Proper execution of the transcolumellar incision in external rhinoplasty.

A conspicuous columellar scar is sometimes regarded as an inevitable consequence of the external rhinoplasty approach. However, an unsightly columellar scar is far more often the result of poor technical execution rather than the incision per se. Optimal design and execution of the incision, coupled with meticulous wound closure, will most often be rewarded with a faint, barely perceptible scar, even in dark-skinned patients.

The merits of the external rhinoplasty approach are now widely acknowledged. Although the optimal transcolumellar incision remains a subject of ongoing debate, several basic principles are commonly accepted. In general, the transcolumellar incision is best located at the narrowest portion of the columella, which results in a shorter, less visible scar and less risk of linear contracture. In order to avoid ischemic compromise of the skin flap, the incision should also be sited at least halfway up the columella (i.e., long, narrow flaps should be avoided). Typically, this location corresponds with the upper two-thirds of the nostril openings. While the shape of the incision may vary from stairstep or gull-wing to triangular or straight, interrupted (geometric) incisions are preferable because they prevent long scar segments and facilitate flap alignment. The author prefers the traditional five-cornered inverted-V incision because the multiple corners facilitate both scar camouflage and precise flap alignment (figure 1).

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Perhaps the most common cause of an unsightly columellar scar is notching or inversion of the incision line. This is usually secondary to an irregular skived incision and/or faulty wound closure. To prevent notching and optimize scar camouflage, the transeolumellar incision must produce smooth, full-thickness skin cuts with squared wound edges. This is best accomplished under firm tension with a #15 knife blade, to create interconnecting stab incisions along each of the four columellar segments (figure 2). The central stab incisions are performed first. Deep penetration of the knife blade, often up to 4 or 5 mm, is required to fully transect the central columellar skin. In contrast to the central columella, the medial crural cartilages are much closer to the skin surface in the lateral aspects of the columella, and therefore these horizontal stab incisions need to penetrate only 2 or 3 mm in depth. All corners should abut precisely, and the two outer corners should form perfect right angles to facilitate flap reapproximation (figure 3).

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Once all of the skin incisions--including the endonasal "marginal" segments--have been made, the columellar skin is bluntly elevated from the underlying cartilage via a vestibular incision (figure 4). Inadvertent thinning of the columellar flap is avoided by elevating all subcutaneous tissues with the flap. The remaining subcutaneous tissue attachments are then cut safely once the scissors tip is passed through the opposite vertical incision.

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Closure of the transcolumellar incision is greatly facilitated by a properly executed incision with multiple alignment points as described above. However, accurate and secure flap approximation is also fundamental to a satisfactory outcome. When vertical wound tension prevents gentle flap approximation, a midline subcutaneous suture of 6-0 Monocryl is often necessary to approximate the flap edges. This deep-layer closure shifts tension to the subcutaneous tissues and prevents gradual widening and inversion of the final scar. Surface alignment is then accomplished at each flap corner with a simple interrupted suture. Surface sutures are placed close to the wound edge at superficial depth to ensure precise edge alignment. Following surface closure, the columellar sill is inspected for step-off deformities and additional sutures are placed if notching is evident. Vertical mattress sutures can be used to evert wound edges when closing tension remains problematic.

Although various sutures are available for surface closure, the choice of suture material is less important than precise suture placement. However, a dissolvable suture is usually preferred because the removal of permanent sutures from the columella is often very unpleasant. In general, short-acting gut sutures should be avoided because they often produce a brisk inflammatory response and may lead to prolonged erythema or hypertrophic scarring in susceptible patients. The author prefers 7-0 Vicryl, which usually dissolves in 12 to 14 days with less inflammation than that associated with gut suture.

Attention to detail and meticulous technique are critical to satisfactory scar camouflage. Although tedious, these efforts are typically rewarded with the creation of a faint, inconspicuous surgical scar in virtually all rhinoplasty patients (figure 5). Therefore, the many benefits of the external rhinoplasty approach should not be excluded on the basis of columellar scarring alone.

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From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, University of Miami School of Medicine.