Columellar lengthening with V-Y advancement flap in aesthetic rhinoplasty
Article information
Abstract
Achieving a harmonious nasal shape requires balance from the frontal, lateral, and basal views. A short columella can lead to inadequate tip projection and drooping. While various methods have been used to lengthen a short columella in cleft lip and palate cases, adapting these techniques for aesthetic surgery presents challenges. This report outlines the design and surgical considerations for this issue. Ten patients with a short columella at risk of skin resistance or retraction were evaluated. The V-Y flap technique was employed, featuring a V-shaped design starting at the midpoint between the columellar footplate and the lowest point of the nostril sill. Standard techniques included a columellar graft to prevent narrowing. The rhomboid flap was trimmed and sutured in place. Results showed that the V-Y flap provided adequate tip projection, reduced columellar flaring, and improved nostril shape. Scarring was comparable to an inverted-V incision, with improvements in the columellar base and philtrum and high patient satisfaction. The technique effectively addressed tip projection challenges in patients with short columella.
INTRODUCTION
In many Asians, the nasal bone and upper and lower lateral cartilage are underdeveloped. Consequently, aesthetic rhinoplasty is frequently sought to attain a more prominent appearance, characterized by a higher nasal bridge and increased nasal tip projection [1].
To achieve these goals, numerous surgical methods have been introduced. However, even with the advent of various techniques, limitations persist in cases with insufficient overlying skin. Columellar skin deficiency is especially problematic, as it complicates the attainment of balanced nasal proportions. Such deficiencies may be congenital or can arise from deformities due to inflammation or infection following rhinoplasty [2-5].
Several techniques have been introduced to address columellar shortening in cleft lip nasal deformities, among which the V-Y advancement flap is considered relatively straightforward [6,7]. However, research on its effectiveness is limited, and detailed explanations in the context of aesthetic surgery are lacking. Therefore, this paper aims to introduce the V-Y advancement flap as an efficient method for columellar lengthening in aesthetic rhinoplasty.
IDEA
Surgical technique
All procedures were performed under intravenous anesthesia, with preparations made for standard rhinoplasty. When autologous costal cartilage was required, preparations for harvesting were also undertaken, following the method previously described [8]. The design for the columellar incision of the V-Y advancement flap includes a V shape starting at the midpoint of the columellar footplate and the lowest point of both nostril sills (Fig. 1A). The dimensions of the “V flap” are tailored to the necessary extent of columellar lengthening, and the V-shaped incision is extended to the infracartilaginous incision. The lower lateral cartilages are then released at the scroll area, the hinge, and the membranous septum. To achieve tip projection, a septal extension graft is fashioned using either septal cartilage or irradiated homologous costal cartilage. Silicone implants are utilized for augmentation, and a tip graft is employed to define the tip shape. To prevent narrowing at the junction of the V incision, a columellar graft is placed.
Surgical procedure for the V-Y advancement flap. (A) The lower “V” indicates the preoperative incision design for the V-Y advancement flap, originating from the midpoint between the footplate of the lower lateral cartilage and the lowest point of the nasal sill. (B) Columellar graft. (C) Trimming and suturing of the residual rhomboid flap. (D) Skin closure in a Y configuration.
In cases involving contracture, the scar tissue is removed, and the mucosa is released to the extent possible. To reconstruct the compromised cartilage structure, a fixed-type columellar graft is placed and sutured to the anterior nasal spine (Fig. 1B). When the caudal septum is weak or damaged, a spreader graft is incorporated to reinforce the structure. Furthermore, the columellar graft is made sufficiently large, extending to the caudal region to prevent narrowing of the columella. Closure begins with the placement of subcutaneous polydioxanone (PDS) 5-0 sutures starting at the Vshaped termini of the lower flap, followed by suturing of the philtral area with 6-0 nylon. Subsequently, subcutaneous PDS 5-0 sutures are applied to the ends of the upper V flap and the gathered lower flap. The rhomboid-shaped V flap is then trimmed, and closure is completed using a Y-shaped technique (Fig. 1C and D). The sutures are removed 1 week postoperatively.
