Plastic surgery of the nasal columella. Specific complications in the nasal tip area

Rhinoplasty is a concept that includes many various techniques by changing the shape of the nose. Some patients require work on the bony part of the back, others on the cartilaginous part, and still others on the soft tissues of the tip of the nose. Often there is a need for correction of the columella. What it is, how this part of the nose is corrected and what effect can be achieved with surgical intervention can be found out by thoroughly considering this issue.

Columella - what is it?

The nasal columella is the part of skin located between the nostrils. Anatomically, the columella includes the medial crura of the cartilages of the nasal wings, but they are not visually visible. It is sometimes called the column or column of the nose.

This small fragment of the nose performs a number of important functional tasks in normalizing the breathing process. By supporting the tip of the nose and maintaining optimal clearance of the nostrils, it makes it possible to freely inhale and exhale air. This means providing the body with oxygen, which is involved in all biochemical processes.

What should a columella look like?

A small area of skin called the nasal columella plays a huge role in the perception of the nose as a harmonious part human face. A beautiful columella should have the following qualities:

its width should not exceed 5-7 mm;
the angle between the nose and lip should be about 100 degrees for women, 95 degrees for men;
the column should not sag;
when looking at the face from the front, the columella should be located lower than the wings of the nose;
the nostrils should be symmetrical.

If these rules are ignored, any rhinoplasty will not be successful. The nose will look disharmonious, and the person may undergo repeated plastic surgery. While in other cases, a simple correction operation can give a more pronounced result.

Columella problems

What problems can there be with the columella to require plastic surgery of the nose - rhinoplasty?

Based on what a columella should look like, ideal in size and shape, we can identify the problems that potential plastic surgeon patients most often encounter:

the nasal column sags;
the columella is located too high;
the angle between the nose and lip is too large, or, on the contrary, small.

A person may regard his nose as too wide, with a curved tip, or snub. But in order to correct your appearance, you do not need to undergo complex and traumatic operations to change the contours of the back or its tip. Simply changing the nose column is enough.

Non-surgical correction

In the event that the column of the nose is small, that is, the angle between the nose and the lip is increased, and there the nose looks snub-nosed, or the columella leg and the wings of the nose are located at the same level, you can use

Its purpose is to inject a special drug under the skin - a filler, which increases the volume of the tissue. As a result of this, the columella of the nose becomes larger, and the nose itself looks harmonious. During the procedure, the doctor injects filler into the columella in the required volume through a needle. The intervention causes minimal pain, but if desired, you can use an anesthetic injection.

The advantages of the method are:

minimum rehabilitation period;
short duration of the procedure;
no need to do tests and functional studies before the procedure.

The main disadvantage of the method is its fragility. The duration of the effect depends on the drug that was injected into the soft tissue of the columella: a more viscous gel will remain in the tissue longer. But it is also necessary to take into account the individual characteristics of a person.

The safety of the method is great, but relative: the introduction of any substance into the body can become a catalyst for pathological processes, for example, exacerbation chronic diseases, development of autoimmune diseases. In order to avoid such consequences, you need to undergo a medical examination and consult with your doctor.

Surgical correction of columella

If the columella has large size or sagging form, the only method of correction is surgery.

But the methods that the surgeon resorts to when performing the operation may be different. Correction of nasal columella should be discussed between the doctor and the patient before surgery so that the operator is as satisfied as possible with the result.

The simplest way to reduce the columella is to remove the soft tissue and, if necessary, the adjacent cartilage. Understanding how the nasal septum is connected to the columella, we can conclude that in some cases it will be necessary to reduce the length of the septum itself, and only then tighten the columella.

During the preparation period, the doctor decides which surgical technique will be more justified in a particular case: raising the column of the nose, or deepening it to create a harmonious angle between the nose and upper lip.

For patients who are not satisfied with a temporary solution to the problem in the form of a biogel injection in a cosmetologist’s office, there is a way to preserve the result for a long time through surgical intervention. In this case we're talking about about lowering the columella or filling the columnar labial angle.

For this, cartilage implants can be used, which are installed in the columella area to lengthen the nasal septum. The implant is fixed using suture material.

Columella changes during rhinoplasty

The goal of a plastic surgeon is not only to correct a specific defect, but also to maintain the overall harmony of the nose and face, and to do this in the simplest possible way. Sometimes the nasal columella has irregular shape, but working with it will not make the face beautiful, but, on the contrary, will make other features more obvious.

Therefore, sometimes, to correct the nasal column, the doctor can make a volumetric correction, based on the structure of the nose of the person who comes to the clinic plastic surgery. The doctor can change the tip higher, thereby tightening the columella. Sometimes plastic surgery of the wings of the nose is effective when the surgeon moves them higher, so the column, remaining in the same place, becomes visually lower.

