Simple Conditions That Can Seriously Affect the Appearance of the Nasal Tip - Columella and Ala Levels
Retracted and Hanging Columella
Hanging Columella
Hanging Columella (drooping columella) is a common condition encountered in rhinoplasty. The tissue between the nostrils, betweenthe tip of the nose and the upper lip, is called the "columella". When this tissue sags more than normal, it can create an aesthetically disturbing appearance, especially when viewed from the front profile. Hanging columella is the condition in which the columella sags more than the lower border of the nostrils. When viewed from the side, it can cause the inside of the nostrils to be seen and the appearance of a long nose.
What Causes Hanging Columella?
The main causes of hanging columella are as follows:
Congenital (Genetic) Factors: In some individuals, the columella may be longer or more prominent at birth.
Trauma: Blows to the tip of the nose can cause the columella to sag. Nasal traumas, especially in childhood, can more easily cause this condition.
Previous Rhinoplasty (Nose Aesthetics): It may develop especially after primary (first) rhinoplasty due to poor adjustment of the columella support or excessive extension of the septum cartilage. Caudal septum resection and replacement of the intra-columella cartilage support tissue or use of an abnormally large graft may cause this condition.
Excessively Extended Septum: Excessive extension of the septum cartilage in the columella region may also cause this condition. The septal extension graft being large may cause this, or the columellar strut graft being wider than normal may also cause the same condition.
🩺 How is Hanging Columella Treated?
The treatment of hanging columella is usually surgical. The methods applied:
Columella Aesthetics (Columellaplasty)
The excess soft tissue or cartilage in the lower part of the columella is removed. Sometimes the placed cartilage graft can be shaved or the caudal part of the inner legs of the alar cartilages can be shaved. In selected cases, it can be done with local anesthesia. A natural appearance can be achieved with minor interventions.
Revision Nose Aesthetic Surgery
If the problem is caused by a previous nose surgery, a complicated revision rhinoplasty can be planned. This operation aims to correct structural disorders in the columella. It can be planned to place cartilage support grafts in the columella region again.
Septoplasty
If the excessive length of the septum is causing the problem, this can also be corrected with surgery. Excision of the caudal septum can be performed to treat the sagging columella.
Retracted Columella
Retracted columella is a condition that should be evaluated in terms of nasal aesthetics and facial proportions. Sometimes it can occur over time as a result of loss of support tissue in the columella and can be seen with a downward sagging at the tip of the nose. The columella is the vertical column of tissue located between the nostrils, separating the tip of the nose from the lip. Normally, this structure should be slightly parallel to the lower border of the nostrils or slightly below. However, if this structure has been pulled upwards and has become too visible of the nostrils (if it is higher than the lower level of the wings of the nose, if it has moved towards the nasal cavity), it is called a retracted columella.
Retracted columella is when the columella is located above the lower level of the wings of the nose (alar). This causes the nostrils to appear more prominent and unaesthetic.
📌 Causes of Retracted Columella?
Genetic Causes
In some individuals, the columella may naturally retract.
The position of the alar cartilages may not support the columella or the supporting cartilage tissue within the columella may be weak. In addition to this, columella retraction may be easier in heavy, fleshy, thick-skinned nasal tips.
Previous Rhinoplasty or Nasal Surgeries
If columella support has not been provided sufficiently in previous nasal surgeries, if excessive resection has been made from the caudal septum, this may reduce the nasal tip support and cause the columella to be pulled upwards.
Trauma or Cartilage Dissolution
The columella structure may retract as a result of blows to the nose or tissue loss. This situation can be easily seen especially in boxers who receive repeated nose blows.
Insufficient Septal Tissue or Support
Insufficient septal cartilage support may negatively affect the columella position.
🩺 How is Retracted Columella Treated?
Retracted columella treatment is performed surgically and different techniques can be applied depending on the patient's current nasal structure:
Columellar Strut Graft (Support Graft)
Cartilage taken from the septum, ear or rib is used.
Tongue in Groove Technique and Septal Extension Graft Application
The cartilage graft is placed inside the Columella and the structure is supported and extended downwards.
Tip Revision (Nasal Tip Aesthetics)
The cartilages at the tip of the nose are reshaped.
The columella position is improved with additional support to the tip area.
Alar Base Improvements
If necessary, balance is achieved by intervening in the lower edges of the nasal wings.
💡 Is Retracted Columella an Aesthetic or Functional Problem?
Retracted columella is generally an aesthetic problem. It does not have a direct effect on breathing functionally. Additionally, when the tip of the nose droops downward, a decrease in the nasal valve angle and narrowing of the nasal airway may also occur. In some cases, it may cause psychological discomfort in the patient due to the wide appearance of the nostrils.
Retracted and Hanging Ala
In the nose, "ala" (Latin: ala nasi) refers to the wings of the nose. In other words, it is the external structure located on the side of the nostrils, made of soft and cartilage, surrounding the nasal opening.
📍 Anatomical Features of Ala
There is one on the outer side of each nostril (right and left ala).
It is supported by alar cartilages. The inner and outer crus of the alar cartilages are important in the support of this structure.
It contains skin, subcutaneous tissue and muscle.
It determines the appearance of the nose from the lower and side profiles.
Its shape and position play an important role in nose aesthetics (rhinoplasty).
