title: Management of severe tip ptosis in closed rhinoplasty: the horizontal columellar strut.
abstract: BACKGROUND
  Tip ptosis is a relatively common nasal deformity, with an incidence as high as 72% in rhinoplasty patients. Different techniques were described for surgical correction of the droopy tip, such as the lateral crural steel, the lateral crural overlay, the tongue-in-groove technique and others. Most authors agreed that an external rhinoplasty approach is necessary for effectively conducting the alar cartilage-modifying techniques mentioned above.
  
  
  METHODS
  In this article we challenge this paradigm and introduce an efficient method for aesthetic correction of severe tip ptosis through an internal rhinoplasty approach. Twenty-three patients with severe ptosis of the nasal tip were operated on by the senior author (MH) between 2000 and 2005 using the described technique. After carrying out the necessary manoeuvres to achieve the desired tip rotation (reduction of cephalic border of alar cartilages, modification of the caudal septum, reduction of upper lateral cartilages), the desired tip position was maintained with the horizontal columellar strut, whose initial operative description appears here.
  
  
  RESULTS
  The desired rotation and projection were maintained in all but three patients over the first year after the surgery. In three patients we observed some loss of tip projection after 1 year. We did not witness complications directly related to the horizontal columellar strut.
  
  
  CONCLUSIONS
  The horizontal columellar strut is an efficient tool for stabilising the corrected position of a severely ptotic nasal tip. We recommend adding the horizontal columellar strut to the array of available rhinoplasty techniques.
authors.affiliation: Department of Plastic Surgery, Hadassah Medical Center of Hebrew University, P.O. Box 12000, Kiryat Hadassah, Jerusalem, Israel. margul13@yahoo.com
authors.forename: Alexander
authors.initials: A
authors.lastname: Margulis
authors.forename: Marcos
authors.initials: M
authors.lastname: Harel
mesh_terms: D000328:Adult; D002356:Cartilage / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009666:Nose / Q000002:abnormalities* / Q000601:surgery; D012225:Rhinoplasty / Q000379:methods*; D013536:Suture Techniques; D016896:Treatment Outcome