Hanging columella after open rhinoplasty. Nose columella. The shape and structure of the nose. Indications, contraindications and at what age it is better to do

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

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

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

The incision is made in the narrowest part of the columella so that the scar remaining after the operation is minimal. Although after complete healing of the wound, it becomes almost invisible.

As a rule, the operation does not begin 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 fixing the position of the nose itself. It also opens access to the site of the future incision. The images above show the described process. The left figure shows its beginning, the right one shows a ready-made incision, which is called the medial-marginal incision. During this part of the operation, a conventional medical scalpel is used.

Next, the lateral part is performed ("lateral" - remote from the middle, i.e. in this case it is the lateral part) of the marginal incision. 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 nose tip its shape. After the incision is made, the cartilage can be seen in its entirety.

In the upper left image, a small red line indicates the lateral portion of the incision. A small red strip next to the columella is the medial part of the incision (the incision running along the columella). Next, both parts of the cut are connected.

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

We return to the outer 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 under it. Scissors (necessarily with blunt ends) are wound from the inside of the columella (figure above). Then they are gently opened, and the skin is separated from the cartilage. This action must be carried out with the utmost care so as not to damage the tightly connected skin and cartilage.

Pay attention to the image. Do not forget that the part of the nose painted in blue is called the columella, in green - 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 must do the same on the colummel. To do this, the scissors are inserted into the medial-marginal incision, and gently 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 gets a better view of the nasal cartilage, which in turn allows the operation to be performed under full visual control.

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

And so we proceed to the dissection of the columella. It is necessary to start the incision at the top of the inverted V. At the same time, the left hand pulls up the tip of the nose, and the little finger of the right hand shifts the columella down, stretching the skin, which in turn facilitates the incision. From the top, the incision 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 push the skin along the edges of the wound. If the columella opens slightly, then the incision was made correctly.

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

Although an external incision results in a scar, in many cases its use is necessary. At the same time, 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.

Consider an example. The surgeon who performed the operation (see image) made many incorrect incisions at the base of the nose. In this case, he made the following mistakes: he incorrectly made a trans-columnar incision (indicated in green), which, if done correctly, leaves no traces at all. The next mistake is the wrong incisions made by him 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 errors can not always be corrected.

Let's get back to the operation. After dissection of the columella with a scalpel, the skin is cut with scissors to the full thickness. This will expose the tip of the nose and get to the right cartilage.

The skin above the incision site is lifted up with a two-pronged retractor. And the lower part remains in place (in the right figure, the red line indicates the place of the incision).

With the tip of scissors, the soft tissues of the columella are separated from the cartilage. The cartilages located at the tip of the nose are called the inferior lateral cartilages (the right cartilage is colored blue in the figure).

The pink color in the upper figure indicates the surface of the skin adjacent to the cartilages of the tip of the nose.

Thus, access to the lower lateral cartilages was obtained. Further, with the help of scissors, the soft tissues of the tip of the nose are completely separated from them.

We all know that the traditional use of scissors is to place an object between the blades and cut it. Most of the time, the rhinoplasty surgeon uses this instrument in a slightly different way. Most often, he performs sliding movements, rather than cutting. To expose the lower lateral cartilage, the surgeon closes the scissors, places the ends of the scissors on the surface of the cartilage, and then opens the scissors, spreading the tissue with the scissor blades.

Now the cartilage of the tip of the nose is completely open and you can see the cartilage forming the back of the nose (highlighted in pink in the figure, the right lower cartilage is indicated in blue).

In order for the skin separated from the cartilage not to interfere with the further operation, a retractor is used to hold it.

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

It should be noted that there is almost no bleeding in the shown pictures. This is explained as follows. The nose, like any other part of the body, has places both with abundant blood supply and areas in which the number of blood vessels is minimal. A qualified surgeon leaves intact places with a large number of blood vessels, which avoids large 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 part marked in pink in the right photo and circled in red in 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.

