Columellar Breakpoint Reconstruction Techniques in Rhinoplasty

Columellar Breakpoint Reconstruction Techniques In Rhinoplasty

ABSTRACT

Goals/Purpose: The columellar breakpoint is an important landmark marking the transition from the infralobular polygon onto the columellar polygon, a critical highlight in surface aesthetics that needs to be managed properly in tip surgery. Absence of this landmark results in a straight humble and unnatural columellar structure, aesthetically unpleasant even in the most attractive nose. Reconstruction of this breakpoint hence is mandatory for any rhinoplasty surgeon.

Techniques used for columellar breakpoint reconstruction are discussed including suture and cartilage graft procedures. A step-by-step algorithm is presented enabling the rhinoplasty surgeon to reconstruct this minor but important landmark of the columellar area.

Methods/Technique: The techniques were used in various combinations in over 400 primary rhinoplasty procedures with a mean follow-up of 12 months.

The columella breakpoint was reconstructed in all of the cases primarily using the C' suture while placing and stabilizing the columellar strut graft, using a suture placed 5-mm to 7-mm inferior to the dome triangle apex, ideally corresponding to the apical edge of the nostrils. The suture is placed from one side through the columellar strut, passing close to the cephalic edge of the medial crus, then back through the medial crus but this time close to the caudal edge, passing in front of the strut (without going through it), through the contralateral crus close to the caudal edge, and then backwards close to the cephalic edge medially towards the strut where the knot is tied.

In cases where this suture was not enough to create the breakpoint, an additional simple suture was placed anteriorly approximating the medial crura caudal edges. This maneuver aims to prevent the superficial fascia of the columellar region to be seated in between the medial crura just at the columellar breakpoint hence augmenting this region.

A final maneuver for reconstruction of the columella breakpoint would be the addition of a C graft. This graft is a small piece of cartilage placed floatingly over the aforementioned sutures to help augment this critical columellar landmark.

Results/Complications: Nasal tip results showed achievement of aesthetically pleasant columellar structures with proper columellar breakpoints demarcating transition from the infralobular polygon onto the columellar polygon.

Conclusion: Although minor in dimension, the columellar breakpoint is an important landmark in columellar and tip aesthetics. Proper reconstruction of this breakpoint using the C' suture technique primarily combined with an extra middle crural suture and even more with the C cartilage graft can have a significant contribution to the overall shape of the nasal tip.