Therefore, preparation for surgery is a productive collaboration between the patient, who must explain what result of the surgical intervention he wants to see, and the doctor, who knows the structure of the nose and the person and understands what results and what methods can be achieved.

Do you need anesthesia?

The need for anesthesia during surgery is determined by the amount of work that will be performed by the surgeon. If the doctor plans to simply excise excess tissue, thereby raising the nasal column to the required height, local anesthesia can be used. For large-scale surgery, it is better to use general anesthesia.

The advantages of anesthesia for rhinoplasty can be indicated by at least two arguments:

the patient, while in a medicated sleep, does not experience anxiety, is not able to make involuntary movements, in other words, prevent the surgeon from performing “jewelry” work on his face;
with general anesthesia, the need to use local anesthetics is reduced, so the doctor has the opportunity to work with “living” tissues, rather than injected with various drugs.

To find out whether anesthesia is needed in a particular case, it is better to consult a doctor. Assessing the scale and duration of the proposed work, as well as the degree of pain of the manipulations, he must recommend to the patient the most suitable option for a particular operation.

Preparing for surgery

Rhinoplasty in Moscow, St. Petersburg and other Russian cities requires a mandatory medical examination of your health status before the intervention. For this purpose, there is a list of laboratory tests and functional studies.

	Benchmarks	Validity period
Complete urine analysis
Clinical blood test
Biochemical blood test	Total protein Creatinine Cholesterol Bilirubin Urea
Test for RW (syphilis)
Hepatitis test
HIV test
Blood clotting test	fibrinogen, PTI
Electrocardiogram
Fluorography

In addition, opinions may be required from the attending physician and, in the presence of chronic diseases, a specialist physician.

Rehabilitation

How long it will last depends on many factors: the doctor’s experience, the extent of the interventions, the patient’s health condition, and the thoroughness of following all the surgeon’s instructions.

On average, tissue healing time for nose surgery is two weeks. But if the doctor corrected only the columella, the person can return to normal life after 2 days.

It is quite possible to reduce the risk of unsuccessful intervention if you remember the plastic surgeon’s brief instructions for the patient.

Choosing a doctor is half the battle. It is important to choose a specialist who will have experience in correcting noses with just such aesthetic defects. Of course, find such a doctor for rhinoplasty in Moscow or another big city much easier.
Before the operation, colds, emotional and physical stress should not be allowed.
After surgery, you need to give the body time to heal the tissues, carefully following all the surgeon’s recommendations.

Rhinoplasty is the most common plastic surgery in the world, which is performed by people of any age and gender. And there is a reason for this: it is the nose that is called the part of the face that is to a greater extent influences the beauty of a person. Therefore, even by slightly changing the structure of a person’s nose, you can achieve a beautiful result.

Rhinoplasty It is not without reason that it is considered one of the most popular and most difficult plastic surgery.
The fact is that the structure of the nose, by its nature, is a lot of complex cartilage and bones, and nose surgery involves changing each component.
The work is painstaking, long, requiring special skills and abilities.
Also, the surgeon performing rhinoplasty must be an esthete in this difficult task, because facial harmony after surgery is a very important point.
He must have a certain taste and understanding of the outcome his manipulations will lead to, because the nose must fit into the overall picture of the face, not be a separate part of the face, and one should not forget about its functionality - the nose must breathe.
Often, rhinoplasty is combined with correction of the nasal septum, that is, restoration of proper breathing - this is already called rhinoseptoplasty, but we will talk about this in a separate chapter of our website.

The nose represents complex system, in front of you anatomical structure external nose.
The shape of the external nose is very reminiscent of a triangular pyramid, which is located with the base downwards.

Of the three surfaces of this pyramid, the back part is practically absent, because it faces the nasal cavity (the inner part of the nose), and the other two form the side walls of the nose.
The line connecting the lateral walls of the nose represents the bridge of the nose.

The nasal cartilages are the remnants of the nasal capsule and form in pairs the lateral walls (lateral cartilages), the wings of the nose, the nostrils and the movable part of the nasal septum, as well as the unpaired cartilage of the nasal septum.
The bones and cartilages of the nose, covered with skin, form external nose

There are two methods of nose surgery:

open;
closed.

Open rhinoplasty it is more often used in cases where it is necessary to work directly with the bony part of the nose or cartilage.
The operation is performed under general anesthesia and lasts on average 3 hours. The incision with this approach is located in the columella area. During the operation, the surgeon sees all the structures of the nose without any problems, everything is in full view.

Yes, rehabilitation is a slightly longer process, swelling and bruising are more pronounced than after closed rhinoplasty, but an undoubted and big advantage is the predictability of the result.