Hump ​​- part of the nose, located, as a rule, in the middle of the back of the nose. Often in this place the nose has a bend (in the figure, 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 border of the separation of bones 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 (therefore, for example, in boxers, the nose is always broken in the lower part).

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

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

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

In the photo above, it's easy to tell the two areas apart. At the junction, the cartilage forms a slight bend, which is indicated by a white line.

Also, the blue arrow points to the place of transition of the collumellar part of the cartilage to the lateral part. It is this area that we perceive as the tip of the nose. This transition is called the dome of the lower lateral cartilage. In the figure, the dome is marked in green.

The upper image shows normally located, previously unoperated cartilages. The right nasal cartilage is colored blue. The skin above it is pulled up with a retractor so that a small part of the cartilage of the back of the nose is visible, colored green.

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

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 a fingernail against the tip of the nose (dome).

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

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 a good view of the cartilage separation area (the left cartilage is highlighted in blue, the cartilage of the back of the nose is highlighted in green).

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

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

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

Instead of normal cartilage, which I would like to see, in this case there are large growths of scar tissue.

Rhinoplasty is a concept that includes many different techniques to change the shape of the nose. Some patients need to work with the bone part of the back, others - with the cartilage part, and the third - with the soft tissues of the tip of the nose. Often there is a need for correction of columella. And what it is, how this part of the nose is corrected and what effect can be achieved with the help of surgical intervention, you can find out by comprehensively considering this issue.

Columella - what is it?

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

This small fragment of the nose performs a number of important functional tasks in the normalization of the breathing process. Supporting the tip of the nose and maintaining the optimal lumen of the nostrils, it allows you to freely inhale and exhale air. So, to provide the body with oxygen, which is involved in all biochemical processes.

What should a columella look like?

A small area of ​​skin called the columella of the nose plays a huge role in the perception of the nose as a harmonious part of the 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;
• nostrils should be symmetrical.

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

Problems with columella

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

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

• the nasal column sags;
• columella is too high;
• the angle between the nose and the lip is too large, or vice versa, small.

A person may regard his nose as too wide, with a curved tip, snub-nosed. But in order to correct the appearance, it is not necessary to do complex and traumatic operations to change the shape of the back or its tip. It is enough just to change the column of the nose.

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 leg of the columella and the wings of the nose are located on the same level, you can use

Its meaning lies in the introduction of a special preparation under the skin - a filler, which increases the volume of tissues. As a result of this, the columella of the nose becomes larger, and the nose itself looks harmonious. During the procedure, the doctor injects the filler into the columella in the required volume through the needle. The intervention causes a minimum of 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 tissues of the columella: a more viscous gel will be retained in the tissues longer. But it is 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 of chronic diseases, the 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 is large or sagging, the only method of correction is surgery.

But the methods used by the surgeon when performing the operation may be different. Correction of the columella of the nose should be discussed by the doctor and the patient before the operation, so that the operated person is as satisfied as possible with the result.

The easiest way to reduce the columella is to excise the soft tissue and, if necessary, the adjacent cartilage. Understanding how the nasal septum is connected with 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 operation technique will be more justified in a particular case: raising the nasal column, or deepening it to create a harmonious angle between the nose and the upper lip.

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

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

Change of columella 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 also to make it as simple as possible. Sometimes the columella of the nose has an irregular shape, but working with it will not make the face beautiful, but, on the contrary, will make other features more obvious.

Therefore, sometimes, in order to correct the nasal column, the doctor can make a volumetric correction, based on the structure of the nose of a person who has come to the plastic surgery clinic. The doctor can change the tip of it higher, thereby pulling up the columella. Sometimes rhinoplasty 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.

Is anesthesia necessary?

The need for anesthesia during surgery is determined by the amount of work that will be carried out 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 in rhinoplasty can be identified by at least two arguments:

• the patient, being in a medical sleep, does not experience excitement, is not able to make involuntary movements, in other words, to prevent the surgeon from performing “jewelry” work on his face;
• with general anesthesia, the need for the use of local anesthetics is reduced, so the doctor gets the opportunity to work with “living” tissues, and not with various drugs that have been injected.

