DOUBLE COLUMELLAR STRUT : A NEW METHOD FOR TIP SURGERY: A STUDY OF 642 CASES WITH A 15-YEAR FOLLOW-UP
The authors declare that they have no conflicts of interest to disclose. This article does not contain any studies with human participants or animals performed by any of the authors.
For this type of study, informed consent is not required.
Goal: Of the first nasal tip modeling procedures performed, the Anderson tripod concept is the most well-known, and many anatomy-related studies have analyzed the components involved in tip surgery. The main goals of nasal tip surgery are to stabilize the tip complex, which largely affects the shape, projection and rotation of the nasal tip.
Objective: The present study describes a new, original method, the double columellar strut, and its main advantages compared to conventional techniques used for structural rhinoplasty.
Methods: The study involved 642 patients (496 women and 146 men, with an average age of 38.67 years) who underwent surgery between 2004 and 2018 by two operators. The patients were re-examined to evaluate the outcomes at least one year after surgery, and long-term results (15 years) were recorded for the oldest patients in regard to esthetics (projection, shape, rotation) and breathing function.
Results: Of the 642 patients, 34 required a surgical revision for minor defects of the tip due to asymmetry, and the natural appearance after the first surgery was not affected. For the primary rhinoplasties, there were no breathing disorders that required revision surgery due to systematic restoration or preservation of the middle third.
Conclusion: The double columellar strut could be performed in the same conditions that the others conventional structural grafts. As a polyvalent alternative, it can be used with closed or open approaches and involves the use of only a limited amount of cartilaginous material. This anatomical approach yields natural results, acting as a foundation for controlling the shape, projection and rotation of the nasal tip. In addition, with or without complementary techniques such as the “tongue in groove” technique or tip grafts, the double columellar strut can be considered a “multifunction pocket knife” for tip surgery.
To properly position and reshape the nasal tip, which is necessary for achieving refined esthetics of the nose, the relationship between underlying structures and the esthetic appearance of the skin surface needs to be well understood.
The architecture of the nasal tip has been the subject of many studies. Janeke and Wrigth  were the first researchers interested in anatomical supports, and first tip modeling attempt was proposed by Anderson as the tripod concept , which was based on the lower cartilaginous vault (LCV). Tardy and Brown provided a multifactorial description of the nasal tip .
It would be more accurate to describe the tip complex, including several different and interdependent entities, such as the cartilaginous vaults (LCV, UCV), the anterior septal angle, and their connections, which some authors refer to as ligaments [4-7]. Thus, the various components act as a single unit, like stained glass. The cephalic orientation of the cartilage and the sidewalls are consistent with this morphological description. These intrinsic fibers make it possible to articulate the various cartilaginous parts between them, reinforcing the coherence of the tip support while allowing some flexibility and stability. This joining, regardless of the surgical approach used, must be preserved, reconstituted, and even reinforced after the cartilaginous parts are reshaped. The perennially and the natural appearance of the final results depend on this step.
This polymorphic unit is supported by a true median main beam, the nasal septum. Adams  showed that septal resection, even partial resection, can decrease the projection of the tip. Beaty emphasized the many attaching or ligamentous fibers join the septum with the lower cartilaginous vault  and constitute a true natural “hammock” that supports the nasal tip [10,11]. Multiple connections with the various layers of the SMAS constitute this ligamentous and cartilaginous framework, thereby revealing the dynamic nature of the nasal tip [12,13].
In addition to its changes with aging, the nasal skin exhibits great disparities in its distribution, particularly in regard to its thickness, which is higher in the middle and lower parts. The relationship between the various layers of the SMAS  and the osseous-cartilaginous structure, which has been studied in detail by Saban, confirms this important inhomogeneity. The skin-related outcomes after surgery are unpredictable in two areas: the supratip and the lobule.
Fat and fibrous septa running from below the skin surface and the SMAS explain why it is difficult to reshape these areas (“skin memory form”). However, any damage to these extrinsic fasteners caused by surgical dissection that is not repaired increases the postoperative risk of randomized cutaneous retraction, specifically in thicker zones such as the supratip. For some authors, the consequence of such a situation associated with cartilaginous overcorrection can result in a lack of tip projection (35% of the cases for Beaty)  and sometimes a cutaneous pollybeak deformity.