Closed rhinoplasty The good thing is that the scars are located inside, along the nasal mucosa, the stitches that are inside tend to dissolve and do not need to be removed.
The closed technique is less traumatic; there is no temporary disruption of blood circulation from damaged columellar arteries. The closed technique also has its disadvantages: suturing the cartilage arches is difficult, which complicates the process of achieving symmetry.

Rhinoplasty is divided into several types:

Nostril rhinoplasty. The purpose of the operation is to reduce the nostrils and change their shape.
Septorhinoplasty. Surgery to correct the nasal septum and restore breathing. Deviations of the septum can be traumatic (resulting from injury), physiological (shifts or growths), compensatory (the shape of the shells, which prevents normal breathing).
Conchotomy. Surgery for mucosal hypertrophy aimed at restoring respiratory function.
Columella correction. This manipulation involves changing the bridge between the nostrils.
Authentic rhinoplasty. Designed for cases where it is necessary to raise the bridge of the nose.
Grafting. Surgery to enlarge a small or very short nose.
Correction of the tip of the nose.
Contour rhinoplasty. It involves cosmetic correction of the shape of the nose using fillers (gels).
Secondary rhinoplasty (repeated). This is a more difficult task in surgery. It involves correcting the shape of the nose after an unsuccessful operation. In this case, it is more difficult for the surgeon to work, especially when it comes to correcting other people’s mistakes, because the surgeon initially sees only the outer nose and has no idea what awaits him inside. Sometimes the nose that seems not so complicated, when “opened”, can turn out to be the most difficult, just like a house, brick by brick, you first have to take the nose apart, then put it back together again.

Indications for rhinoplasty:

“saddle” nose shape;
thickening of the tip of the nose;
excessive length of the nose;
wide or large nostrils;
breathing problems;
wide bridge of the nose;
deformations (after injuries);
congenital deformity;
curvature of the nasal septum (cleft palate, cleft lip);
hump.

Contraindications

infectious diseases;
malignant neoplasms;
diabetes mellitus (we are talking about uncompensated);
psychological diseases;
bleeding disorders;
diseases of the cardiovascular system;
age less than 18 years;
atrophic rhinitis;
It is forbidden to perform operations during menstruation;
pregnancy
lactation period;
inflammatory processes in the oral cavity;

Two weeks before surgery, the patient should stop taking any medications containing aspirin;
One day before surgery; it is necessary to avoid fatty foods;
Six hours before surgery, the patient should not eat or drink;
It is better to refrain from smoking on the day of surgery.

Operation.

After preparatory stage for rhinoplasty is completed, and it includes a preoperative consultation, tests, and a conversation with an anesthesiologist.
It's time for surgery. First of all, the patient should not worry and be prepared for a good outcome.
Before the operation you must:

wash off makeup;
remove all jewelry;
remove polish or other coating from nails.

The operation, we repeat once again, is performed under general anesthesia, which is administered by drip.
The patient is asleep during the operation and is unconscious and intubated. The anesthesiologist remains in the operating room during the operation and closely monitors all instruments.

Depending on the surgical technique and the desired result, the doctor makes incisions and tissue detachment (in inner edge mucous membrane or in the columella area).

Nostril surgery. Occurs without interfering with the bone structures of the nose. Correction occurs by excision of mucocutaneous and skin fragments along the contour of the nostrils at the base of the nose. In the final version, small scars remain, which become invisible by the age of one year.

Septorhinoplasty. It involves the correction of not only aesthetic aspects, but also the restoration of nasal breathing - correction of the curvature of the nasal septum. During the operation, the curved cartilage and bone parts of the nasal septum are removed, which make it difficult for the patient to breathe.

Conchotomy. Consists of resection (partial or complete removal) pathologically enlarged nasal turbinates. The turbinates are bony projections in the lateral wall of the nose, covered with mucous membrane. This operation is one of the types of operations to restore nasal breathing.

Columella correction. The operation involves engraftment cartilage tissue(if enlargement is necessary), and excision (if volume decreases). Most often combined with plastic surgery of the tip of the nose.

Authentic rhinoplasty. It is a manipulation aimed at raising the height of the bridge of the nose. This can occur through the installation of a graft from the cartilaginous part of the nasal septum and auricle or an osteochondral graft from the rib.

Grafting. Involves increasing the length of the nose. The choice of surgical technique depends on the original shape of the nose. In some cases, downward rotation of the tip of the nose will help, in others, reducing the support of the medial crura after resection of the quadrangular cartilage.

Correction of the tip of the nose. The operation involves changing the shape of the tip of the nose; the technique also depends on the original nose.

Contour rhinoplasty. Correction of the shape of the nose using gels. Depending on the desired result, the specialist injects the gel into the areas being corrected.