To find out if 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 manipulation, he should recommend to the patient the most suitable option for a particular operation.

Preparing for the operation

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

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

Rehabilitation

How long it will last depends on many factors: the experience of the doctor, the extent of interventions, the state of health of the patient, the thoroughness of fulfilling all the surgeon's instructions.

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

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

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

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, which to a greater extent affects the beauty of a person. Therefore, even slightly changing the structure of the human nose, you can achieve a beautiful result.

Immediately, let's define what a columella is. 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 the large alar 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 the aesthetic function, an anatomical load is also assigned to the columella - it must maintain the tip of the nose in an elevated state and form an adequate lumen of the nostrils, ensuring unhindered entry of air into the nasal cavity.

When is columella plastic surgery performed:

• Too upturned tip of the nose due to high columella.
• Descent of the tip of the nose.
• Too sharp or too obtuse nasolabial angle.
• "Dangling columella" is an anatomical feature when the columella is lowered too low compared to the level of the nostrils.

The columella is enlarged by transplantation of the patient's own tissues or biocompatible transplants. With a decrease, on the contrary, its partial excision is required. However, changes in the appearance of the columella do not always imply surgical work with 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 nose column in one of the following ways:

• Install cartilage grafts.
• Suture the medial crura of the alar cartilages.
• Introduce fillers or the patient's own adipose tissue into the columella area.

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

With a pointed nasolabial angle, an increase in the nasal septum is performed using biocompatible expanding grafts or suturing is used on paired alar cartilages.

The operation on the columella is performed under anesthesia or with the use of local anesthesia, depending on the volume of intervention, the duration of which is 20-40 minutes. Long-term hospitalization is not required.

Contraindications for columella plastic surgery

Contraindications are standard, as for most plastic surgeries:

• Chronic diseases in the stage of decompensation.
• Violation of the blood coagulation system.
• The 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. Difficulties in nasal breathing are not observed. For the first 1.5-2 months, swelling and pastosity of the operated tissues are possible, but visually this is noticeable only in the first weeks.

There are also no special restrictions in the postoperative period. Recommend reasonable abstinence from excessive physical exertion, exclusion of the action of thermal procedures - baths, saunas, hot baths. You also need to protect the nose from physical injury, in particular,
In order not to accidentally damage the tip of the nose during sleep, it is better to sleep on your back.

The nose is the most pronounced part of the face, thanks to which the face can change beyond recognition. The part of the skin located between the nostrils is called the columella and greatly influences the appearance of the nose. Also, this small part of the nose is very important for the breathing process to be normal, and for this, it performs important functional tasks. At rhinoplasty the columella is often corrected to remove an aesthetic flaw and create a harmonious nose.

Columella - what is it?

Between the human nostrils there is a unique part of the skin, which is called the columella. Anatomically, the columella of the nose consists of the medial crura of the alar cartilages, however, these cannot be seen. There is another name for this anatomical term: column or column of the nose.

The huge role of columella lies in the perception of a person's nose as something normal, not interfering with existence. These qualities are inherent in a beautiful columella:

• width - no more than five to seven mm;
• in women the angle between nose and lip is about one hundred degrees, in men ninety-five;
• there should be no sagging of the column;
• the location of the columella cannot be higher than the wings of the nose, when viewed from the front.
• symmetry of the nostrils.

The success of rhinoplasty directly depends on these rules. If you do not take them into account, the image of the nose will be very wrong, as a result, the appointment of a second plastic surgery is possible. In other cases, excellent results can be obtained with a simple operation to improve the nose.

In some cases, people may have problems with the columella of the nose, for the solution of which it is necessary to carry out rhinoplasty of the nose in Moscow. Patients of a plastic surgeon, based on how the ideal columella of the nose should look like in size and shape, most often face the following problems:

• sagging of the nasal column;
• very high location of the columella;
• a very small, or vice versa, large, angle between the nose and the lip.