Three main elements affect the surgical approach: the shape, projection and rotation (or height) of the tip. A combination of procedures targeting each of these criteria can lead to total tip control. The shape is mainly dependent on the lower cartilaginous vault, thickness, and cutaneous distribution. The projection depends on the length, medial crus resistance, and septum. Rotation is closely related to the position of the columellar lobular junction with the anterior septal angle, the scroll area between the two cartilaginous vaults, and the supratip skin in particular. All of these elements are interdependent. Regardless of the type of procedure performed, the skin must always be controlled by the carrying structure and the ligamentary connections. Thus, the open structure rhinoplasty concept was developed in 1990 by Johnson and Toriumi , who clearly established the fundamentals, and was advanced by Tebbets in 1994 . This concept was recently completed  with the description of the ligamentary system.
Another consequence of tip flexibility can be the unaesthetic effect of a plunging or smiling tip. This phenomenon is caused by connections between the SMAS and the nasal ligamentary system, particularly when the nose is under tension. Nevertheless, its effects remain very limited [18,19], and this phenomenon alone cannot lead to significant plunging movements. In fact, the retraction of the upper lip, followed by the rising of the nostrils , can worsen this dropping feeling. In addition, a closed naso-labial angle can reveal a lack of osseous support (hypoplasia of ANS or premaxilla) or a high insertion of the depressor septi nasi muscle. This angle, measured according to the definition provided by Goode , is usually between 95.4° and 100.1° for women and 93.4° and 98.5° for men .
Thus, given this information, what are the criteria that need to be met for an ideal nasal tip? It is very difficult to answer this question because the answer is dependent on fashions and trends. When one considers paintings or famous literary descriptions over time or across cultures, there is not a gold standard for the esthetics of the nose, and trying to define the tip with a mathematical model, even with very precise measurements, always leads to complex and not very useful classifications [23,24]. Sheen emphasized the importance of the harmony and the continuity of natural lines , such as those that join at the head of the eyebrow and continue to the tip, defining a landmark determined by dome angulation. As painters use shading and lighting to create the three-dimensionality and contours of the nasal tip, Toriumi used the same method to highlight and shade zones of the nasal tip, delimitating smooth zones and surfaces [26,27]. In the same way, Cakir juxtaposed a series of polygons delimited by precise landmarks . Every nose can thus be seen as an assembly of zones with soft transitions.
Nasal tip surgery has a two-fold objective. On the one hand, the shape, projection and rotation of the lobule is controlled by the application of an algorithm. On the other hand, a few surgical revisions are still needed despite numerous precautions being taken.
For many years, rhinoplasty has been based on cartilaginous resection. In recent times, however , the importance of preserving, respecting and reinforcing the integrity of the nasal osseous-cartilaginous structure as much as possible has become increasingly recognized . Although the concepts of “push-down” or “let-down” are presently at the forefront of nose surgery, a nonaggressive philosophy can also be applied in tip surgery, respecting the genuine cartilaginous framework as much as possible. While the aim is preservation, this approach also allows reorientation of the tip cartilage, according to the Tardy formula . Thus, a stabilized nasal base can be obtained by reinforcement of the medial and middle crus, thereby allowing additional procedures to be performed for the modification of other tip characteristics. While it is very anatomical, the double columellar strut adheres obviously to the standards of structural rhinoplasty but permits limited cartilaginous resection. The results, after fifteen years of follow-up for the oldest patients, show that the modifications are stable and long-lasting.
I described this technique in an article for the first time in 2014 . The initial step is to separate the external side of each medial and middle crus between the dome and the footplate (Fig 1). This submucoperichondrial dissection starts from the medial crus with or without the infiltration of saline solution. At this point, any mucous tears that are present must be sutured to prevent intranasal exposure of the grafts. The vestibular skin dissection should not extend beyond the posterior edge of the medial crus. In the lower part, the natural horizontalization of the footplate, due to the curvature of the medial crus, limits the dissection to the rear area. Indeed, the grafts are positioned vertically rather than obliquely when the crus is doubled, thereby preventing stability and projection loss (Fig 2). This condition is assessed particularly in patients with a plunging tip with or without a closed nasolabial angle (< 90°).
