Complications of Rhinoplasty - Page 7

Alar—Columellar Disproportions

Alar–columellar disproportions can be areas of significant patient concern. The range of normal columellar show is generally considered to be 2 to 4 mm. The complexities of the alar–columellar relationship have been categorized by Gunter and colleagues, who describes the position of the ala and the columella in relationship to a line drawn through the long axis of the nostril. All patients have a hanging, normal, or retracted ala and a hanging, normal, or retracted columella. Thus, there are nine possible anatomical combinations mak­ing up the alar–columellar relationship (Fig. 39–2).

Alar–columellar disproportion may exist in the unoper­ated nose; also, it may be caused by surgical misadventure (Fig. 39–1). A protruding or hanging columella may be due to a persisting uncorrected deformity, such as an overly wide medial crura or an overly long caudal septum.' The defor­mity may be increased columellar show secondary to retrac­tion of the alar margins rather than an actual protrusion of columella. A deficient or retracted columella may be due to a preexisting uncorrected deformity, or it may be due to exces­ sive resection of soft tissue, cartilage, or nasal spine. The sur ­geon should avoid excessive resection of the caudal septum, and should avoid resection of the nasal spine.

Management of a protruding or hanging columella may include resecting full-thickness tissue from the membranous columella, including skin, soft tissue, and perhaps a portion of the caudal end of the septum itself. If the medial crura is excessively wide, management may include a conservative excision of the caudal margin of the medial crura.

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