Secondary rhinoplasty. The most difficult thing about rhinoplasty. Aesthetic surgery aimed at changing the nose after unsuccessful primary surgery. The consequences of unsatisfactory plastic surgery can be very different. The technique of performing secondary rhinoplasty depends on this.

After the operation, open or closed, the doctor applies a plaster cast and packs the nasal passages to prevent bleeding.

Nasal tampons are removed after at least 6 hours. Everything depends on individual characteristics, and is performed at the discretion of the surgeon.
The cast is usually worn for 8-9 days, after which it is safely removed along with the sutures (in the case of open rhinoplasty).

in the first days it is better not to be active, lead a calm lifestyle, and get more rest;
physical activity is prohibited for a month;
saunas, steam baths, hot baths and solariums are prohibited for 3 months;
the first week it is better to eat warm food and drink warm drinks (not cold or hot);
It is forbidden to wear glasses for 3 months, use lenses.

Side effects that you don’t need to worry about after surgery:

hematomas around the eyes;
extensive swelling of the face and nose;
difficulty breathing (stuffiness due to swelling of the mucous membrane);
after surgery, weakness and nausea are possible;
numbness of the nose, as well as disruption of the usual facial expressions;
nasal discharge (blood, mucus);
increase in temperature;

Let's also talk about complications that are more serious in nature. After all, forewarned is forearmed.

Complications that you may encounter:

Aesthetic dissatisfaction (external);
"saddle" shape;
Deviation of the nose;
drooping tip of the nose;
beak deformity;
scars and adhesions;
divergence of seams.
perforation of the septum;
toxic shock;
abscess (inflammation);
breathing problems caused by incorrectly performed surgery.

Rhinoplasty gives excellent results, makes the patient happier, helps many get rid of complexes, and become more self-confident. But the decision about surgery must be balanced and thoughtful. If you don’t know exactly what you want, don’t understand what doesn’t suit you, and what you expect from plastic surgery of the nose, it’s better to wait your time and take your time.

This chapter describes the first stage of rhinoplasty surgery. At this stage, the necessary incisions of the nose are made, allowing you to see its basis - bones and cartilage.

Look at the images above. An external incision is made along the dotted line in the shape of an inverted V; other incisions are made in the nasal cavity on the mucous membrane. An operation during which the skin is cut is called open rhinoplasty. If access is made only from the nasal mucosa, closed rhinoplasty is used.

The part of the nose where the incision is made is called the columella or column. In the picture the columella is colored blue ohm The incision is made in its narrowest part (indicated by red arrows). This is called a "trans-collumer" incision. The columella is at its greatest width above and below this place.

The incision is made in the narrowest part of the columella, so that the scar left after the operation is minimal. Although after the wound has completely healed, it becomes practically invisible.

As a rule, the operation begins not with an external incision, but with one of the internal ones. With the left hand (the operation in the photographs is performed by a right-handed surgeon), the tip of the nose is turned to the left, thereby securing the position of the nose itself. This also opens up access to the site of the future incision. The images above demonstrate the process described. The left figure shows its beginning, the right one shows a ready-made incision, which is called the medial-marginal one. During this part of the operation, a regular medical scalpel is used.

Next, the lateral part (“lateral” is distant from the middle, i.e. in this case it is the side part) of the marginal incision is performed. The incision is called a marginal incision because it is made along the edge of the nasal cartilage (shown in blue in the top image) that gives the tip of the nose its shape. Once the incision is made, the entire cartilage can be seen.

In the top left image, the small red line indicates the lateral part of the incision. The small red stripe next to the columella is the medial part of the incision (the incision along the columella). Next, both parts of the cut are connected.

Pay attention to the work of the surgeon's hands. Left hand fixes the nose in the required position, pulls the cartilage to the side, which is necessary for making precise cuts, and also performs many other functions. In this case, the left hand holds a retractor, which opens access to the right nostril. The finger of the hand presses on the nose, opening a place for the incision and giving direction to the scalpel, which is held, accordingly, with the right hand.

We return to the external cut (indicated by the red line).

The next stage of the operation is to separate the skin of the tip of the nose from the cartilage located underneath. Scissors (necessarily with blunt ends) are wound from the inside of the columella (picture above). They are then carefully opened and the skin is separated from the cartilage. This action must be carried out with utmost care so as not to damage the tightly connected skin and cartilage.

Pay attention to the image. Don't forget that the blue part of the nose is called the columella, the green part is the tip of the nose, and the base is circled with a red triangle.

After we have separated the skin from the cartilage at the tip of the nose, we need to do the same on the colummel. To do this, the scissors are inserted into the medial marginal incision and carefully advanced further until they appear on the other side (see image below).

The main advantage of external rhinoplasty over internal rhinoplasty is that the surgeon receives best review nasal cartilage, which in turn allows the operation to be performed under full visual control.