In the middle crus, a complete dissection of the vestibular mucosa from the cartilage in the area of Converse’s weak (or soft) triangle is not recommended to limit the need for secondary graft displacement. Each pocket allows the placement of a cartilaginous graft with a width of 2 millimeters and a length of at least 20 millimeters. The graft must not be thick (< 0.5 mm) so that the medial crus is not bulky. The length depends on the magnitude of projection that the surgeon wants to create. The longer the graft (up to a maximum of 24 millimeters in our study), the greater projection of the tip. If no additional projection is required, shorter grafts with a length of 18 millimeters are sufficient to stabilize the columella. Concerning cartilaginous material, remaining the first choice for harvesting, the residual septum must leave a solid “L-strut”. The double columellar strut needs obviously more cartilaginous material than the single columellar strut does but certainly less than a caudal septal extension graft does. The results reveal a high level of incorporated grafts in the cartilaginous skeleton, with long-term stability.
Two following aspects need to be assessed.
First, the quality of the cartilaginous graft needs to be assessed. Importantly, the graft should be resistant and able to withstand the pressure placed on it. The septal cartilage, due to it being straight and elastic, remains our first choice. Alternatively, although it is more fragile, the costal cartilage allows regular and straight grafts to be obtained, so it is the preferred harvest area for one of the senior authors (J.C.) . We have also tested the cartilaginous part of the hump, but this portion lacks rigidity. The auricular cartilage is not preferred because of its inhomogeneous levels of resistance and irregular shape. Each graft of the same length must be introduced upward under a small degree of tension. Once it is in place, it must be overlapped by the medial and middle crus along its entire length, from the dome to the vertical part of the footplate. Suturing with PDS 5/0 (Ethicon, a Johnson & Johnson company, New Jersey and Cincinnati, USA) is quite important, and simple or mattress stitches are used with the genuine framework. Light pressure, with a finger on each dome, is crucial to ensure the stability of the frame and to detect a tendency of displacement.
The second point is the rectitude of the caudal edge of the septum, specifically the inferior part. If there is an inferior malposition of the septum, the deviated septum needs to be corrected. If this is not done, the columella could also deviate.
Normally, after this first step, the crus must be straightened, particularly in the infratip lobule (middle crus) area, which is often the site of accordion-like folds. In preoperative examination, the infratip lobule is often in a low position due to a lack of support, clinically resulting in a droopy nose. This condition can be fully corrected without cartilaginous resection. To narrow a broad tip, the incision can be closed by transdomal and interdomal stitches [34,35]. We would rather use the hemitransdomal suture , which is placed as cephalically as possible to avoid any unaesthetic angulation of the weak triangle. In the event of a “dog ear” on the median cephalic edge of the domes, limited cartilaginous resection can be indicated. The two domes are then joined along their cephalic edge by an interdomal suture that restores the physiological angle (at least 30°) between them (Fig 3). To prevent enlargement of the nasal base, it is important to close each medial and middle crus with several stitches.
Only if necessary, stabilization of the septum/medial crus couple  can be performed by transfixing one or two sutures to the caudal border of the septum and the two footplates or the anterior nasal spine if the septum cannot be used. The loss of tip projection reported in the literature with the use of the single columellar strut is primarily due to the absence of anchoring (floating struts ). Sometimes, if more projection and/or rotation is needed and the septum length permits it, a standard “tongue in groove” procedure could be used. Care should be taken not to tie the sutures too high on the caudal edge of the septum to prevent tip over-rotation and columellar retraction.
Placing sutures close to the medial crus results in restoring the fasteners to the caudal septum and a decrease in the columella width (Fig 4). If tip refinement still appears to be necessary and to facilitate control of the cutaneous supratip, particularly in the event of a secondary nose or with thick skin, we use “on lay”  or “shield” grafts  (Fig 5), with or without a subcutaneous spanning mattress suture in the supratip area.
Nevertheless, such tip grafts or the “tongue in groove” technique should not be used routinely. Another exceptional supplementary procedure is the transposition of the lateral crus with a “lateral crural steal”, particularly in cases of cephalic malposition of the lateral cartilage . Closing of the cutaneous mucosa is achieved with Vicryl Rapid™ 5/0 (Ethicon, a Johnson & Johnson company, New Jersey and Cincinnati, USA). No additional procedures, particularly on the facial muscles, were carried out in our study.
The middle third of the nose is then rebuilt mainly by “spreader flaps” [40,41] using mattress sutures at the level of the new septal cephalic edge. If omitted, the middle third of the nasal tip may widen, and the harmonious lines of the nasal dorsum may be interrupted. Each cartilaginous part is rolled while each triangular cartilage is dissected one millimeter below the osseous sidewalls. Spreader grafts are rarely used and are usually reserved for secondary rhinoplasties or cases with valve insufficiency.
