Hoe Can My Nasal Sill Be More Elevated?

Q: Dr. Eppley, In attempting to find a solution for my columella show (image included below) I recently read a paper “Alar Batten Cartilage Graft: Treatment of Internal and External Nasal Valve Collapse” published in Aesthetic Plastic Surgery (paper attached).

My photo below shows my current situation – my previous surgeon seems to have conducted an alar rim reduction in conjunction with the lip lift. As a consequence, I have less support in my sill and very little philtrum. Elevating my columella also raises my upper lip (which is not an entirely unwanted effect [exaggerated below] as it helps to address some asymmetry).

I found the paper very informative, largely because it contains a case showing a nasal sill being elevated and stabilised through the use of an alar batten graft. This is in Figure 11 (shown below), which also demonstrates a case of congenital nasal valve collapse. The postoperative images show a profound improvement in the nasal sill anatomy, which I find quite remarkable. While I understand the primary purpose of the alar batten grafts, I’m curious about the specific forces at play that led to this significant change in the nasal sill.

Do you have any insight into this effect and how it might be applied to my situation? My hope was that through a series of alar grafts and a columella retraction suture(s) I might be able to improve my current situation, though I’m unsure whether increasing the projection may also assist. 

A:The answer to your question regarding nasal sill/rim retraction is that structurally the three maneuvers of alar rim grafts, tip derotation and columellar retraction suturing are all that is possible to try and improve your current situation. All I can say about them is to increase the chance of their success is: 1) all three must be done concurrently (difficult problems require maximal effort)  and 2) a rib graft may be needed to provide adequate material for the grafting. The other alternatives are combined septal and ear cartilage grafts.

Dr. Barry Eppley

World-Renowned Plastic Surgeon