The columellar strut

What repeats

Five findings that hold across the literature.

It does not reliably raise the tip

One hundred consecutive primary rhinoplasties with a columellar strut were measured on standardised photographs at one year or more. Tip projection decreased in 65%, increased in 27% and was unchanged in 8%. The nasolabial angle increased in 46%, decreased in 34% and was unchanged in 20%. The authors conclude the strut unifies the tip and controls its final position rather than pushing it forward.

Rests on: Rohrich et al., effect on tip position.

Against the septal extension graft it gives up a small amount of projection and rotation

In 133 primary rhinoplasties by one surgeon, 40 had a columellar strut and 37 a septal extension graft. Projection loss at one year was 4.7% for the strut and 0.2% for the extension graft (P < 0.0001), and mean rotation loss was 4.9 degrees against 1.3 degrees (P < 0.0001). Using a strut carried a 5.1-fold increased risk of losing more than 4% of projection (P < 0.005).

Rests on: Bellamy and Rohrich, long-term tip stability · Rohrich et al., changing roles.

The pooled comparison points the same way, on eight studies

A meta-analysis of 8 studies covering 256 strut and 371 extension graft patients found the long-term nasolabial angle favoured the extension graft (p < 0.05), with no difference in Goode's ratio between the groups. A separate systematic review included 8 studies with 571 patients, 46% of them strut cases, and reports patient-reported outcomes in only 2 of those studies.

Rests on: Ozgenc et al., meta-analysis · Amador et al., systematic review.

Breathing is the same with either graft; appearance scores are not

A cohort of 165 patients at one practice compared the two grafts with airway testing and questionnaires. The change in nasal peak inspiratory flow was almost identical, 20.0 L/min against 19.9 L/min (p = 0.983). The cosmetic score favoured the septal extension graft, 7.20 +/- 2.97 against 5.69 +/- 3.45 (p < 0.01), and photographic analysis showed less distortion of the nasolabial angle in that group.

Rests on: Lathif et al., strut against extension graft · nasal airway obstruction.

It changes rotation only when the surgeon sets out to change it

Across 173 open septorhinoplasties, neither nasolabial angle nor tip projection changed significantly when upward rotation was not the aim, whether the strut was used alone or alongside other steps. Where rotation was intended, the mean nasolabial angle increased by 4.4 degrees, and conchal struts performed significantly better than septal ones.

Rests on: Bucher et al., projection and rotation.

By how the strut is fixed and shaped

The name covers several different grafts.

Floating between the medial crura

The classic form. The strut sits in a pocket between the two inner legs of the tip cartilage without touching the septum, which is why it can settle. Compared against tongue-in-groove fixation in 69 patients, the short floating strut group moved from a mean nasolabial angle of 100.8 to 104.2 degrees, a change that did not reach significance, while the tongue-in-groove group moved from 96.8 to 108.2 degrees (P < .001). Projection rose significantly in both groups.

Rests on: Aksakal, tongue-in-groove against strut.

Fixed to the caudal septum or to a flap

Anchoring stops the settling. In 22 patients the strut was placed in a pocket made from a posteriorly based mucosal flap at the nasal spine, with the tip complex suspended to the caudal septum. Follow-up ran 12 to 24 months, no significant complications occurred and no patient needed revision for lost projection.

Rests on: Ceran et al., mucosal flap pocket.

Fixed to the sides of the medial crura

Placing the strut on the outer faces of the medial crura rather than between them was done in 51 primary cases. Mean nasolabial angle was 90.2 degrees before surgery and 104.2 degrees at follow-up (P < 0.05).

Rests on: Yucel et al., lateral columellar strut.

Extended forward as a strut and tip graft in one

A single unit combining the strut and a tip graft was used in 155 endonasal cases over 15 years, 110 of them secondary. Six patients in the secondary group had complications, three with a visible graft and three with asymmetric placement, and two of those had revision surgery.

Rests on: Pastorek et al., extended columellar strut-tip graft · open versus closed rhinoplasty.

Branched, wide-based and three-dimensional variants

A Y-shaped strut carved from ear cartilage was used in 37 patients, raising the nasolabial angle significantly (P < 0.00001), with mild tip deviation at one year in three congenital cases. A three-dimensional Y-shaped strut was used in 78 patients with a mean follow-up of 15 months. A wide-based strut for weak caudal septum and spine was used in 32 patients, 25 of them from rib cartilage, with one mini-revision for a visible tip graft.

