Columellar Incision

The external rhinoplasty approach includes a columellar incision. Great care must be taken when making this incision not to bevel it but rather to ensure that the incision is perpendicular to the skin, thereby avoiding the complication of a trapdoor deformity. Great care must be taken in closing the incision to avoid notching at the margins or other deformity (Fig. 394).

A single subcutaneous 6-0 polydioxanone (PDS) suture can be positioned in the dermal tissues to enhance skin edge eversion and take tension off of the closure. This suture should provide skin edge alignment and slight eversion. Excessive eversion will create a deformity that may require many months to resolve. The level of the skin edges must be precisely aligned with this suture; otherwise an unsightly scar may result. if there is no tension on the closure, a subcu taneous suture may not be needed.

To close the skin, five 7-0 nylon vertical mattress sutures are used. The first suture lines up the apex of the inverted V. The next two sutures are angled from medial on the lower flap to lateral on the upper flap to properly align the closure. A 6-0 chromic suture is used to line up the vestibular skin at the corner of the columellar flap. This corner suture is impor tant because aberrant healing of this corner can result in a visible notch defect.

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