Also, the use of external rhinoplasty is justified in case of repeated surgery. As a rule, such a need arises after the previous one was unsuccessful.

And so we move on to dissecting the columella. It is necessary to start the cut at the top of the inverted letter V. At the same time, the left hand pulls the tip of the nose upward, and the little finger right hand moves the columella down, stretching the skin, which in turn facilitates the incision. From the top, a cut is made to the base sequentially in both directions.

In order to ensure the successful completion of the stage of the operation, it is necessary to slightly spread the skin along the edges of the wound. If the columella opens slightly, then the incision is made correctly.

The thickness of the skin of the columella is minimal, so the incision must be made very carefully so as not to damage the cartilage lying directly under the skin.

Although the external incision produces a scar, in many cases its use is necessary. It should be noted that if the operation is performed by a qualified surgeon, then the scar is almost impossible to see. Especially after it has healed (look at the images above, the red line indicates the location of the scar).

Here it is worth touching a little on the topic of unqualified doctors. Although this requires a separate discussion, and not within the scope of this article.

Let's look at an example. The surgeon who performed the operation (see image) made many incorrect cuts at the base of the nose. In this case, he made the following mistakes: he made the trans-collumer incision incorrectly (indicated green), which, if done correctly, leaves no traces at all. The next mistake is the incorrect cuts he made to reduce the size and thickness of the skin of the nostrils (indicated in red and blue respectively).

Therefore, carefully approach the issue of choosing a plastic surgeon. After all, postoperative mistakes cannot always be corrected.

Let's return to the course of the operation. After dissecting the columella with a scalpel, the skin is cut through its entire thickness with scissors. This will expose the tip of the nose and get to the desired cartilage.

The skin above the incision site is lifted upward using a two-pronged retractor. And the lower part remains in place (in the right picture the red line indicates the location of the cut).

The tip of the scissors separates the soft tissue of the columella from the cartilage. The cartilages located at the tip of the nose are called lower lateral cartilages (in the picture, the right cartilage is colored blue).

The pink color in the top picture indicates the surface of the skin adjacent to the cartilage of the tip of the nose.

Thus, access to the lower lateral cartilages is gained. Next, using scissors, the soft tissues of the tip of the nose are completely separated from them.

We all know that traditional use scissors involves placing an object between the blades and cutting it. Most of the time, the rhinoplasty surgeon will use this instrument slightly differently. Most often he performs sliding movements rather than cutting ones. To expose the lower lateral cartilages, the surgeon closes the scissors, places the ends of the scissors on the surface of the cartilage, and then opens the scissors, pushing the tissue apart with the blades of the scissors.

Now the cartilage of the tip of the nose is completely open and you can see the cartilage that forms the bridge of the nose (shown in pink in the figure, the lower right cartilage is indicated in blue).

To ensure that the skin separated from the cartilage does not interfere with further surgery, a retractor is used to hold it in place.

Now the lower and upper cartilages have become available (in the photo the upper cartilage is indicated in green, and the lower ones in blue and red, respectively).

It should be noted that in the images shown there is almost no bleeding. This is explained as follows. The nose, like any other part of the body, has areas with abundant blood supply and areas in which the number of blood vessels is minimal. A qualified surgeon leaves areas with a large number blood vessels, which avoids major bleeding and does not interfere with the operation.

Let's clarify some points on anatomy and terminology (see photo above).

The tip of the nose is the designated part pink on the right photo and circled in red on the left photo.

The bridge of the nose is the part between the tip of the nose and its upper point, located between the eyes. In the image, the bridge of the nose is marked in blue.

A hump is a part of the nose, usually located in the middle of the bridge of the nose. Often in this place the nose has a bend (in the picture the hump is indicated by a green arrow).

The upper part of the nose, located closer to the eyes, is formed by the nasal bones, and the lower part is formed by cartilage. In the image, the boundary between bone and cartilage is shown as a black wavy line.

The nasal bones are firmly attached to the bones of the skull. The lower part of the nose, formed by cartilage, is much more mobile (that’s why, for example, boxers’ noses are always broken in the lower part).

The border separating the nasal bones and cartilage is located at the very top of the nasal hump (if, of course, it is noticeable, otherwise this place can be determined by touch).

The photograph does not show the bony part of the nasal bridge, despite the fact that the skin is pulled upward with a retractor (the cartilage that forms the nasal bridge is colored green).

The right lower lateral cartilage in the photograph is painted in two colors. The red color indicates the lower part of the cartilage, which forms the columella, and the yellow color indicates the upper part, which is located above the nostrils. At the junction of these areas (indicated by the blue arrow), the most protruding part of the tip of the nose is formed.