Between January 1st, 2004 and December 31st, 2018, 727 rhinoplasties were carried out using the double columellar strut technique and the open approach. Of these cases, 84 were not re-examined and were hence withdrawn from our study, so 642 cases were assessed (610 rhinoplasties were performed by the senior author (Y.J.), and 32 were performed by an associate colleague (C.B.)).
Of these patients, 496 were women (77.25%), and 146 were men (22.74%), with an average of 38.67 years. All of the patients were re-examined at least one year after the initial intervention. Of these 642 cases, 481 were primary rhinoplasties (74.92%), 91 were secondary rhinoplasties performed by other surgeons (14.17%), and 70 were posttraumatic cases involving a posttraumatic deviated nose (10.90%). Pictures were taken at the same distance with a 105-mm NIKON™ lens macro (Nikon Corporation, Shinjuku, Tokyo, Japan) with conventional viewing angles (front and lateral views, ¾ X 2, basal view). A NIKON™ ring flash was initially used for lighting, while for the past three years, our preference has been the use of two 500 W ELINCHROM™ (Elinchrom SA, Switzerland) strobe lights.
The esthetic factors assessed by the experts for a neutral assessment were as follows:
In the lateral view, the dorsum line, supratip, projection and rotation of the lobular columellar junction, hanging and nasolabial angle were assessed.
In the frontal view, the smoothness of the tip (distance between the considered luminous points), width of the nasal bones, and harmonious lines of the nose were assessed.
The breathing characteristics were also analyzed in the study based on Glatzel’s mirror (concentric circles) and the patients’ experience in this regard. A preliminary study using 3D stereophotogrammetry (VECTRA™, Canfield Scientific, Fairfield, N.J.) pre- and postoperatively is currently being undertaken.
The patients were reviewed at two months, six months, one year and every two years thereafter. Unfortunately, revision rhinoplasty remains a common occurrence. The revision rates reported in the literature are highly variable; the rates are typically between 5 and 20%, but some authors have reported even high rates considering all zones [41-44]. In our series, tip defects were 2½ times less common than the problems affecting the dorsum were, and 34 cases, or 4.97% of all the cases we treated, required surgical revision (table I).
Residual plunging tip
Residual hanging columella
TABLE I: REVISION CASES
East classified unsatisfactory results into two categories: those due to omission or inadequacy of the procedure, such as residual hump, and those due to excessive resection that lead to a “pinched-nose” or nostril retractions, which are always difficult to correct by revision surgery . In our series, we did not encounter problems in the second category since we did not perform any resections (except for the hump). Rather, the postoperative problems were related more closely to the dorsum, including a residual hump and irregularities (84 cases, or 13.04%), than to defects of the tip.
Additionally, our series did not reveal any functional problems due to primary surgery for esthetic reasons, according to the follow-up of the patients. Two temporary cases of cacosmia were reported, which were resolved favorably without further treatment. The revision surgeries for persistent pre-existing breathing disorders concerned previous valve dysfunction and hypertrophic turbinate.
The doubling of the medial crus by grafts can result in the widening of the columella, and four cases in our series required surgical correction for this issue. This problem was ultimately improved with positioning the graft posteriorly so that it overlapped or was hidden by the medial and middle crus. No cases of “clicking” or a rigid or a stiff tip were reported by the patients.
When I started performing this method in 2004, I only carried out it during secondary rhinoplasties for projection loss and poor-defined tips. Before this time, the medial columellar strut was my preferred method, but I sometimes hesitated to place a cartilaginous graft in a scar mucosa. Previously, the medial and middle crus were rarely undermined, and it was easy to dispose of a cartilaginous graft in these new pockets. I realized that this technique can affect the shape and rotation of the tip and restore an appropriate magnitude of projection. Moreover, I observed that the tip stability was reinforced, in accordance with the structural rhinoplasty concept.
Therefore, I increasingly extended the indications to primary rhinoplasties, following the single columellar strut indications, specifically including cases needing reshaping and those with a lack of rotation. Cases of an overprojected nose and a perfectly natural tip were excluded. At the same time, I stopped using all of the cartilaginous resection techniques involving the cephalic border of the alar cartilage, resecting only the cartilaginous portion of the hump (cephalic edge of the septum).
The first improvement observed is in the infratip-columellar angle, specifically in cases of a droopy tip. In my opinion, this procedure is very appropriate for these cases because the medial and the middle crus can be reinforced, and the infratip lobule can be straightened.
