Alar-columellar relationship — Hanging columella, alar retraction and their combinations
The millimetres that define profile balance, Gunter’s six-type classification and what corrects each alteration, from the Levet manoeuvre to the chondrocutaneous graft.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Assessed on the lateral view with two measurements: the columella should sit 1-2 mm from the nostril long axis and the alar rim 2-3 mm.
- The first task is deciding which element is malpositioned: columella, ala, or both. The profile looks the same and the treatment is opposite.
- In alar retraction one fact saves reoperations: a graft placed in normal anatomical position will not lower the alar margin until the scar tissue is released.
- In retractions under 2 mm with preserved mucosa, a release-and-reposition manoeuvre may suffice, without a graft.
- Alar retraction is mostly iatrogenic: over-resection of cartilage or vestibular skin, or a badly applied dressing.
What is measured and where
In a normal alar contour seen in profile, the nostril is oval and the alar rim describes a gentle inferiorly concave curve. On that image two distances are drawn relative to the long axis of the nostril: the columella should lie 1 to 2 mm away and the alar rim 2 to 3 mm. Those two figures are what turn an impression — “too much columella shows” — into a named diagnosis, and above all distinguish which of the two structures is out of place.
Gunter’s classification, in six types
| Type | What happens |
|---|---|
| I | Hanging columella |
| II | Retracted ala |
| III | Combination of hanging columella and retracted ala |
| IV | Hanging ala |
| V | Retracted columella |
| VI | Combination of hanging ala and retracted columella |
A clarification about the classification
Simplified four-group versions of this classification circulate — normal, descended columella, elevated columella and both altered — which are didactic but lose a distinction that matters in theatre: whether the displaced element is the columella or the ala. The original describes six types, precisely because it separates the four isolated alterations from the two combinations. And that separation dictates the manoeuvre: resect in a hanging columella, add in alar retraction. Working with the four-group version leads to operating on the wrong element.
Hanging columella
It produces exaggerated, conspicuous exposure of the nasal mucosa, and may be primary or secondary. There are three primary causes: excessive convexity or width of the medial crura, excess caudal septum or excess membranous septum. In operated noses it appears when the alteration was untreated or insufficiently treated. Treatment is subtractive: resection of the excess posterior border of the medial crura or of the caudal septum, with or without mucosal removal. It is one of the few alterations in this area where removing is the right answer.
Do not confuse it with alar retraction
This is the most worthwhile confusion to avoid in this whole subunit, because both give a very similar profile — a lot of mucosa shows — and treatment is exactly opposite: hanging columella is resected, alar retraction requires adding tissue. They are distinguished by measuring both distances from the nostril axis separately: if the abnormal one is the columella’s, it is hanging; if it is the ala’s, it is retraction. Operating on one believing it is the other worsens the profile instead of correcting it.
Retracted columella
Here the alar rim is well positioned but sits at the same level as or below the columella. In unoperated noses the cause is usually a short caudal septum. In secondary cases the range is wider: over-resection or untreated deviation of the caudal septum, division or resection of the medial crura, or cicatricial retraction of the mucosa or columellar skin after open rhinoplasty. Correction follows the cause: a strut graft between the two medial crura where support is lacking, or properly completing the caudal septoplasty where the problem is septal. Exceptionally, septal mucosal advancement flaps are needed alongside the graft.
Alar retraction: what produces it
It is the loss of continuity or notching of the alar rim, with arched or elevated nostrils. The primary mechanism has two components acting together: malposition of the alar cartilages leaving the caudal border incompetent to prevent ascent of the alar rim, and the forces pulling it upward — skin elasticity and the action of the alar levator muscles. It also occurs in nostril asymmetry and the mixed-ancestry nose. But usually it is iatrogenic: over-resection of upper or lower lateral cartilages, resection of vestibular skin, or a badly applied dressing.
Alar retraction: treatment steps
- Under 2 mm, mucosa preservedLevet manoeuvre: prerimal incision, superior mucosal undermining releasing the fibrosis, and more caudal repositioning of the alar rim, held with transcutaneous sutures for 2 to 4 days
- Mild or moderateRestore lobule-to-ala continuity with a simple cartilage or alar rim graft. Septal is preferred, as it avoids opening a new field; failing that, conchal
- SevereWider alar grafts, whose lower placement brings the rim down; or a V-Y mucosal advancement flap; or an auricular chondrocutaneous composite graft of skin and cartilage
- Extreme, with collapseBone graft from the perpendicular plate of the ethmoid, for its rigidity
The graft will not lower the ala unless the scar is released
This is the detail that prevents most reoperations here: cartilage placed in its normal anatomical position will not lower the alar margin until the scar tissue has been removed. Put another way, the graft holds the rim where you leave it, but does not by itself overcome the force pulling it up. Hence the correct sequence: release the fibrosis first, confirm the rim descends, and only then place the graft to hold the position gained. Doing it the other way round produces a correction that looks good in theatre and vanishes within weeks.
Hanging alae
This is the least frequent alteration of the group, and the key is not to study it in isolation: one must assess where the columella stands, which may be retracted, normal or even hanging. That combination defines the Gunter type and with it the plan. In extreme cases treatment is longitudinal resection of the alar rim, a manoeuvre to be reserved and measured, since a scar on the free border of the ala is hard to camouflage.
A lot of mucosa shows in profile: whose fault is it?
Measuring from the nostril long axis, which distance is abnormal?
References
- 1.Arquero P. Alteraciones nasales: equilibrio alar columelar. rinoplastia.eu.
- 2.Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepancies in rhinoplasty. Plast Reconstr Surg. 1996;97(3):503-509.
- 3.Rohrich RJ, Afrooz PN. Revisiting the alar-columellar relationship: classification and correction. Plast Reconstr Surg. 2019;144(2):340-346.
- 4.Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002;109(7):2495-2505.
- 5.Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas. Cham: Springer; 2018.
Related specialty: Rhinoplasty