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Background Three-dimensional surface imaging is established in many disciplines for objective facial acquisition regarding anthropometry. Former studies addressed the validation of landmark-based measurements for single race. In order to distinguish racial difference, the reproducibility of the landmark measurements must first be validated. Objectives Our purpose is to validate the reproducibility of 46 facial soft-tissue landmarks on x, y, z axes to prove their reliability as 3D reference points. Methods The study included 80 European Caucasian and 80 Chinese volunteers. Standardized 3D surface imaging was performed using Vectra 3D system. Two raters identified and defined 46 landmarks (138 coordinates), then repeatedly 3D-imaged volunteers' facial region in separate sessions. Coordinates' reproducibility of landmarks is divided into three categories (< 0.5 mm, < 1 mm, and >1 mm) for intra- and inter-rater reproducibility assessments. Results Coordinates' reproducibility of 160 samples was distributed as follows: Intra-rater: < 0.5 mm (45%), < 1 mm (42%), >1 mm (13%); inter-rater: < 0.5 mm (31.2%), < 1 mm (42%), > 1 mm (26.8%). The reproducibility of landmarks in nasal tip region differs slightly between Caucasians and Asians. Compared to females, males typically have higher landmark reproducibility in lip and chin region. However, there were no differences in the reproducibility ranking of landmarks by gender. Conclusion The majority of the 46 landmarks in the 3D plane are reproducible to 1 mm, which is clinically acceptable. All selected landmarks showed strong consistency across race and gender, suggesting their potential use as reference points in prospective clinical practice. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The outcome of rhinoplasty was evaluated in patients undergoing tongue-in-groove technique (TIG) with and without septal extension grafts (SEG) placement for stabilization of nasal tip rotation. Three hundred and sixty-seven patients who underwent rhinoplasty using TIG from 2016 to 2020 were included in this study. SEG was used if the caudal segment of the septum was not suitable for TIG. All patients were photographed pre- and postoperatively. Columellar Facial angle (CFA) and Nasolabial angle (NLA) were measured preoperatively at three intervals including up to six months after the operation (early or T1), up to one year after T1 (midterm or T2), and up to two years after T2 (late or T3). Two hundred and nine patients (56.94%) underwent TIG and the rest of them (43.06%) received SEG plus TIG (SEG+TIG). The TIG group had a mean CFA of 95.9±7.56 degrees preoperatively, 106.5±6.77 degrees at T1, 105.4±6.48 degrees at T2, and 104.8 ±7.52 at T3. The SEG+TIG had a mean CFA of 98.9±7.65 degrees preoperatively, 108.8±6.58 degrees at T1, 107.7±6.86 degrees at T2, and 106.2 ±15.6 at T3. Comparison of T1, T2, and T3 showed that the CFA changes were less than 1%, indicating a nonsignificant difference. The same results were obtained for NLA as well. Adding of SEG to TIG may be an effective technique to create and maintain a stable rotation comparing to TIG independently. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