It's easy to tell the two areas apart from each other in the photo above. At the junction, the cartilage forms a slight bend, which is indicated by a white line.

Also, a blue arrow indicates the place where the collumellar part of the cartilage transitions to the lateral part. It is this area that we perceive as the tip of the nose. This junction is called the dome of the inferior lateral cartilage. In the figure, the dome is marked in green.

The top image shows normally positioned, previously unoperated cartilage. The right nasal cartilage is colored blue. The skin over it is pulled upward with a retractor so that a small part of the cartilage of the dorsum of the nose, colored green, is visible.

The photo above shows both cartilages from the same patient. This is a rare case when the cartilage is completely symmetrical. They usually vary slightly in size and shape, making rhinoplasty surgery difficult.

When the cartilages of the tip of the nose are strong enough, and the skin covering them is thin, a small visible groove forms between the cartilages (shown in blue in the photo).

It can be easily detected by pressing your fingernail on the tip of the nose (dome).

If the groove between the cartilages is clearly visible, then the tip of the nose is called cleft.

The picture above shows a typical view of the tip of the nose after it has been opened. The lower right cartilage is bent down with a special metal hook, which allows you to clearly see the area of separation of the cartilages (the left cartilage is highlighted in blue, the cartilage of the nasal dorsum is highlighted in green).

It is necessary to pay attention once again to the fact that the shape and size of the cartilage are clearly visible only when they are thoroughly cleaned of soft tissue.

Look at the top photos. On the left is a previously unoperated patient with normal lower cartilages. On the right is the result of a poorly performed rhinoplasty. In this case, the cartilage is covered with a thick layer connective tissue, so it's quite difficult to see them. Repeated surgery, which must be performed due to unsatisfactory results of the previous intervention, will be somewhat difficult because In this case, it is not easy to isolate the cartilage without damaging it.

Here is another patient's nose after a failed rhinoplasty.

Instead of the normal cartilage that one would like to see, in this case there are large growths of scar tissue.

Let's immediately define what a columella is. The columella, or, as it is also called, the column of the nose, is a fold located between the nostrils. It is formed by the skin component and the legs of large wing cartilages. The aesthetic appearance of the nose, the contours of its nostrils and their symmetry depend on the columella. According to modern canons of beauty, it is generally accepted that it should be slightly below the level of the nostrils.

In addition to its aesthetic function, the columella also has an anatomical load - it must maintain the tip of the nose in an elevated state and form an adequate lumen of the nostrils, ensuring the unimpeded entry of air into the nasal cavity.

When is columellaplasty performed:

The tip of the nose is too turned up due to a high columella.
Drooping of the tip of the nose.
The nasolabial angle is too sharp or too blunt.
“Dangling columella” is an anatomical feature when the columella is lowered too low compared to the level of the nostrils.

Columella enlargement is performed using transplantation of the patient's own tissue or biocompatible grafts. If it decreases, on the contrary, its partial excision is required. However, changes appearance columella does not always require surgical treatment of it; most often, complex plastic surgery of the tip of the nose, including its wings, is required. Let's look at the operations in a little more detail.

You can enlarge the nasal column in one of the following ways:

Install cartilage grafts.
Apply sutures to the medial crura of the alar cartilages.
Inject fillers or the patient’s own fat tissue into the columella area.

If the patient has a smoothed nasolabial angle, partial excision of the columella or resection of the edge of the quadrangular cartilage is performed.

In case of a pointed nasolabial angle, the nasal septum is enlarged using biocompatible expanding grafts or sutures are used on paired alar cartilages.

Columella surgery is performed under general anesthesia or local anesthesia, depending on the extent of the intervention, which lasts 20-40 minutes. Prolonged hospitalization is not required.

Contraindications to columella plastic surgery

Contraindications are standard, as for most plastic surgeries:

Chronic diseases in the stage of decompensation.
Violation of the blood coagulation system.
Presence of skin diseases in the area of intervention.
Acute respiratory diseases.

Postoperative period

Recovery after columella plastic surgery is much easier than with rhinoplasty, because In the case of this operation, the bone structures of the nose are not affected. There is no difficulty in nasal breathing. During the first 1.5-2 months, swelling and pastiness of the operated tissues is possible, but this is visually noticeable only in the first weeks.

There are also no special restrictions in the postoperative period. Recommend reasonable abstinence from excessive physical activity, excluding the effects of thermal procedures - baths, saunas, hot baths. You also need to protect your nose from physical injury, in particular
To avoid accidentally damaging the tip of your nose while sleeping, it is better to sleep on your back.

