How to: A Dynamic Endonasal Columellar Strut Placement

INTRODUCTION 

The nasal tip framework depends on the structural integrity of major and minor tip support mechanisms. The weakening of these supporting mechanisms is caused by the natural and physiologic process of aging, but it is also a common outcome of rhinoplasty surgery, particularly in those treated using an open approach. The common outcome for all patients with compromised structural integrity of nasal configuration is nasal tip ptosis, a common un-aesthetical facial deformity (Plast Reconstr Surg. 2012;129:118e–125e). 

The columellar strut graft is among the techniques frequently used to enhance nasal tip aesthetics. It is employed to strengthen and lengthen the medial crura, correcting asymmetry, projection, and rotation of the nasal tip (Plast Reconstr Surg. 2012;129:118e–125e; Aesthet Surg J. 2020;40:NP65–NP71; Acta Otorhinolaryngol Ital. 2013;33:169–176; Arch Facial Plast Surg. 2005;7:176–184). The standard practice of inserting columellar struts would follow an open septorhinoplasty under direct identification of the medial crura; however, the constant search for minimally invasive techniques among facial plastic surgeons increasingly favors the use of endonasal approach techniques because they offer numerous advantages over the standard practice, such as reduced surgery time, concealed incisions, and quicker postoperative healing, while preserving nasal structural anatomy (Acta Otorhinolaryngol Ital. 2013;33:169–176). 

Numerous techniques of endonasal graft placement and design have been described. The most widely used technique consists of inserting the columellar strut graft in the intercrural pocket through direct visualization via a columellar marginal incision. Another commonly described technique is the endonasal delivery technique, which delivers the lower lateral cartilage using a combination of marginal and intercartilaginous incisions (Acta Otorhinolaryngol Ital. 2013;33:169–176). 

In this article, we provide a detailed description of our technique, consisting of the insertion of a standard columellar strut through a hemi-transfixion incision in an indirect retrograde fashion. We also describe its clinical relevance and its impact on patients after they have undergone routine septoplasty. 

METHOD 

A 53-year-old male presented to our clinic with complaints of right nasal obstruction after a traumatic event to the face two years prior to his appointment. He denied additional sinonasal symptoms. Preoperative examination revealed no evidence of displaced nasal fracture and no palpable step-off. Facial evaluation showed adequate width and symmetry of the upper, middle, and lower nasal vault. Nasal tip evaluation showed a slightly bulbous tip with mild nasal flaring. Lateral examination revealed a mild dorsal hump and decreased nasolabial angle and projection. Basal view revealed caudal deviation of the columella toward the right. A paranasal sinus computerized tomography scan showed adequate nasal bone with healed comminuted fractures and an S-shaped deviation with a displacement of the anterior septum toward the right and posterior septum toward the left. After a conversation with the patient about the possible benefits and risks of surgery, he agreed to undergo a functional rhinoplasty, involving septoplasty with possible columellar strut graft. 

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.