The second improvement is its determinant action on the shape and rotation of the tip. For tip projection, the double columellar strut can preserve or restore a loss of projection, but it is limited if more projection needs to be created. In this last case, additional procedures such as the “tongue in groove” or “shield” graft technique could be applied but is rarely used (< 10%). The positioning and symmetry of the nasal tip is facilitated because the pre-existing reinforced domes can be used as landmarks. Regarding this last point, in my experience, it is difficult to compare the results with those of the SEG because I never needed it.
Rohrich, in a recent paper , studied the different properties of SEG and columellar strut and their limits. The caudal septal extension graft lengthens the nose, is very unstable, requires an absolutely straight septum and a substantial amount of cartilaginous material, which sometimes requires graft harvesting from the rib cartilage. Moreover, the single columellar strut does not allow precise control of the tip rotation and has poor efficiency in tip projection.
This stability of the double columellar strut is created by the antagonistic stresses being distributed appropriately on the tip. Indeed, reinforcement of the medial crus, specifically the middle crus, is focused on the two natural domes. The key load-bearing are is located at the junction between the caudal septum edge and the middle crus. The stress on the tip is distributed between the two domes. Reinforcement of these natural settings adds more resistance and more cohesion to counter scar contracture forces and compensates for the disruption of the attachment. These two components are sufficiently reinforced by each graft to absorb this additional pressure. With the other techniques, the main stress is exerted medially on the tip in an unnatural manner and tends to move the domes in opposite directions laterally (Fig 6).
Another well-known factor that remains difficult to manage is the cutaneous behavior and its very random elastic properties, particularly in patients with thick skin. To prevent or correct a cutaneous pollybeak deformity, we used the association of a shield graft on the tip and a spanning mattress suture (PDS 7/0) in the supratip area.
The absence of postoperative functional disorders can be explained by a double action; first, the external nasal valve is opened, and second, the internal nasal valve is reconstructed systematically.
In cases of a dynamic “smiling tip”, no additional procedures on the mimic muscles were necessary, particularly on the depressor septi nasi muscle. Last, the resulting appearance was very natural and hence generally met the patients’ expectations.
Fewer than 5% of the patients required tip revision, and an analysis of these patients’ data showed that revision was needed due to technical deficiencies. According to East, we can say that we have moved from an attitude leading to resection to an attitude of safeguarding and reshaping. This conservative approach leaves the cartilaginous skeleton of the tip largely intact without destabilizing it, thereby yielding favorable long-term results. While resection excesses are in fact rare, the analysis of the failures shows that some rhinoplasties resulted in asymmetry.
However, the double columellar strut presents two risks:
The first risk is of widening the columella, which is controlled by stitches between the two medial crus. I did not notice that the association with the “tongue in groove” technique also affects the width of the columella.
The second risk is of nostril asymmetry. It is necessary to check the symmetry of each nostril before closing the skin.
In my opinion, the double columellar strut is a fundamental procedure, in addition to which surgeons can perform procedures at their discretion to improve some specific tip characteristics. This method is an alternative to and can be performed in addition to rhinoplasty procedures.
Its great flexibility of use explains why we have used routinely this method for more than 15 years and why we extended the indications to ensure perennial stability of the nose tip. The low level of postoperative dissatisfaction of patients who tend to have very high expectations regarding the appearance of their modified nose reassures me that this procedure is appropriate for natural postrhinoplasty results.
The double columellar strut can be considered a “multifunction pocket knife” in nasal tip surgery, in light of its versatility; moreover, it requires little cartilaginous material and has an anatomical nature, thereby yielding very natural results. The other options, such as the use of different kinds of septal extension grafts, are certainly good methods for secondary rhinoplasty or ethnic rhinoplasties to lengthen the tip projection, but they are not as flexible as the double columellar strut. On the other hand, regarding rhinoplasty, the double columellar strut technique is a highly attractive option for tip surgery due to its simplicity, rapidity, reproducibility, and effectiveness.
Special thanks to Dr. Bianca Knoll and Dr. Jay Calvert for their help
Result 1: Primary rhinoplasty, results at 2 years postoperatively.
Result 2: Primary rhinoplasty, results at 1 year postoperatively.
Result 3: Secondary rhinoplasty, results at 2 years postoperatively.
Result 4: Primary rhinoplasty, results at 1 year postoperatively.
Result 5: Primary rhinoplasty, results at 1 year postoperatively.
Result 6: Primary rhinoplasty, results at 1 year postoperatively.
Result 7: Posttraumatic rhinoplasty, results at 5 years and 15 years postoperatively.
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