For East Asians, rhinoplasty procedures are predominantly focused on reconstructing a well-defined nasal tip. In this study, the authors present a new graft design for the columellar strut that is similar to the shape of a comma mark. As one integrated piece, the graft undertakes the roles of providing solid support for the tip, modifying different angles, as well as relationships between the tip and columella. One hundred and sixty-five female patients, ranging in age from 18 to 42 years (average 27.1 years), received augmentation rhinoplasty surgery over the past 4 years with an average postoperative follow-up of 12 months. Among these patients, 78 of them were primary cases and others were secondary or more. The cartilaginous framework was reconstructed based on comma strut with other grafts including spreaders and dorsal onlay grafts. Patients’ own evaluations on the overall improvements of the nose rendered high satisfaction rate. During the long-term follow-up, 8 cases presented asymmetrical nostrils with slightly deviated columella; minor revision surgeries were performed. Another 3 cases presented dorsal graft warping and were also corrected. No other major complications were encountered. The comma strut provides a reliable support for the nasal tip; its dual curved structure plays the instrumental role in defining the lobular-columellar angle as well as modifying the supratip break. This graft design offers good control of tip and columella; as a result, consistent, reproducible results can be achieved. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Of the first nasal tip modeling procedures performed, the Anderson tripod concept is the most well known, and many anatomy-related studies have analyzed the components involved in tip surgery. The main goals of nasal tip surgery are to stabilize the tip complex, which largely affects the shape, projection and rotation of the nasal tip. The present study describes a new, original method, the double columellar strut and its main advantages compared to conventional techniques used for structural rhinoplasty. The study involved 642 patients (496 women and 146 men, with an average age of 38.67 years) who underwent surgery between 2004 and 2018 by two operators. The patients were re-examined to evaluate the outcomes at least 1 year after surgery, and long-term results (15 years) were recorded for the oldest patients in regard to esthetics (projection, shape, rotation) and breathing function. Of the 642 patients, 34 required a surgical revision for minor defects of the tip due to asymmetry, and the natural appearance after the first surgery was not affected. For the primary rhinoplasties, there were no breathing disorders that required revision surgery due to systematic restoration or preservation of the middle third. The double columellar strut could be performed in the same conditions that the others conventional structural grafts. As a polyvalent alternative, it can be used with closed or open approaches and involves the use of only a limited amount of cartilaginous material. This anatomical approach yields natural results, acting as a foundation for controlling the shape, projection and rotation of the nasal tip. In addition, with or without complementary techniques such as the “tongue-in-groove” technique or tip grafts, the double columellar strut can be considered a “multifunction pocket knife” for tip surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

It is important to reinforce nasal tip support for long-term satisfactory results. Two workhorses of tip support are strut grafting and the tongue-in-groove technique. Tongue-in-groove causes retraction and stiffness; the strut causes loss of rotation and projection of tip. We introduced a novel technique that avoids these consequences. Between February 2018–February 2019, 40 female underwent primary rhinoplasty. Mean age: 27 years (18–41 years). Follow-up:1–2 years. In first group (20 patients), caudal septum was resected and strut was not fixated to caudal septum. In second group (20 patients), tongue-like extension (septal autoextension) was preserved at caudal septum and sutured to strut. Preoperative, peroperative, and postoperative images were compared. Tip projection ratio calculations, nasolabial angle measurements were evaluated by statistical analyses. The change in projection ratios between peroperative period and 1-year postoperative period of strut-only group was higher than septal autoextension group (p = 0.001). This result indicates that nasal tip projection loss in strut-only group was higher compared to septal autoextension group. The change in nasolabial angle measurements from peroperative period to 1-year postoperative period differed significantly between two groups (p = 0.001). Significant difference was observed between 1-year postoperative nasolabial angle measurements of two groups (p = 0.006); septal autoextension group measurements were higher than strut-only group. These results showed that fixation of strut graft to the septal autoextension provides better preservation of the nasolabial angle and stabilization of nasal tip projection. Fixation of septum and strut graft through septal autoextension provides satisfactory stabilization of tip projection and rotation without stiffness or rigidity.

The plunging nasal tip is a challenging condition because, although it is predominantly a dynamic deformity which occurs during smiling, it also indicates a structural problem. When a person smiles, the paired depressor septi nasi muscles pull the tip caudally at the same time as the levator labii superioris alaeque nasi muscles pull the alar base and lateral lip cephalically. This movement causes straightening of the alar rim. Even though surgical rhinoplasty is the gold standard to restore nasal appearance, the procedure may fail to treat the dynamic cause of the drooping tip. This article outlines the anatomical concepts that lead to a drooping tip and presents a technique that can treat both the dynamic and structural causes of the drooping tip using hyaluronic acid filler. Cases are also presented that illustrate these concepts. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Rhinoplasty is often performed to narrow the nasal tip. Compared with extensive cartilage excision, scoring, and transaction, suture techniques are a favorable method. Suturing techniques offer favorable esthetic and functional outcomes. However, deformities and unnatural appearances may occur if sutures are overtightened or placed incorrectly, and it is possible to inadvertently narrow the external nasal valve and invert the caudal sides of the lateral crura. In this retrospective study, author analyzed the functional and esthetic outcomes of a novel suture method developed to support the external nasal valve by caudocephalic rotation of the lateral crura. The outcomes of the lateral crus caudocephalic rotation suture (CC suture) method were assessed in 24 patients (22 females, two males; age 18–43 years) who underwent primary septorhinoplasty and had iatrogenic or genetic inversion of the caudal sides of the lateral crura. The patients were followed up for 12–36 months. During this time, no serious complications were noted in any patient, and there was no requirement for revision surgery. Satisfactory or acceptable results were obtained in all patients. The CC suture technique is a simple, reversible, and nondestructive technique that benefits from minimal graft use, decreased operation time, improved function and cosmesis, and a short learning curve. Level of evidence: Level V, therapeutic study.