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Dropped tip

The most important principle in preventing unwanted changes in the nasolabial angle is to evaluate the anatomy and supporting mechanisms of the nasal tip and then maintain or enhance tip support, which will restore more natural look nose As noted above, actions that result in loss of tip support can create the appearance of a dropped tip (tip ptosis and hyperacute nasolabial angle). Normal nasolabial angle (the angle determined by the intersection of lines drawn from the upper point of the columella to the subnasale and from the subnasale to the border of the red border upper lip) is equal to 90-120°. Within these limits, a more obtuse angle is desirable for women, and a sharper angle for men. Loss of tip support can lead to nasal ptosis and decreased projection.

Treatment for complications associated with a drooping nose is based on restoring nasal support and prominence. If a complication such as nasal tip drooping occurs, future correction depends on correct diagnosis. There are many ways to increase nasal tip support and restore nasal prominence and rotation (Table 1).

Table 1

Operational actions

Increased rotation

Truncation of lateral legs
Sewing the arches with through seams, displacinglateral legs to the center
Resection of the caudal septum from the base upward(not permanent effect)
Cephalic resection (variable effect)
Pplication of the lateral legs
Rounding grafts (not permanent effect)
Apparent rotation - increase in double kink,rounding grafts (make the nasolabial angle more stupid)

Decreasing rotation (reverse rotation)

Full through (transfixation) incision
Replanting a two-layer graft into the tip
Shortening of the medial crura
Rebuilt L-brace, as inreconstruction of the saddle nose with costal cartilage(single back graft/support for columella)

Increasing protrusion

Truncation of the lateral legs (increased protrusion and rotation)
Transplantation to the tip
Rounding grafts
Anteriormaxillary grafts
Sutures of the septum and columella (hidden)
Columella support (not permanent effect)
Caudal extension graft

Reducing protrusion

High partial or full through cut
Plication of the lateral crura (reduction of protrusion,increase in rotation)
Reduction of the nasal bridge
Vertical division of vaults with excision of excessmedial legs followed by suturing

Length increase

Caudal extension graft
Root graft
Double layer tip graft
Rebuilt L-brace

Length reduction

See increased rotation
Also deepening of the nasofrontal angle

Excessively upturned (rotated) nose

On the contrary, you may encounter an overly rotated nose, with an angle that is too obtuse. Excessive resection of the caudal septum is common cause out of excess rotation of the tip of the nose. This rotation creates an unsightly appearance.

Careful preoperative assessment may identify those patients in whom surgical rotations should be avoided. Treatment for complications associated with a short, upturned nose is based on lengthening the nose and reversing its rotation. There are special rhinoplasty procedures that lengthen and rotate the nose (Table 1).

Bulges

A bulge is a fracture of the lower lateral cartilage at the tip of the nose due to the force of scar contracture acting on the weakened cartilages. Patients with thin skin, strong cartilage, and a bifurcated nasal tip are at particularly high risk. Excessive resection of the lateral crura and failure to correct vault discrepancy may play some role in the formation of the bulge. It is believed that the bulges are a consequence of scar contracture of an overly narrowed marginal strip, leading to postoperative healing to the formation of a rounded protrusion. Some researchers have described a connection between cartilage splitting techniques and the formation of bulges. However, others are confident that vertical vault division methods are reliable in correct execution and do not create such problems.

As an isolated deformity, bulges are usually corrected through a small marginal incision with minimal undercutting over the affected side, followed by clipping or excision of the portion of cartilage causing the deformity. In some cases, a thin backing of cartilage, fascia, or other material is used to smooth and conceal the area.

Pulling the wings back

To improve the appearance of the nasal tip, cephalic resection of the lateral crura of the inferior lateral cartilages is often attempted. If excess cartilage is left, the contractile healing forces will, over time, cause the alar tissue to be pulled posteriorly (Figure 1).

Rice. 1. A patient many years after rhinoplasty with a disproportion between the alae and columella due to posterior retraction of the nasal alae

This is a frequently visible consequence of over-resection of the lateral crura. The surgeon's heuristic rule is to protect the entire strip with a width of at least 6-9 mm. However, anatomical study of the alar base shows that in the normal population, a thin alar margin is present in 20% of patients. This anatomical variant must be recognized to prevent the risk of retraction of the alar alar region and/or collapse of the external nasal valve. Such patients may require an even more conservative approach. It is necessary to preserve the mucous membrane of the vestibule, since its excision promotes scar contracture with retraction of the wings.

Retraction of the nasal wings in simple cases (1-2 mm) can be corrected with cartilage grafts. The area of retraction is marked before the anesthetic is administered, and a small marginal incision allows for the creation of a precise pocket. An excised cartilage graft (usually from auricular or septal cartilage) can be inserted into this precise pocket; it should extend down to the sesamoid cartilages and be wide enough to mimic normal shape lateral crus and fornix.