Rests on: Martino et al., Y-strut · Topkara, three-dimensional strut · Soylu et al., wide-based strut · ear cartilage grafts.

What to ask about a columellar strut

Questions the evidence supports asking.

Strut or septal extension graft

The extension graft holds position better and scores higher for appearance. The strut leaves the septum alone and needs less cartilage. Ask which one the surgeon plans and what makes a nose unsuitable for the other.

Rests on: Bellamy and Rohrich · Lathif et al. · Amador et al..

How much projection will settle out over the first year

Published loss for the strut is 4.7% of projection and 4.9 degrees of rotation at 12 months. Ask whether the surgeon builds that in, and ask to see photographs at one year rather than at two months.

Rests on: Bellamy and Rohrich · Rohrich et al. · what recovery looks like.

Where is the cartilage coming from

Septum first. Conchal struts outperformed septal ones on rotation in one 173-patient series, and rib is used when the septum and spine are weak or already harvested.

Rests on: Bucher et al. · Soylu et al. · costal cartilage harvest.

What are the complications of a rib strut

A systematic review of 14 studies and 1,358 patients having tip-stabilising grafts from costal cartilage found a pooled complication rate of 4.7%. Warping was the commonest problem with the patient's own rib at 1.7%, and resorption was commoner with irradiated donor rib, 2.4% against 0.49% (p = 0.002).

Rests on: Kowalski et al., costal cartilage complications · irradiated rib grafts.

Is a strut right for a cleft nose

In a randomised comparison in secondary cleft rhinoplasty, tip projection fell progressively in the strut group where the septal extension graft group stabilised after six months. The authors state the extension graft gives more predictable long-term support in that setting.

Rests on: Acil et al., cleft lip rhinoplasty.

The terms, defined

The words used about this graft.

• Columellar strut: a piece of cartilage placed upright between the medial crura in the columella. [23018701]
• Columella: the column of skin between the nostrils, running from the tip to the lip. [36041106]
• Medial crura: the inner legs of the lower lateral cartilages, which the strut sits between. [36041106]
• Floating strut: a strut not fixed to the septum or the nasal spine. [33080208]
• Septal extension graft: cartilage fixed to the septum and carried out to the tip, the main alternative. [36728586]
• Tongue-in-groove: fixing the medial crura directly onto the caudal septum instead of using a strut. [33080208]
• Tip projection: how far the tip stands out from the face. [23018701]
• Tip rotation: how far the tip is turned up, read from the nasolabial angle. [32062744]
• Nasolabial angle: the angle between the columella and the upper lip. [32062744]
• Goode's ratio: a photographic measure of tip projection against nasal length. [40854551]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what the surgeon should assess before operating and what should be recorded afterwards, whichever graft is chosen.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries chapters on tip support, where the strut sits among the other options. They are written for surgeons and go further into technique than a patient page should.

• Supporting the Nasal Tip
• Nasal Tip Contour and Support Management
• Tip Rhinoplasty: Alar Structural Support Techniques

The operation on video

The same archive hosts recorded operations placing the strut.

• Columellar Strut
• Benefit of using a columellar strut

The reference summary

Rhinoplasty Tip-Shaping Surgery in StatPearls, on the National Library of Medicine's Bookshelf, gives the tip anatomy, the graft options and the complication list in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

Three registered trials name the columellar strut.

• Outcomes Assessment of Septal Extension Graft Versus Columellar Strut Graft in Rhinoplasty, not yet recruiting, 60 participants.
• Lateral Crural Steal With Columellar Strut Graft in Primary Open Rhinoplasty, recruiting, 22 participants.
• Comparison of Septal Advancement Flap and Columellar Strut Effect on Nasal Tip, completed, 30 participants.

What is not settled

• Most comparisons are single-surgeon retrospective cohorts. The systematic review found patient-reported outcomes in only 2 of 8 included studies. [40864612]
• The projection numbers come from photographs. A photograph measures position, not the stiffness of the tip a patient feels. [23018701] [36728586]
• Whether a fixed strut behaves like a septal extension graft is untested. The techniques that anchor the strut report no revision for lost projection, in series of 22 and 51 patients with no control group. [41215840] [36041106]
• The choice of donor cartilage is unresolved. One series found conchal struts significantly better than septal for rotation, and no other study repeats that comparison. [32062744]
• The strut remains standard practice even where the evidence favours the alternative. It was the most reported technique for caudal septal deviation in a survey of paediatric otolaryngologists, at 66.7%, and it produced significant nasolabial angle change in a 510-patient graft comparison. [42462583] [41849710]