ABSTRACT Background: Columellar reconstruction is a challenging endeavor, both functionally and aesthetically. Columellar retraction leading to tip collapse can be the result of trauma, infection, malignancy, iatrogenic cause or congenital deformity. The purpose of the present study was to present a novel technique of columellar lengthening via the sublabial approach. Methods: Thirty-two patients (21 men, 11 women) with columellar collapse underwent columellar reconstruction via the sublabial approach. Mean age of the patients was 33.8 years (range 17 to 58 years). Operative technique: Donor cartilage is harvested. The ideal source is the nasal septum.Other sources are conchal or rib cartilage. A graft, 5 mm wide X 2 to 2.5 cm long X 2 mm thick is carved with carefully beveled edges. An inverted V-shaped incision is made in the midline of the labial mucosa, beginning at the gingiva, avoiding the frenulum . The incision is carried on cephalad toward the nasal septum and includes sectioning of the origin of the depressor septi nasi muscles until reaching the nasal spine. Blunt dissection with Metzbaum scissors is then performed, superiorly into the columella between the medial crura of the lower lateral cartilage and into the membranous septum. The graft strut is then introduced through the sublabial tunnel created . Graft bulging above the level of the domes should be avoided. The graft strut is fixed using a straight needle and an absorbable suture. A transfixion suture is made to support the graft to the anterior septum. An additional crescent-shaped graft is carved and introduced transorally, through the tunnel created, embracing the base of the fixed graft, thus securing it in position, and keeping it from migrating anteriorly and into the upper lip. This graft is fixed to the periosteum of the maxilla or to the nasal spine . Case presentations: Case 1- A 38-years old man who underwent mandibular advancement at 15 years of age and submucosal resection 6 years before admission because of respiratory difficulties is presented.Preoperative photos and postoperative result at one year following graft insertion via the sublabial approach and a conservative hump removal via an intercartilagenious incision are demonstrated. Case 2- A 45-year old man who underwent submucosal resection 1.5 years before operation is presented .His chief complain was nasal obstruction. Examination revealed columellar retraction,absent caudal septum and anterior nasal spine and an obstructed internal nasal valve. Preoperative photos and postoperaive results at 15 months following insertion of a conchal graft via the sublabial approach are demonstrated. Results: The mean follow-up was 21 months. Postoperative complications included graft absorption in 2 cases (6.25%), graft extrusions in 2 cases (6.25%), and postoperative infection in one case (3.12%). Reoperation rate was 4/32 (12.5%). Average operating time was 35 minutes for septal graft, and 55 minutes for conchal graft. Conclusion: Columellar reconstruction via the sublabial approach is an anatomic, minimally invasive, time-saving procedure. The operative technique is easy to perform with a short learning course. The septal grafts introduced via the sublabial approach anatomically position the columella, address columellar retraction and establish columellar length. They create tip definition and projection, brace the external valve against collapse, support the lining of the vestibule and restore lobular shape. The resultant, inconspicuous scar is cosmetically superior to the visible scar created by open rhinoplasty. The sublabial approach may be indicated in cases of revisionary rhinoplasty when previous scar tissue may entail a difficult dissection and manipulation and limit reexpansion and reshaping of the covering skin, while a virgin operative field will allow a secure and time-saving procedure. It is advantageous in cases of previous septal operations and when septal perforation is present.

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