Drooping nasal columella showing nostrils? Understanding the scope of change with columella elevation surgery

Columella elevation surgery corrects the appearance of the nasal columella (the partition between the left and right nostrils) protruding downward.[1]However, the cause of the drooping appearance often lies deeper than the columella itself. The surgeon first examines the lower edge of the nasal septum (the partition dividing left and right nasal passages), the width of the membranous septum (the non-cartilaginous skin portion of the columella), and the shape of the medial crus (the thin cartilage running through the columella) before deciding which area to shorten.[1][2].

What is the true nature of a drooping nasal columella?

This condition is called "columellar ptosis (drooping of the nasal columella)." When viewed from the side, the columella appears prominently protruding downward beyond the edge of the nostril. Textbooks cite excessive width of the membranous septum as one cause[1], and also explain that forward protrusion of the lower edge of the nasal septum (caudal nasal septum) can be a contributing factor.[2]While what is visible is the columella, what actually needs correction often lies deeper in the septum.[2].

Where does adjustment occur to elevate the columella?

In most cases, a single procedure alone is insufficient. Textbooks explain that the correction can be achieved by combining multiple surgical techniques: shortening the nasal septum, reshaping the medial crus, and fixing the position with sutures.[1]When the lower edge of the nasal septum (caudal nasal septum) protrudes too far forward, it is corrected by removal, repositioning, or both.[2]Regarding how to manage the caudal nasal septum, there are surveys of surgeons practicing in North America and systematic reviews (reports that compile and organize multiple studies). These summarize the various approaches available and the respective outcomes of each.[3].

Who is a candidate? The issue is not always limited to the columella alone

If the nose is long, the medial crus is weak, and the nasal tip points downward, simply elevating the columella alone will not result in a balanced appearance.[1]For this type, the recommended sequence involves shortening the caudal nasal septum, reshaping the upper portion of the nose (cephalically), shortening the cartilage forming the lateral aspect of the nostrils (lateral crus), and excising the membranous septum. Then, supporting cartilage is added to the columella as structural reinforcement.[1]If the caudal nasal septum is deviated, it can cause tilting of the columella or asymmetry of the nostrils. Therefore, it is considered an area that should be assessed before revision surgery.[1]The patterns of septal deviation are classified into categories such as C-shaped or reverse C-shaped, and these terms are used as common language for surgeons to communicate about the condition.[4].

Is there a standard numerical value for normal appearance?

No, we did not find a numerical standard in the reviewed materials that defines how much visibility indicates a normal state. When viewed from the side, it is often said that a columella appearing slightly beyond the edge of the nostril looks balanced. However, we did not find data within the scope of this review that substantiates this statement with numbers.[1]Rather than relying solely on numbers, examining the nasal tip direction and angle with the upper lip together provides a judgment closer to clinical reality.[2].

Points to note: recurrence and loss of structural support

A concern is weakening of the nasal support. Even when supporting cartilage is placed in the columella, if the overall structural support of the nasal base is insufficient, loss of nasal tip support and height often occurs after surgery, and the tip tends to return to pointing downward again.[5]The role and application of supporting cartilage are organized in review articles (explanations summarizing existing knowledge). The procedure to elevate the columella and nasal tip support cannot be considered separately.[6]Additionally, over-excision of the membranous septum can result in the columella appearing retracted. Precise judgment of the excision amount is critical.[1].

What to confirm during consultation

During examination, the surgeon first distinguishes whether the drooping appearance is of the columella itself, forward protrusion of the caudal nasal septum, or drooping of the nasal tip.[1][2]Taking a lateral photograph and viewing the angle between the nose and upper lip along with the nasal tip direction makes it easier to determine which area should be shortened for optimal balance.[2]If previous nasal surgery has been performed, the amount of remaining septal cartilage determines which surgical methods are available. Therefore, this assessment begins the evaluation.[1]How much to elevate is individually determined by the surgeon based on overall nasal proportions.