Several techniques have been described in the literature for columellar reconstruction. These methods encompass skin grafting, composite grafting, and various types of local flaps [4]. Nevertheless, the visibility of donor site scarring resulting from these techniques might be as prominent as the initial defect, contingent upon factors such as the patient's age [4,5]. In children, labial and nasofacial incisions are particularly difficult to conceal [4,6].

The literature discusses various techniques for columellar reconstruction, such as full-thickness skin grafts, local random pattern flaps, regional flaps, and composite grafts. Direct primary closure and skin grafts are seldom suitable, except for superficial defects. Flap coverage, often requiring adjunctive cartilage or composite grafts, is frequently necessary due to the composite nature of the columella. Chondrocutaneous auricular composite grafts are effective for providing cartilaginous support with compatible, non-hair-bearing skin [7,8]. These grafts are useful for columellar defects, although meticulous technique and ideal conditions are crucial for success. Local random pattern flaps offer advantages in terms of vascularization, with various options described for columellar reconstruction, including upper lip flaps, alar margin flaps, and nasal septal flaps, among others. Regional flaps, such as the forehead flap, may be utilized when local tissue is insufficient [9].

Composite flap procedures, like the preauricular flap, provide both external coverage and internal support without relying on a well-vascularized bed [10,11]. The optimal reconstructive approach depends on factors such as the cause of the defect, the involved components of the columella, and donor site availability [9].

For isolated columellar defects without significant scarring or vascular compromise, a 2-stage reconstruction with bilateral nasal sill flaps coupled with an auricular composite graft is recommended [12]. This approach involves forming the external columellar outline with nasal sill flaps in the first stage, followed by placement of a chondrocutaneous graft from the helical root to enhance the desired contour of the new columella in the second stage. This method is particularly suitable for patients with high aesthetic demands willing to undergo multiple stages for optimal results. The resulting scars are camouflaged, and the procedure addresses both functional and aesthetic concerns [9,13,14].

Potential complications of all columellar reconstruction procedures include partial or complete graft or flap loss, scar contracture, and contour abnormalities. These complications can lead to decreased tip projection, compromised airway patency, and unsatisfactory aesthetic outcomes. Graft survival is primarily determined by size, with general consensus suggesting that grafts larger than 10 mm are unsuitable for nasal reconstruction due to metabolic demands and recipient site vascularity [9]. Some studies have proposed postoperative cooling to improve graft survival by reducing metabolic requirements, but the evidence supporting this is limited [15]. Additionally, to account for inevitable contraction, the harvested graft should be slightly larger than the columellar defect. Transient narrowing of the nasal base and decreased tip projection may occur postoperatively, but typically resolve over time [14].