Perform complete full facial analysis with a focus on nasal tip projection, rotation, and symmetry.

Confirm adequate cartilage availability for the length and strength of the columellar strut that will be required to address the specific aesthetic and functional goals.

Harvest cartilage that is of the proper size and strength for a columellar strut. Ideally, septal cartilage is preferred for a primary rhinoplasty. Costal cartilage is used for columellar struts in secondary rhinoplasty cases where the septal cartilage is inadequate or in patients with a need for significant tip support. Auricular cartilage can be used, but may require multiple fragments to be sutured together to construct an adequately strong and symmetric columellar strut graft.

Harvested cartilage is carved into a quadrangular shape that is 2 to 4 mm wide, 15 to 25 mm long, and 2 mm thick.

Avoid warped or twisted portions of cartilage so as to maximize symmetry in the final construct.

The cartilage should be shaped to create a slight angle at each end. These angled ends are ideal for placement into the soft tissue pocket proximally and distally while also creating the proper transition from the infratip lobule to the nasal tip.

Dissect a soft tissue pocket between the medial crura posteriorly toward the maxilla leaving a portion of soft tissue intact to prevent postoperative “clicking” of the columellar strut on the maxillary crest. The pocket dissection depth is critical as it must match the goals for the columellar strut (Fig. 24.1). A limited depth pocket is ideal if the strut graft is to be used dynamically to project the nasal tip and/or if the strut graft cartilage is short. A deeper pocket may be ideal if there is adequate graft material and/or if the graft will be used in a static fashion to only maintain tip projection.

A double hook is used to retract the lower lateral cartilages anteriorly while advancing the columellar strut graft posteriorly in relation to one another based on the desired effect on tip projection (Fig. 24.2). If more projection is desired, the lower lateral cartilages can be advanced anteriorly while the columellar strut is displaced posteriorly. The graft–lower lateral cartilage interface tension can then be set with a 25-gauge needle placed through the medial crura and graft construct.

The interrelationship of the structures is then assessed and sutured together using 5–0 PDS sutures in a horizontal mattress fashion. Sutures are placed inferiorly and then again in the infratip area. Careful attention is paid to ensure the medial crura are oriented in a symmetric fashion in all planes.

If an increase in projection is desired, and a dynamic columellar strut has been placed, the surgeon can expect a 1 to 2 mm decrease in projection over time as the nose heals. This often means that an overcorrection of tip projection is required when using a columellar strut to increase tip projection.

The columellar strut graft is placed to ensure that it is an invisible graft, which is used to structurally support the lower lateral cartilages and avoid any direct contact with the skin. Particularly in the interdomal area, any visibility of the graft beyond the lower lateral cartilage is to be avoided.

See Video 24.1.