How to: A Dynamic Endonasal Columellar Strut Placement

Surgical Technique 

We performed all surgical procedures under general anesthesia. The senior surgeon performed a routine endonasal septoplasty using a left-sided hemi-transfixion incision while standing on the patient’s right side. Local anesthetic was used for hydrodissection and hemostasis. L-strut measurements were performed with a caliper to preserve at least 10 mm from the dorsum and caudal portion of the septum to maintain adequate nasal dorsum and tip stability. The senior author attempted to harvest approximately 3.0 cm x 1.0 cm of septal cartilage to prepare for the possibility of needing additional cartilage for multiple grafts. In patients with severe caudal/columellar deviation, such as our patient, the swinging door technique is performed by incising the inferior border of the caudal septum, releasing it, and suturing it to the anterior maxillary spine. 

The columellar strut was sculpted with a #11-blade; dimensions of approximately 25 mm x 5 mm are usually obtained. The objective is for the strut to extend from below the domes to just above the premaxilla. The measurements of the graft are dictated by how much rotation and projection the surgeon wants to achieve (Figure 1). 

The first step in performing the dynamic retrograde intercrural columellar strut (DRIC) insertion was the creation of the dynamic pocket in the intercrural space. Obtaining adequate exposure via a hemi-transfixion incision is the essential precondition for the success of the procedure. Adequate exposure was obtained by placing a double-pronged skin hook at the caudal portion of the incision and retracting the columella with the left hand toward the right side of the patient, while simultaneously applying contralateral pressure at the septum with the left index finger. This maneuver stretches the intercrural space and provides adequate exposure for dissection. Using the right hand, iris-curved scissors were gently inserted in a retrograde fashion into the membranous portion of the septum. Blunt dissection was used to create and expand a dynamic pocket between the medial crura of the lower lateral cartilages. The pocket was expanded superiorly and inferiorly, first, by directing the scissors toward the interdomal space while simultaneously palpating the nasal tip to ensure adequate dissection, and then, by rotating the scissors counterclockwise in the space and directing them inferiorly toward the columellar base near the premaxilla. The oral cavity was palpated simultaneously to avoid overdissection, which could lead to graft sensation. 

The second step involved columellar strut graft insertion. The same maneuver to expose the intercrural space was used. Adson forceps were then used to insert the graft into the elastic pocket in a retrograde fashion. Upon insertion, stretching and falling-into-place sensations were felt when the graft was set in place. 

Finally, the senior surgeon likes to secure the graft to the medial crura to enhance the stability of the columella. The columellar strut was secured in place with percutaneous through-and-through 4–0 plain gut straight needle suture. After the graft was secured in place, mucoperichondrial flaps were laid back into position against the septum, and interrupted sutures were used to close the hemi-transfixion incision in standard fashion. 

RESULTS 

The DRIC graft technique achieves the same functional and cosmetic results as external rhinoplasty or other endonasal approaches with columellar strut placement. Our techniques help to give cartilaginous support to the tip and columella and aid in external nasal valve patency. They also allow an increase in the projection and rotation of the nasal tip.