width, fixed in excessive curvature by the lateral crura (Figure 4).

Figure 5. A. Preoperative view. B. intraoperative view following the repair of the hanging columella. C. The external approach demonstrates excessively curved medial crura. 0, Repair was performed with angle transection, columellar strut. and tailoring of the medial crural feet.

In all cases division of the alar cartilages at the angle of the me-dial and lateral crura separated the connection of these structures and allowed the medial crura to be straightened, from) an exaggerated C-shape to a straight line or minimally curved configuration (Figure 5).

The distance from the most caudal portion of the columella to the nostril reference line was reduced as noted in all postoperative photographs. This was paralleled by an obvious decrease in columellar show in all patients. Eight of the 10 patients had no previous nasal surgery; 2 had undergone previous rhinoplasties.

Preoperatively. 5 patients had reported unsightly nostril show, while the other 5 reported dissatisfaction with the appearance of the nasal tip. In this group the hanging columella was noted as a component of the nasal base deformity by the surgeon (A.I.G.).

	*c-r indicates the columella equals the reference line distance measured in preoperative and postoperative photographs. t Patient underwent previous rhinoplasty. Only patient for whom the surgeon trimmed the feet of the medial crura.

Slight septal shortening was required in 2 cases (patients 3 and 7). This was primarily done to accommodate a columellar strut with an extended shield graft in patient 3 and to assist in nasal shortening in patient 7. Tailoring of the feet of the medial crura assisted in straightening in 1 case (patient fI). columellar struts were used in 5 patients (Table).

Although these provided additional medial crural staightening, their function was mostly for tip support, rotation, and projection.

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