Alar-columellar disharmony using the tongue-in-groove maneuver in primary endonasal rhinoplasty

Williams EF.

What this paper says

This technique article presents the tongue-in-groove suture, previously described through the open approach, as a long-term fix for a hanging columella done through incisions inside the nose, which the author states preserves more tip support; the abstract reports no patient counts.

Overview

When the columella hangs below the nostril rims, too much of it shows from the side. This alar-columellar disharmony is often overlooked in rhinoplasty and can spoil an otherwise good result. The tongue-in-groove maneuver tucks the inner legs of the tip cartilages back onto the septum to lift the columella. The author applies it through the closed approach in first-time rhinoplasty.

Sections of note

Technique description; no series size, follow-up or outcome data in the abstract.
Correction of alar-columellar disharmony is described as challenging and often neglected.
The tongue-in-groove suture had been described in the literature via the open approach.
The endonasal approach is stated to preserve greater tip support than the external approach.
Presented as an effective long-term tool for the hanging columella together with other variant anatomy.

What it means for a patient

A columella that shows too much from the side can be corrected by stitching the tip cartilages onto the septum, and this can be done without an external incision.
The maneuver also sets tip position and rotation, so it changes more than the columella.
No results are given in the abstract, so durability and complication rates cannot be judged from it.

Why this paper matters

Alar-columellar relationships are a frequent source of revision complaints, and the tongue-in-groove is one of the few maneuvers that addresses a hanging columella without removing cartilage. This paper extends it to the closed approach. Outcome data remain unreported.

Terms

Alar-columellar disharmony: an imbalance between the nostril rim and the columella seen from the side, showing too much or too little columella.
Columella: the strip of skin and cartilage between the nostrils.
Hanging columella: a columella that sits too low below the nostril rims.
Tongue-in-groove: setting the medial crura into a pocket on the caudal septum and suturing them there.
Endonasal approach: rhinoplasty through incisions hidden inside the nostrils.
Medial crura: the inner legs of the tip cartilages that run down the columella.

Summary written by rhinoplasty.cc from the abstract, 2026-09-08; not medical advice. The authors' own abstract follows.

From the abstract

“The correction of alar columellar disharmony can be very challenging and is often neglected during rhinoplasty. Failure to address alar columellar disharmony may adversely affect an otherwise satisfactory outcome. The tongue-in-groove suture technique has been described in the literature using an open approach as an…”

Excerpt; the full abstract is on PubMed.