How to Fix A Hanging Columella And Alar Retraction Using Tongue In Groove Setback And Alar Rim Grafts

Thomas Lamperti, MD narrates the his latest operating room video in which he demonstrates how to repair a hanging columella, alar retraction and excess nostril show using a open revision rhinoplasty technique utilizing a Tongue In Groove Columellar Setback along with bilateral Alar Rim Grafts.

To learn more about this patient's surgery head to her rhinoplasty before and after gallery to see more photos.

Video Transcript:

"This is Seattle facial plastic surgeon, Dr. Thomas Lamperti. Today I'm going to go over a revision rhinoplasty surgery case of mine in which I correct a hanging columella and alar retraction using a tongue in groove setback technique along with alar rim grafting.

This patient had  two prior rhinoplasties done elsewhere and you can see how she was left with a persistently prominent hanging columella and retraction of her nostril rims.

I’ll now go ahead and show you the 7 month postoperative results and then we’ll go over the steps I used to make these changes. You can see how there is much reduced columnar show and an improvement to the patient’s nostril retraction from this left profile angle. Similarly you can see how the right side also has marked improvement to the relationship between the columella, nostril rims and nostril show. Lastly, let’s look at the frontal view. Note how the columella is much less prominent and hanging even from this angle. The nostril positions are also improved as well.

I began the revision rhinoplasty by using an open rhinoplasty approach to gain the needed access to the patient’s nasal tip. Having already done that I’m now separating the medial crura from each other. Given the patient’s prior rhinoplasty surgery I’m encountering quite a bit of scar tissue in the area. I’m carefully separating the tissue and ultimately we’ll see the caudal edge of the patient’s nasal septum.

In order to properly set back the medial crura onto the caudal septum using a tongue in groove technique I must also free up the skin lining that is in the area. This will also give me access to the patient’s septal cartilage so I can harvest a portion of the cartilage to carve the planned rim grafts for later in the surgery. I’m now elevating the skin covering over the septum on both sides to allow me to perform the septoplasty surgery and harvest some septal cartilage. Using various tissue elevators I’m now lifting the septum lining. There is normally a nice natural tissue plane here but due to the previous surgeries there is a lot of scar and adhesions making this process a bit more complex. I just carefully dissect both sides free.

Now that the septal cartilage is properly isolated I’ll now use a scalpel to incise the cartilage to allow me to remove a piece for rim graft carving. Here I’m separating the cartilage from any bone attachments. And now I’ll remove the harvested cartilage. I’m placing it a a small saline bath to keep it hydrated.

Now we’ll move onto the tongue in groove columellar setback. You can see the power of totally freeing up the tip and medial crura in this fashion as I now have the ability to reliably place the medial crura where I want them. In this case I will be overlapping the two medial crura with the patient’s caudal septum and then suturing all three layers together using a mattress suture. I’ve moved the columellar edge upward several millimeters in this case in order to correct the pre-existing hanging columella. The suture I’m using in this case (a 5-0 monocryl) will dissolve in a few months after which time the cartilages will have properly scarred together. I bury the knot via a stab incision over the left medial crural footplate.

I’m now visually assessing the new columella position to make sure I’m happy with the amount of setback I created. I’ll now secure the remainder of the tip cartilage starting with the intermediate crura. These sutures will be totally buried. This suture will add the needed amount of additional tip support to allow for a nice long term result. I’m checking the columella position once again to make sure I’m still happy with the result. You can see that it looks better already. We do have to be careful that we aren’t inadvertently rotating the patient’s tip upward as we put the tip back together. Of course, if the patient had a droopy tip we could rotate it if we wanted to, but this patient’s tip rotation is excellent already. I’m now placing an interdomal suture to secure the the domes together. We don’t need to change the interdomal distance so we’re just re-approximating the cartilage to where they were originally.

Now it’s time to carve the alar rim grafts. I’ve removed the harvested septal cartilage from its saline bath. I’ll now carve strips from the cartilage to then use as the rim grafts. I’ll now dissect a small tunnel where I want to insert the rim graft on the left side. I’m making the tunnel fairly narrow so the cartilage won’t have any room to wiggle out of position. I’ll now insert the cartilage into this tunnel. I’ve softened the medial end with forceps and carved the end to further bevel the edge. I’ll now place a dissolvable suture loop around the cartilage to keep it in position. I’ll now repeat the entire process on the right side. Here you can see how I’m chamfering the edges a little bit. Once I’m happy with the rim graft carving and size I’ll insert the graft into the right side tunnel. I’ll now fine tune the medial edge shape and soften it by morsalizing  the tip with forceps. Lastly, I’ll suture the medial end in place. Now you can  see the final appearance once we’ve sutured the rhinoplasty incisions closed.

Well thanks for watching. You can read more about this patient’s case and see additional before and after photos at the link provided in the video description."