Crooked Tip and Columella & Nostril Asymmetry Case Study 3

After rhinoplasty, it is surprisingly common for the tip and columella to become crooked and the nostrils asymmetric, accompanied by nasal obstruction.

Unhappy with how it looks and stressed every time they see it, patients go back to the clinic that performed the surgery,

only to be told, "The swelling has not fully gone down and things have not settled yet, so let's wait a little longer."

Quite a few of them wait 2-3 months, see no improvement, and then come to my clinic.

A crooked columella and tip and asymmetric nostrils after rhinoplasty are stressful enough,

and patients are anxious and worried, unsure whether it will improve on its own with time or needs to be corrected.

However, this never improves on its own simply by waiting.

Corrective surgery must be performed in order to restore the original appearance.





To correct this, the cause must first be identified through endoscopy and a careful examination, and then the twisted tip cartilages and septum must be returned to the midline. Technically, there are two methods.

Because the patient did not want any further cartilage grafting, the open approach was used, but the procedure was close to a simple repositioning. The left photo shows the state before correction, in which the tip cartilages in the columellar area were severely buckled and bent. The right photo shows the result after simple suturing; had a more comprehensive surgery been performed together with cartilage grafting, a greater degree of correction could have been achieved, which is regrettable.





In the preoperative photo, the left and right alae differ considerably in size, which shows that asymmetry was present from the beginning. After surgery, the nasal tip sits in the center and the deviation has also improved considerably.





After surgery, the axis of the columella has been straightened. However, some asymmetry of the nostrils and alar rims caused by facial asymmetry remains; correcting it would require additional procedures such as a columellar strut, lateral crural strut grafting, and left alar reduction, but the patient did not wish to have them.





The dorsum and tip, which appeared disconnected before surgery, are smoothly connected after surgery.





The side view clearly shows the columella at the tip pressed by the silicone implant and bent downward. After surgery, the bent columella has straightened out, and the length of the nose has also settled in a straight line.









Donor costal cartilage had been used for both the septal extension graft and the onlay graft on the tip. On the left, the onlay graft and the septal extension graft can be seen. Because the donor costal cartilage was thick, the columella had become too thick. The septal extension graft was fixed to the left side of the septum, and it had been fixed in a tilted position. Because the tip cartilages are fixed to the tilted extension graft, the tip inevitably tilts as well. Such a large, bulky septal extension graft would have narrowed the left nasal cavity and made breathing difficult.




Removal of the septal extension graft.




After removal of the septal extension graft, the septum is seen to be deviated.





Although there is much debate about early removal performed within 3 weeks after surgery, at our clinic, when an excessively exaggerated nasal shape, functional problems, inflammation, or similar issues occur after surgery as in this case, we proceed decisively with early removal.

That said, while early removal poses no problem in theory, technically it is a surgery that requires extensive experience and meticulous technique. The patient in this case achieved good overall balance and recovered well without tissue damage or scarring.








Left: Before early removal, 10 days after surgery at another clinic. Right: Both the tilted tip and columella have been straightened, and the nostril asymmetry has been completely corrected. The collapsed left nasal cavity has also widened, and breathing has become much easier.





The unnatural Pinocchio-like tip has been reduced, giving a much more natural appearance.