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The Hanging Columella and Notched Ala

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Procedure Details

The columella, composed of skin and cartilage, is the exposed portion below the nasal septum, or the partition that separates the left and right nasal passages. The columella is the strip of tissue that connects the nasal tip to the nasal base, shaping the base of the nose and providing its structure.

A hanging columella refers to a cosmetic condition that is characterized by a protruding or downward extending columella, which leads to an exaggerated columellar show. Also referred to as a plunging columella, this nasal condition is particularly noticeable in profile view. When the columella is too visible, it can affect the overall aesthetic balance of the nose.

There are several possible reasons that a hanging columella may occur in individuals. In most cases, a hanging columella is either a naturally-occurring feature or related to a previous nose surgery.

  • Congenital Condition. In some patients, a hanging columella may present itself at birth. It may result from a disproportionately long septum pushing the columella downward. Alternately, it may be due to the positioning and orientation of the columellar cartilages.
  • Previous Nasal Surgery or Trauma. A hanging columella may arise after a prior rhinoplasty surgery, often due to excessive cartilage resection and alar, or nasal, retraction. It can also be caused by a columellar strut—a cartilage graft used to increase tip projection and/or stabilize a newly shaped tip—that protrudes too far.

Evaluation and Treatment

A hanging columella can resemble a retracted ala, or alar notching, a condition where the nostril(s) are “pulled” too far back. In some cases, both problems coexist. However, the treatments for a hanging columella and a retracted ala are completely different. Because of this, it is extremely important to accurately distinguish between the two conditions during the surgical evaluation. During the evaluation, the patient’s nasal columella will be carefully examined in relation to the alar region. If a patient has a history of a previous nose surgery, special consideration will be made to assess to what extent the primary rhinoplasty influenced the appearance of the hanging columella. Once it has been confirmed that the columella is “hanging” too low, Drs. Litner and Solieman will determine the best surgical approach to address the issue.

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Surgical Techniques

The goal is to reshape the columella in order to establish a harmonious relationship between the columella and the nostril area (also called the alar region). The surgical technique will likely involve reducing the columella and lifting the cartilage upward. This is often done through a tongue-in-groove procedure where the columellar parts of both tip cartilages are bound to the septum behind the tip, preventing the columella from hanging again after surgery. It is a delicate procedure that requires precision detail and skill. Drs. Litner and Solieman give full attention to the shape of the nostril, the tip rotation, the presence of alar notching, the strength and volume of the tip cartilages, the shape of the alar margin, the position of the septum, and the relationship of the tip and columella to the upper lip when correcting a hanging columella in both primary and revision rhinoplasty.

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