Extended columella strut grafting is an essential tool in structure, ethnic, custom, revision and reconstructive rhinoplasties, whenever the tip of the nose and its underlying columella support needs to be totally redesigned, providing the location, prominence, shape, size, angle or specific custom look desired by the patient or deemed technically required by the surgeon, from an ambitious change up to a totally brand new custom made tip and columella projection; common indications are the poorly supported tip due to weak columella, short septum, short nose, ethnic noses, revision of poor results, feminization cases, sunken columella, upturned noses, droopy tip, poorly defined tip, aging tip, associated with tip grafting, etc.
This kind of extended columella strut grafting is inserted between and along the entire the inner side of the medial cruras from the bottom at the maxilla to the top at the nasal tip, then the tip projection assessed and adjusted, and finally securing the assembly by means of suturing them three en bloc to act as a firm tip projection and columella reinforcement element, with or without combination with tip grafting, being the ideal donor sites the nasal septum, ear concha and the rib.
Normally the caudal septum and the medial cruras are separated, floating free and forming the frontier between the mobile tip and annexes unit and the stable immobile pyramid parts of the nose, with the mere separation of the subseptum soft areolar tissue, making the tip support and projection fully dependant on the lateral and medial cruras of the lower lateral cartilages, however mainly on the medial cruras. The extended columella strut graft is an additional pillar for that supportive role or reinforces the previously existing one and makes the tip, or at least the medial cruras and the tip solidary and firmly conjoined to the graft.
The extended columella strut graft technical reshaping power comes from the securing and firm fixation of the medial cruras and tip against or towards the graft, which is a very stable and firm projection point.
The extended columella strut graft technique is indicated when it is deemed unsafe, unstable, unpredictable or unlikely successful letting the tip, the columella and the nasolabial angle float free to acquire their shape, position, projection and angle or alternatively when other less interventionist maneuvers with the same purpose are unreliable, unfeasible or have already failed, like simple suture plications; it is one of the most powerful and versatile maneuvers which can be performed on a nose.
For its performance a non short septum is required or, alternatively, rebuild the septum length with caudal septal extension grafts or septocolumella grafts and assemble the extended columella strut graft in them, with or without an associated tongue in groove maneuver to form an L shape scaffold called septocolumella graft.
With that said there are clear and necessary indications of the extended columella strut graft, in those noses with undoubted an undisputable requirement of extraordinarily firm projecting and support of the tip and columella, as long as they are managed by highly experienced surgeons.
It is considered a highly demanding technique of high difficulty of calibration but of low to medium difficulty in its execution, short time consuming in the operating room and pretty much artistic in terms of its versatility, allowing full deployment of creativity reshaping noses.
This gesture can be done by either closed or open approach rhinoplasties, notwithstanding the open approach is a must of safety, reliability and precision for its execution.
Patients warning: only highly experienced surgeons who have underwent optimal training and have performed already a large number of closed and open approach structure and non structure rhinoplasties should execute high end rhinoplasty cases, should they feel capable and comfortable with the challenge.