In certain cases, a person considers that his nose is large, with a curved tip, snub-nosed. To correct the appearance, in general, it does not require heavy and traumatic operations aimed at changing the shape of the back or its tip. A change in the nasal column will also suffice. For this purpose, we recommend paying attention to rhinoplasty of the nose, the price of which will pleasantly surprise you.

Columella correction during rhinoplasty

Maintaining a perfect combination of nose and face is the goal of a plastic surgeon when correcting a certain flaw. This should also be done in the most simple way. With an irregular shape of the columella, the result of working with it will not make the face beautiful, but will reveal other features.

Sometimes when correcting the nasal column, the doctor does a lot of work. It depends on the structure of the nose of a person who has expressed a desire to provide plastic surgery services. In such cases, the tip of the nose can be changed by the doctor, raised higher, and with it the columella of the nose.

It happens that the effect can be achieved with columella plastic surgery. In this situation, the surgeon transfers them higher without touching the column. As a result, it becomes, as it were, lower. The doctor and patient must work closely together in preparation for surgery. The patient should be explained what he would like to see at the end of the operation, and the doctor, knowing all the subtleties of such a process, the structure of the nose, should tell you which methods are best used to achieve the desired result.

The amount of work depends on how much anesthesia is needed during the operations of the surgeon. In cases where the doctor needs to remove unnecessary tissues to raise the nasal column to the intended height, it is enough to use local anesthesia. If you need to do more, general anesthesia is indispensable.

Advantages of anesthesia causes the following:

• thanks to medication sleep, the patient is not aware of the excitement, he is physically unable to move, and interfere with the surgeon in his work;
• general anesthesia makes it possible to almost not use local anesthetics, and, as a result, the doctor works with those tissues that have not been exposed to various drugs.

The importance of anesthesia in a particular case is discussed with the doctor. After assessing how large and how long the work required, coupled with the degree of soreness, he should advise the patient to use the most appropriate option in a particular case.

Many factors affect the recovery time after columella plasty. In particular, these include:

• doctor experience;
• how severe the intervention was;
• how accurately the instructions of the surgeon were followed.

Two weeks after rhinoplasty in Moscow is optimal rehabilitation period after rhinoplasty . But there is an exception. After two days, you can return to normal life if only columella has been corrected by the doctor.

People of all ages and any gender turn to rhinoplasty, wondering: how much does a rhinoplasty of the nose cost? The reason for this is clear - the nose is that part of the face that adorns a person more than other parts of the face. It is enough to order a rhinoplasty of the nose in Moscow, and an excellent result is guaranteed.

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Dropped tip

The most important principle to prevent unwanted changes in the nasolabial angle is to assess the anatomy and support mechanisms of the nasal tip and then maintain or increase the support of the tip, which will restore a more natural appearance of the nose. As noted above, actions that result in loss of nasal tip support can create the appearance of a dropped tip (tip ptosis and too acute nasolabial angle). The normal nasolabial angle (the angle determined by the intersection of the lines drawn from the upper point of the columella to the subnasal and from the subnasal to the border of the red border of the upper lip) is 90-120 °. Within these limits, a more obtuse angle is desirable for women, and a sharper one for men. Loss of support for the tip of the nose can lead to ptosis and decreased prominence.

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

Table 1

Operational actions

Excessively upturned (rotated) nose

On the contrary, one may encounter an excessively rotated nose, with a too obtuse angle. Excessive resection of the caudal septum is a common cause of excessive rotation of the nasal tip. This rotation creates an unsightly appearance.

Careful preoperative evaluation may identify those patients in whom surgical rotation should be avoided. Treatment of complications associated with a short, upturned nose is based on lengthening the nose and rotating it in the opposite direction. There are special rhinoplasty manipulations 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 the scar contracture on the weakened cartilages. Patients with thin skin, strong cartilage, and a bifid nasal tip are at especially high risk. Excessive resection of the lateral crura and failure to repair the divergence of the arches may play some role in the formation of the bulge. It is believed that the bulges are the result of cicatricial contracture of an overly narrowed marginal strip, leading to the formation of a rounded protrusion during postoperative healing. Several researchers have described a link between cartilage splitting techniques and bulge formation. However, others believe that the methods of vertical division of the vaults are reliable when performed correctly 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, the area is covered with a thin layer of cartilage, fascia, or other material to smooth and hide the area.

