Most rhinoplasty surgeries done today use an open approach. By degloving the nasal tip skin through a columellar skin incision, the exposure to see the underlying cartilage structure offers more consistent and controlleable structural changes. While most of the attention focuses on the incision located at the midportion of the columellar skin, the true tradeoffs for making this open approach are more occult.
When the skin is lifted off the tip of the nose, scar tissue will develop from the middle vault across the tip down to the base of the columella. Scar tissue notoriously contracts as it heals. By doing so a scar band develops which can contribute to a nasal tip deformity marked by a rounded and less defined tip and less tip projection. This process is magnified if additional dissection is done to resect the caudal end of the septum or trim the distal ends of the upper lateral cartilages, disrupting a large number of suspensory ligaments and creating even more scar.
While suturing of the tip cartilages, as is often done to reshape them, can restore some support, it is often not enough to resist the protracted effects of scar contracture. The proven and now commonly used method to support the nasal tip is the columellar strut graft. Almost always harvested from the nasal septum due to its straightness, it is a long thin graft secured along the medial footplates of the lower alar cartilages. It can be extended from the anterior nasal spine up to the domes.
Like an internal tentpole, the columellar strut provides support to the tip that is more than adequate to resist contracture deformities. It can also be used to help build up a weak tip for more projection or refinement or, increase or decrease tip rotation. When attached to septal extension grafts, it a very effective component to lengthening the short or over rotated nose. Its effectiveness has made the columellar strut concept a staple of modern day rhinoplasty.
While the septum is the preferred harvest site for the columellar strut, depletion of this donor site from previous surgeries may make it unusable. Since a straight stiff strut piece is needed, an alternative option is an alloplastic implant. My preferred alloplastic strut is composed of resorbable polymers, either a PDS or PLA-PGA material. Available is straight pieces of 1mm think, columellar struts of any length can easily be cut. Sutures can pass through the material to secure it to any cartilaginous point. These polymer struts will take up to a year to completely resorb and are presumably replaced by scar tissue.
Columellar strut are the most common graft used in open rhinoplasty. Since a septoplasty is frequently performed as part of many nasal procedures, good pieces of cartilage can be easily obtained. At the least, columellar struts help prevent nasal tip distortion. When used with other graft techniques, they can help actually increase tip projection or derotate the tip.
Dr. Barry Eppley
Dr. Chris Ueno