In this study, we decided to investigate the changes in elasticity of the nasal tip using Columellar strut graft versus toung in groove method over a year after rhinoplasty. In this before-after randomized clinical trial study, 44 candidates for rhinoplasty were enrolled Columellar strut graft group (n = 22) and toung in groove group (n = 22). Also 22 patients who referred to ENT clinic without any previous rhinoplasty and without any decision for it during the next year, considered as control group. One group underwent columellar strut graft and the other one underwent tongue in groove rhinoplasty and in control group participants received no intervention. Nasolabial angle and elasticity of the nasal tip were recorded and compared before the surgery, immediately after the surgery, 3 months and one year after the surgery. There was no significant difference between the mean elasticity of the nose and the nasolabial angle before the surgery, immediately after the surgery and 3 months after the surgery between the groups. However, there was significant differences in the mean elasticity of the nose and the nasolabial angle between the groups one year after the surgery (P value

The tripod theory explains the dynamics of the nasal tip, where surgery is difficult because of anatomic variations and pathologies and the various surgical possibilities. Abnormalities or weaknesses of the lateral crura can result in concavity in ala or alar collapse and cause aesthetic and functional impairments of the nose. Several tip plasty techniques and lateral crura modifications are used in rhinoplasty. To describe the vertical alar folding (VAF) technique for making modifications in the lateral crura (LC) and rotation of the tip. Included in the study were 83 patients (59 women, 24 men) undergoing rhinoplasty using VAF with the senior author as surgeon between 2013 and 2018. The mean age was 26.3 years (range 18–47). Mean postoperative follow-up period was 26.7 months (range 12–64). Patients who completed the 1-year postoperative period completed the rhinoplasty outcome evaluation (ROE) questionnaire. Outcome measures were performed at examinations, and preoperative and postoperative photographs of the patients were analyzed. In the span of 5 years, no revision surgery was required for technique-specific reasons. In patients who had a droopy or asymmetric tip or long and concave lateral crura, we saw remarkable functional and aesthetic improvements with VAF. According to the ROE questionnaire, 90.3% (75 out of 83) of the patients were content with the aesthetic and functional results. VAF is a useful and effective method for modifying the LC and tip of the nose. VAF allowed for controlling the rotation and projection of the tip, changing the length of the lateral crus and nose with durability and smooth, symmetric contours, and correcting concavity of a lateral crus for better functioning and aesthetics. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BACKGROUND: Human facial bites are uncommon and usually cause a wound that presents major challenges for the reconstructive surgeon. PURPOSE: The purpose of this study is to present the advantages and disadvantages of using a superiorly based interpolated nasolabial flap for reconstruction of a nasal tip defect. METHODS: We present a case of serious injury of the nasal tip as a result of a human bite. Early maxillofacial surgical intervention resulted in restoration of the facial anatomy and function of the structures involved. RESULTS AND CONCLUSION: We present a serious mutilating injury of the tip of the nose in a young patient as a result of a human bite. These injuries can be rather destructive and cause a facial defect which may have a significant adverse psychological impact on the patient. Because of the proximity and the skin colour match of the melolabial fold to the nose, nasolabial flaps are a very attractive and reliable reconstructive choice for nasal tip defects. The relative advantages over other reconstructive options and the limitations of an interpolated superiorly based nasolabial flap are discussed. The elaborated use of a nasolabial peninsular pedicled skin flap may deliver a very satisfactory outcome from a functional and cosmetic point of view.