In more severe cases, composite ear grafts are often used. The best contour is provided by the concha of the opposite ear (for example, left wing - right ear). After an incision is made a few millimeters from the edge of the nostril, a careful dissection is made to separate the adhesions, create a pocket, and displace the alar rim downward. The appropriately excised composite graft is carefully sutured into place.

Disproportions of the wings and columella

Alar and columella imbalances can cause significant distress to the patient. The degree of normal protrusion of the columella down from under the wings is usually 2-4 mm. The complexity of the relationship between the alar and columella was grouped by Gunter et al., who described the position of the alar and columella in relation to a line drawn through the long axis of the nostril. All patients are divided into those with drooping, normal or retracted wings, as well as a sagging, normal or retracted columella. That is, there are nine possible anatomical combinations, relationships between the wings and the columella (Fig. 2).

Rice. 2. The relationship of the wings and columella can be described by nine possible anatomical combinations (from Toriumi DM, Becker DG. Rhinoplasty Dissection Manual. Philadelphia: Lippincott Williams & Wilkins; 1999. With permission).

Disproportion between the alar and columella can also be observed in the unoperated nose; it can also be caused by surgical failure (Fig. 1). A protruding or sagging columella may result from a remaining uncorrected deformity, such as a medial crura that is too wide or a caudal septum that is too long. The deformity may represent excessive downward protrusion of the columella from under the wings, secondary to retraction of the wing margins rather than true protrusion of the columella. An insufficient or retracted columella may be a manifestation of a pre-existing uncorrected deformity and may also be caused by excessive resection of soft tissue, cartilage, or nasal spine. The surgeon should avoid excessive resection of the caudal septum, as well as resection of the nasal spine.

Correction of a protruding or sagging columella may involve full-thickness resection of the membranous columella, including the skin, subcutaneous tissue, and possibly part of the caudal end of the septum itself. If the medial crura is too wide, correction may involve sparing excision of the caudal edge of the medial crura.

Columella retraction can be corrected with rounding grafts inserted at the base of the columella to change the acute nasolabial angle; For minor deformities, columella supports may also help. A cartilage graft can be used to lengthen a short nose. The use of composite grafts has been described.

Beak deformity

A beak deformity is defined as varying degrees of fullness above the tip of the nose combined with an unnatural tip-to-above-tip relationship (Figure 3). There may be several reasons for this, including failure to maintain adequate tip support (postoperative reduction of protrusion), inadequate removal of the cartilaginous hump (anterior septal angle), and/or dead space/scarring in the area above the tip of the nose.

Rice. 3. Patient with an over-resected bony dorsum and an under-resected cartilaginous dorsum. Her beak deformity was associated with a long cartilaginous dorsum and was therefore corrected by additional excision of the cartilaginous dorsum. To create a more balanced profile, the excessively reduced upper third of the nose has been enlarged. (A) Lateral view before surgery. (B) Lateral view after surgery.

Correction of coracoid deformity depends on the anatomical cause. If the cartilaginous hump has not been sufficiently resected, the surgeon must additionally remove part of the nasal septum. Adequate tip support must be maintained; therefore, manipulations such as installing a columella support may be useful. If the bony hump is excessively resected, a graft may be required to augment the bony dorsum. If coracoid deformity is associated with significant scarring, then Kenalog injections or nasal splinting with a tape should be used in the early postoperative period before considering surgical revision.

Columella section

The external approach for rhinoplasty involves a columella incision. Great care must be taken when making the incision to make it not oblique, but perpendicular to the skin, thereby avoiding complications such as the formation of a manhole cover-type deformity. Also, great attention should be paid to the process of suturing the incision to prevent tucking of the edges or other deformations (Fig. 4).

Rice. 4. When performing external rhinoplasty special attention attention should be paid to the columella incision and suturing. To prevent visible deformation, great care must be taken to perform these manipulations correctly (see text) (from Toriumi DM, Becker DG. Rhinoplasty Dissection Manual. Philadelphia: Lippincott Williams & Wilkins; 1999. With permission).

A single subcutaneous polydioxanone (PDS) suture may be placed to improve eversion of the skin edges and relieve tension on the suture line. This seam should ensure that the edges of the skin are aligned and turn out easily. Excessive eversion will create a deformity that may take many months to resolve. This seam should accurately align the skin sections; otherwise, an unattractive scar may form. If there is no tension on the skin, a subcutaneous suture may not be necessary.

Five vertical mattress sutures made of 7-0 nylon are used to close the skin. The first seam trims the top of the inverted "V". To properly align the incision, the next two sutures are angled from the medal portion of the inferior flap to the lateral portion of the superior flap. A 6-0 chrome catgut suture is used to smooth the vestibular skin at the corner of the columellar flap. This corner suture is important because improper healing at this corner can result in visible retraction.

Daniel G. Becker

Complications of rhinoplasty