Pull back wings

To improve the appearance of the nasal tip, a cephalic resection of the lateral crura of the inferior lateral cartilages is often undertaken. If excess cartilage is left, the diminishing forces of healing will eventually cause the wings to be retracted posteriorly (Fig. 1).

Rice. 1. Patient many years after rhinoplasty with disproportion between the wings and columella due to the posterior retraction of the wings of the nose

This is a frequently seen consequence of overresection of the lateral pedicles. The surgeon's heuristic rule is to protect the entire strip at least 6-9 mm wide. However, anatomical study of the base of the wings shows that in the normal population, a thin edge of the nasal wing is present in 20% of patients. This anatomical variant must be recognized in order to prevent the danger of the wings being retracted and/or the external nasal valve collapsing. Such patients may require an even more conservative approach. It is necessary to preserve the mucous membrane of the vestibule, since its excision contributes to cicatricial contracture with retraction of the wings.

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

In more severe cases, compound ear grafts are often used. The best contour is provided by the bowl of the conch of the opposite ear (for example, left wing - right ear). After an incision a few millimeters from the edge of the nostril, a careful dissection is made with the separation of the adhesions, the creation of a pocket and the displacement of the wing rim downwards. The suitably excised composite graft is carefully sutured into place.

Disproportions of wings and columella

Disproportions of the wings and columella can be a cause of considerable concern 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 wings and the columella was summarized by Gunter et al., who described the position of the wings and the columella in relation to a line drawn through the long axis of the nostril. All patients are divided into those with lowered, normal or retracted wings, as well as 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).

The disproportion of the wings and columella can be observed in the unoperated nose; it can also be caused by surgical failure (Figure 1). A protruding or sagging columella may be due to remaining uncorrected deformity, such as too wide medial crura or too long caudal septum. The deformity may be excessive protrusion of the columella downward from under the wings secondary to retraction of the wing margins rather than true protrusion of the columella. Insufficient or retracted columella may be a manifestation of pre-existing uncorrected deformity, it 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 consist of a full-thickness resection of the tissue of the membranous part of the columella, including skin, subcutaneous tissue, and possibly part of the caudal end of the septum itself. If the medial crus is too wide, correction may include sparing excision of the caudal margin of the medial crura.

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

Coracoid deformity

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

Rice. 3. A patient with an excessively resected bony dorsum and insufficiently resected cartilaginous dorsum. Her coracoid 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 unnecessarily reduced upper third of the nose has been enlarged. (A) Side view before surgery. (B) Side view after surgery.

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

Section of a columella

External approach for rhinoplasty includes a columella incision. Great care must be taken when making the incision to make it not oblique, but perpendicular to the skin, thereby avoiding the complication of manhole cover deformity. Also, great attention should be paid to the process of suturing the incision to prevent folded edges or other deformations (Fig. 4).

Rice. 4. When performing external rhinoplasty, special attention should be paid to the incision of the columella and its suturing. To prevent visible deformity, 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 skin eversion and relieve tension from the suture line. This seam should provide equalization of the edges of the skin and easy eversion. Excessive eversion will create a deformity that may take many months to resolve. With this seam, the skin sections must be exactly aligned; otherwise, an unattractive scar may form. If there is no tension on the skin, a subcutaneous suture may not be required.

Five vertical mattress sutures made of 7-0 nylon are used to close the skin. The first seam equalizes the top of the inverted "V". To properly align the incision, the next two sutures are bent at an angle from the medal part of the lower flap to the lateral part of the upper flap. To equalize the skin of the vestibule in the corner of the columellar flap, a 6-0 chrome-plated catgut suture is used. This corner suture is important as improper healing in this corner can lead to visible retraction.

Daniel G Becker

Complications of rhinoplasty