Assessment
A 34-year-old woman presented with exposure of the costal cartilage at the nasal tip and columellar contracture. She had undergone augmentation rhinoplasty with a silicone implant 11 years prior and revision rhinoplasty using autologous costal cartilage 1 year earlier. The patient also exhibited nasal dorsal indentation, columellar shortening, and nostril asymmetry (Fig. 2A). Revision surgery involved a V-shaped incision design. After the removal of the previously implanted silicone, costal cartilage was used to establish columellar and spreader grafts. The skin was subsequently closed in a Y-shaped configuration (Fig. 2B). At the 9-month follow-up, notable lengthening of the columella was noted, and the nostril asymmetry was lessened. The patient exhibited no complications, such as infection, warping, or deviation. The scarring showed improvement and was comparable to that seen with traditional inverted-V incisions, with the patient expressing satisfaction with the results (Fig. 2C). In our clinic, 10 patients underwent the V-Y advancement flap procedure. These included three men and seven women, with an average age of 36 years (range, 24–40 years). The follow-up period ranged from 3 to 12 months. All 10 patients demonstrated significant improvement in columellar lengthening and nostril symmetry, without the need for additional revisions or complications. The patients were generally satisfied with the aesthetic outcomes.
V-Y advancement flap used for columellar lengthening in aesthetic revision rhinoplasty. (A) Preoperative photograph. (B) V-shaped design and Y-shaped closure. (C) Postoperative photograph, taken 9 months after surgery.
DISCUSSION
A short columella can be caused by a variety of factors, including congenital conditions, cleft lip nasal deformities, infections, trauma, or secondary capsular contracture following nasal implantation. To address this phenomenon, several surgical techniques have been proposed, such as local flap transfers (including forked flaps and alar margin flaps), composite grafts, and, in more severe cases, free flap reconstruction [3,9,10]. However, the application of these methods in aesthetic surgery presents challenges due to procedural complexity, donor site morbidity, and scarring. In cases of Binder syndrome, a modified V-Y advancement flap technique has been developed that extends the incision into the nasal sill to provide better tissue coverage and create a naturally wider columellar base [11]. Our technique aims to further improve outcomes by minimizing scar visibility. This is achieved by strategically planning the V-shaped incision within the columella and avoiding extension into the philtral column. This method aligns more closely with the incisions typically used in standard open rhinoplasty, effectively reducing visible scarring.
In designing the incision, the starting point and width of the “V” should be determined based on several factors. These include the required length of the columella, the locations of existing scars in cases of revision surgery, and the skin tension. These factors are instrumental in defining the operative range within the columella, particularly between the footplate of the medial crus and the inferior border of the nostril sill. When only minimal columellar lengthening is required, it is preferable to opt for a narrower V-design to minimize tension. In comparison, substantial lengthening necessitates a wider V-design. However, before proceeding, it is recommended to use instruments such as forceps to determine whether suturing is possible within the intended range. In cases in which the V-design is widened, the area of the columella where the ends of the “V” converge may become constricted. To avoid the resulting hourglass shape, it is important to use an adequate columellar graft or a shield-type graft. The V design of the upper flap results in the formation of rhomboid-shaped redundant skin. Rather than immediately trimming this skin after the incision is made, particularly in cases of columellar retraction, we advise removing as little as possible. This approach allows the excess skin to serve as a potential replacement for the mucosa flap, should the latter prove insufficient. Thus, by transposing the redundant skin to serve as the mucosal lining, tension is reduced. This facilitates easier suturing of the incision site and allows for effective columellar lengthening overall.
This technique has several limitations, and further research is warranted. In patients with severe columellar deficiency, attaining tension-free skin closure can be challenging. Moreover, poor perfusion of the skin flap may occur following the removal of excessive scar tissue. In such cases, the need for additional soft tissue coverage may be inescapable, complicating the application of this method. Furthermore, long-term follow-up is necessary to monitor for complications and to observe any changes in appearance over time. To effectively assess the outcomes of this technique, larger-scale studies with more participants and the implementation of objective measures are required.
In conclusion, this technique, as a form of local flap, is less invasive than alternative procedures and yields superior outcomes regarding scar formation. It is relatively straightforward and has traditionally been employed for columellar lengthening in corrective rhinoplasty for cleft lip deformities. However, its use in aesthetic rhinoplasty has shown promise, improving nasal tip projection through columellar lengthening in patients with a short columella due to nasal contracture. The procedure results in high patient satisfaction, underscoring its potential value in cosmetic surgery.
Notes
No potential conflict of interest relevant to this article was reported.
Patient consent
All patients provided written informed consent for the publication and the use of their images.