Response to “Anatomic Columellar Strut, An Alternative Paradigm?”

I thank Lehao et al for their compliments about our article “Concept of Anatomic Columellar Strut Grafting in Rhinoplasty: An Algorithmic Approach.” ¹ In addition to their comments, they pose 2 questions in their Letter to the Editor:² (1) How we can apply the anatomic strut concept in the Asian population? (2) What considerations need to be given to septal extension graft vs columellar strut grafting to ensure long-term results and stability of the anatomic columellar strut?

The concept of the anatomic columellar strut aims to add a 3-dimensional element to the columellar strut according to the natural anatomy between the medial cruras, and provides a basis for patient selection in terms of skin thickness. Thick skin needs a strong strut which can be constructed from lower septum; struts for medium-thickness skin can be made from dorsal resection material; but thin skin requires a tailor-made strut.

I prefer the closed approach for rhinoplasty and I organize the annual Closed Atraumatic Rhinoplasty Course³ to demonstrate my surgical philosophy, including my methods for Asian rhinoplasty—a subject in itself. Problems in Asian patients include the thick, bulbous tip and short columella with a low dorsum, wide base, and pyramidal angle. If one elects in this population to apply a columellar strut with the anatomic approach, the best option will be to utilize the lower septal part. However, if one decides to apply a septal extension graft with the anatomic approach, an anatomic columellar septal extension graft can be created. In this way, one can enjoy the best of both worlds (Figure 1).³

Figure 1.

A demonstration of the anatomic columellar septal extension graft.

I read the article cited by Lehao et al and disagree that there are just 2 ways, ie, columellar strut and septal extension graft, to provide tip rotation and support. Also, the method should be individualized for each patient to achieve good results instead of considering mean projections.⁴ As Toriumi mentioned, ethmoid graft is very useful for stabilizing the septal extension graft,⁵ and I use it when taking the closed approach.⁶ However, I disagree that septal extension grafts offer the only option and that the nose should be built up on this segment. Septal extension grafts can be effective when performed on just the central leg of Alexander’s tripod. However, we have 3 legs on the lower crura with which to arrange tip rotation and projection. Medial cruras are the central leg of this tripod and lateral cruras establish the lateral legs on both sides. Here, I offer a useful trick: the ST (superior-based transposition) flap technique⁷ is a very powerful weapon that involves utilizing the lateral legs of the tripod to achieve tip rotation and projection. Figure 2 shows how just the ST flap technique was sufficient to achieve tip projection and rotation in an Asian patient.

Figure 2.

A 34-year-old male Asian patient from the Closed Atraumatic Rhinoplasty Course.³ (A) At the start of the operation. (B) Just after the application of the ST (superior-based transposition) flap technique,⁷ a considerable tip projection and rotation was achieved without the need for any kind of strut grafting. After creation of the ST flaps, dorsum surgery, alar excision, anatomic columellar strut grafting, and airway surgery, the operation ended. (C, D) Before and after images on the table.

Another trick is to rotate the septum caudally so that it can serve as a septal extension graft by exploiting the fix-down technique.⁶Figure 3 shows how this approach can create a natural septal extension graft. If you are not satisfied with the tip support or rotation, a variety of adjunctive techniques can be used, such as deep superficial musculoaponeurotic system suture,⁸ tongue-in-groove suture, or septocolumellar suture (Figure 4).

Figure 3.

The fix-down technique⁶ enables a considerable septal advancement to be achieved to create a natural septal extension graft. Advanced septum is fixed to the nasal spine with a spider network suture to ensure a robust fixation. A 28-year-old female patient is shown.

Figure 4.

Deep superficial musculoaponeurotic system suture technique⁸ provides additional tip rotation and projection and can be used as an adjunctive tipplasty procedure. A 21-year-old female patient is shown.

There is no perfect technique for all kinds of noses. However, as rhinosurgeons, we need to approach the nose with the philosophy “not only preserve but also support” ⁹ to achieve long-lasting, beautiful results.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.