Hanging Ala
Hanging Ala, or drooping nose wing, is a deformity encountered in rhinoplasty. "Ala" refers to the nose wings that form the side of the nostrils. Normally, they should be slightly higher than the lower level of the columella. When this structure is positioned lower than normal or creates a drooping appearance, it is called hanging ala. In other words, the lower border of the nose wing (ala) located on the side of the nostrils is lower than the normal anatomical line. This situation can cause the nostrils to appear droopy, especially when viewed from the side or below. It disrupts the aesthetic appearance and can negatively affect the proportion between the tip of the nose and the lip.
📌 Causes of Hanging Ala
Genetic Causes
Nose wings being longer than normal or their soft tissue being droopy, alar cartilages being positioned downwards.
Previous Rhinoplasty (Nose Aesthetics)
If the alar cartilages are not supported sufficiently in previous surgeries, hanging ala may occur. If the outer crura of the alar cartilage are excessively thinned during alar cephalic resection, especially in patients with thick skin structure, and if the alar cartilages are not supported with a cartilage graft when it is seen that they are too soft and weak, hanging ala may be seen. Sometimes nasal valve collapse may also be seen together.
Unbalanced tissue removal. Especially if the alar cartilages are weakened too much, hanging ala may be seen after rhinoplasty or nasal tip plasty.
Scar or contracture (shrinkage) effect that develops during healing. During healing, sagging and hanging may be seen in the alar wings.
Trauma or Aging
Loosening of the nasal structure over time may occur due to the natural aging process.
Tissue sagging may be seen after blows to the alar region.
🩺 How is Hanging Ala Treated?
Hanging ala is usually an aesthetic problem and is treated surgically.
Alar Trimming
Tissue is removed from the sagging ala.
Cartilage grafts can be used to raise the nasal wing to its natural border.
Alar Base Revision
The alar region is reshaped.
If necessary, the alar edges are moved upwards again.
Supporting Cartilage Grafts
If alar support is insufficient, support can be provided with cartilage taken from the ear, rib cartilage or septum.
Retracted Ala
Retracted ala, that is, retracted nasal wing, is when the lower level of the nasal wings is higher than it should be normally and the columella becomes visible from the side, it is a deformity that should be considered in rhinoplasty. “Ala” is the lowest level of the nasal wing next to the nostrils. When this structure is located higher than normal and causes the nostrils to be seen too much, it is called retracted ala. Pulling the nasal wing (ala) upwards makes the nostril more visible. The nostrils appear wide or upturned. When viewed from the front, it can cause the inside of the nostrils to become visible even if the tip of the nose is not upturned.
📌 Causes of Retracted Ala
Genetic Causes
Inadequate development of alar cartilages.
Shortness of alar edge soft tissue.
Previous Rhinoplasty (Nose Aesthetics) or Nasal Tip Aesthetics
Especially pulling up the alar edge as a result of excess tissue removal. The outer crura of the alar cartilages are very important in preventing alar retraction. If this cartilage section is weakened, alar retraction may become apparent with the scar tissue that occurs during healing.
Insufficient cartilage support or scar (scar) contracture. During rhinoplasty operations, supporting the marginal rim areas with cartilage grafts may prevent alar retraction. Again, during the healing period, it may be important to closely monitor the patient by using devices that provide support for the nostrils, such as nostril retainers.
Trauma
Deformity may occur as a result of blows to the wing of the nose.
Cartilage Erosion or Poor Tissue Support
Dissolution of the cartilage in the alar region or loss of support over time.
🩺 How is Retracted Ala Treated?
Retracted ala is usually corrected with surgical intervention. The aim is to balance the appearance of the nostrils by bringing the nasal wing to its natural position.
Alar Rim Grafting
Cartilage taken from the ear, septum or rib is placed under the alar rim. During primary rhinoplasty operations, it is useful to reuse the alar cartilage pieces removed during alar cephalic resections as rim grafts. In revision rhinoplasties, the resulting scar tissue and hardened skin structure can make it difficult for the retracted parts to move downward and make surgical treatment more difficult. The nasal wing is supported downward and a more natural contour is provided.
Composite Graft (Tissue + Cartilage Graft)
Especially in advanced deformities, both cartilage and skin tissue are transplanted. It is usually taken from the ear.
Alar Base Repair or Modifications
If necessary, the alar base can be expanded or repositioned by pulling down.
Retracted Ala and Hanging Columella Combination
When Retracted Ala + hanging columella are seen together, the lower appearance of the nose becomes significantly unbalanced. While the nostrils become more visible when viewed from the front; when viewed from the side, it can be noticed that the columella appears more prominent and the hairy area inside the nose is more visible. While the nostrils appear to be upturned, the columella in the middle hangs down. In the treatment of this condition, both structures usually need to be corrected in the same session. Different procedures need to be performed for both the columella and the wings of the nose.
Hanging Ala and Retracted Columella Combination
The combination of hanging ala and retracted columella is a condition that seriously disrupts the aesthetic balance of the lower nose area. Since both structures are positioned in the opposite direction than they should be, an asymmetrical, disproportionate and generally unnatural lower appearance of the nose emerges. When viewed from the side, the lower level of the nose wings (ala) remains seriously below the columella. When viewed from the front, the part of the nose tip adjacent to the lip may appear to have a single nostril, as it is inward. In treatment, various cartilage grafts are used to reconstruct the columella cartilage support; while various cartilage graft applications and alar base modifications may be required for upward movement of the area.
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Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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