Surgical approach for nasal obstruction, a drooping tip, and lowering the columella

Hello, I am Dr. Peter C. Kang.

Today, I would like to share a surgical case of a patient who sought treatment for right-sided nasal obstruction, a drooping nasal tip, and lowering the columella.

In cases like this, the patient had already undergone two prior rhinoplasty procedures, making this their 3rd surgery.

1. Preoperative design consultation

Let us take a detailed look at the patient's preoperative condition and requests:

Patient's surgical history:

• July 2022: Rhinoplasty using ear cartilage and a silicone implant

• April 2023: Rhinoplasty using autologous rib cartilage and a silicone implant

Patient's main requests:

1. Lowering the columella

2. Refining and elevating the drooping nasal tip

3. Creating a natural nasolabial angle

4. Improvement of right-sided nasal obstruction

Analysis of preoperative condition:

Front view:

Front view

• The nose appears crooked

• The nasal bridge implant shows through

Profile view:

Profile view

• The nasal tip is drooping

• The columella is retracted

• The nasolabial angle looks unnatural

Nostrils:

• Nostril asymmetry is present

• The columella is tilted

Additional findings:

• Complaints of right-sided nasal obstruction

• CT scan and nasal endoscopy findings:

  • Deviated septum

  • Hypertrophied inferior turbinates

  • Mucosal adhesion in the right nasal cavity

Right intranasal synechia (indicated by arrow) is visible.

2. Surgical plan

Taking into account the patient's condition and requests, the following surgical plan was established:

a) Septal extension using autologous rib cartilage

b) Nasal bridge implant replacement (widening the width)

c) Lowering the columella

d) Nasolabial angle correction

e) Septoplasty

f) Mucosal adhesiolysis

g) Radiofrequency submucosal resection of the inferior turbinates

3. Surgical procedure

a) Autologous rib cartilage harvest and grafting:

• The patient's rib cartilage was harvested to secure an adequate amount of cartilage required for nasal reconstruction.

b) Septal extension graft:

• Autologous rib cartilage was used to extend and reinforce the septum.

• This elevated the drooping nasal tip and reinforced structural support.

c) Nasal bridge implant exchange:

• The existing implant was removed and replaced with a wider implant.

• This addressed the visible implant show-through and created a natural contour.

d) Lowering the columella:

• The retracted columella was lowered appropriately to improve overall nasal balance.

e) Nasolabial angle correction:

• Lowering the retracted columella created a natural nasolabial angle.

f) Septoplasty:

• The deviated septum was straightened to relieve nasal obstruction.

g) Mucosal adhesiolysis:

• Adhesions in the right nasal mucosa were released to relieve nasal obstruction.

h) Inferior turbinate reduction:

• Hypertrophied inferior turbinates were reduced using radiofrequency to relieve nasal obstruction.

All procedures were performed using a closed approach, completing the surgery without external scars.

4. Comparison of before-and-after photos

Comparing photos taken immediately after surgery on day 0 shows the following improvements: Photos taken immediately after surgery show swelling and may differ from the final result.

Front view:

• The crooked nose was straightened.

• The visible implant show-through along the nasal bridge has significantly improved.

• The nose presents an overall well-balanced appearance.

Profile view:

• The previously drooping nasal tip has been naturally elevated, improving overall facial balance.

• The retracted columella was brought down appropriately, forming a natural line.

• The unnatural nasolabial angle was corrected, improving harmony between the nose and lips.

Oblique view:

• The nasal deviation was corrected, creating a smooth line.

• The contour of the implant has been naturally improved.

Nostrils:

• Nostril asymmetry has improved, resulting in a balanced appearance.

• The tilted columella has been straightened.

5. Photos immediately after surgery (Day 0) Immediate postoperative photos show swelling and may differ from the final result.

6. Overall evaluation

This case is a good example of achieving aesthetic and functional improvements simultaneously. Despite two previous rhinoplasty surgeries, the patient remained dissatisfied and continued to experience functional discomfort from nasal obstruction.

Septal extension using autologous rib cartilage played a major role in correcting the drooping nasal tip and reinforcing the overall nasal framework. Additionally, replacing the bridge implant resolved the implant show-through and achieved a much more natural contour.

Lowering the columella and correcting the nasolabial angle improved overall balance and harmony between the nasal tip and perioral region. Beyond altering nasal shape, this played a significant role in softening the patient's overall facial impression.

Particularly noteworthy in this surgery was the comprehensive approach to resolving nasal obstruction. Septoplasty, mucosal adhesiolysis, and inferior turbinate reduction together addressed functional airway issues. This is an area where expertise as a board-certified otolaryngologist proved essential.

Using a closed approach shortened the postoperative recovery period and allowed surgery to be completed without external scars. This contributed significantly to patient satisfaction.

7. Conclusion

I hope this case offers encouragement to those troubled by complex nasal concerns, such as nasal obstruction, a drooping tip, and an unnatural columella. In particular, I hope it helps patients who continue to struggle with unsatisfactory outcomes after previous rhinoplasty procedures.

Revision rhinoplasty requires rebuilding the framework while working around structural changes from prior procedures, making it more complex and demanding than primary surgery. Therefore, guidance from a surgeon with extensive experience and dedicated expertise is essential.

Furthermore, rhinoplasty should never be approached solely from an aesthetic standpoint. Because the nose is an essential organ directly tied to breathing, functional aspects must be evaluated alongside cosmetic goals. When nasal obstruction, a deviated septum, or rhinitis are present, addressing them together during rhinoplasty is advisable.

Drawing on anatomical knowledge and extensive surgical experience as a board-certified otolaryngologist, I provide surgical plans tailored to each individual patient. Through a comprehensive approach that considers both functional and cosmetic improvement, I strive to create a beautiful and healthy nose.

I will be with you every step of the way to achieve a beautiful and healthy nose.

This was Dr. Peter C. Kang. Thank you.

Thank you.

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