A good understanding of nasal tip support mechanisms is essential for achieving successful and functional rhinoplasty results. The loss of nasal tip support resulting from different maneuvers adopted during rhinoplasty and how this loss is affected by reconstructive applications should be known. This study evaluated and compared changes in nasal tip support perioperatively after different techniques were used during septorhinoplasty.Patients who underwent primary open rhinoplasty between January 2018 and March 2018 in a tertiary medical center were included in this prospective blind case series. Nasal tip resistance measurements were taken after perioperative maneuvers by creating enough force to achieve 1 mm, 2 mm and 3 mm of displacement at the tip region. Measurements were obtained during six different stages using a Newton meter: preoperatively, after caudal septal resection, after skin flap elevation, after the columellar strut or tongue-in-groove procedure, after tip suturing and postoperatively. Our hypothesis was that during septorhinoplasty, each maneuver used changes the tip support intraoperatively. The predictor variables were the different rhinoplasty techniques used. The outcome variable was nasal tip resistance to compression intraoperatively and immediate postoperatively. Appropriate statistics were computed, and a p 0.05 value was considered significant.Ten of the 15 patients were female, and 5 were male. The patient age ranged from 19 to 40 (mean 24.8 ± 4.9). The tongue-in-groove technique was applied in 5 of the patients, while columellar strut grafting was performed in 10. The application of columellar strut grafting did not create a significant increase in nasal tip support (p 0.05). An increase in nasal tip support was observed at each stage (85%, 53%, 35%) after application of the tongue-in-groove technique (p 0.05).A novel and reproducible technique for digitally evaluating manual force is presented for determining changes in nasal tip support with different maneuvers applied in living patients undergoing rhinoplasty. No significant difference was noted between the preoperative and postoperative measurements for columellar strut grafting. The tongue-in-groove technique is an important maneuver that has a significant effect on nasal tip support. According to our data, the interdomal and intercrural ligaments, the medial crus-septum connections and the connections between alar cartilage and overlying skin and muscle tissue are important structures for tip support.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The columellar strut graft is one of the most commonly used invisible grafts in tip plasty techniques for nasal tip projection. However, the columellar strut graft induces cephalic rotation of the dome with nasal tip projection. This is an effective change in Western people with a long nose; however, this change should be avoided in Asians who have a relatively short nose and visible nostrils. We designed a more convenient and effective technique using a rein-shaped columellar strut graft that can prevent cephalic rotation of the dome. A total of 32 patients underwent surgery with a rein-shaped columellar strut graft with a septal cartilage. The projection and location of the nasal tip, nasal length, and nasolabial angle were measured after taking a photograph of the lateral view, and the preoperative and postoperative results were compared. There were statistically significant differences between the preoperative and postoperative values of the nasal tip projection ratio and nasal tip location ratio. There were no revision surgeries and no direct complications associated with the use of the columellar strut graft. We performed tip plasty with a modified columellar strut graft—the rein-shaped columellar strut graft. In most cases of using this method, the tip projection was increased and the cephalic rotation of the tip was prevented. This surgical procedure can also be used for lengthening (rotating caudally) of the nose in some cases, as well as for the purpose of preventing the cephalic rotation of the tip. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Caudal extension graft technique is a versatile technique in rhinoplasty providing good tip support and maintaining tip projection. In this study, we evaluated the clinical outcomes of this technique and performed anthropometric analysis of nostril shape from the basal view. Thirty-two patients undergoing caudal extension graft technique were identified from December 2011 to July 2016. Patients with a minimum of 12 month follow-up were included. Quantitative analysis was performed on standard pre- and postoperative photos. Nasal tip protrusion and columellar width were increased significantly (p value

Preoperative and intraoperative assessments are very important for surgeons to plan or regulate tip projection. But how to measure the tip projection is a difficult problem even with a ruler or on full-size pictures. In this paper, the author introduces a method to measure the nasal tip projection with a remodeled syringe.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

Orthognathic surgery in reference to the maxilla attempts to correct underlying skeletal deformities and improve function. Consequently, it has the potential to significantly alter the central esthetic unit of the face, the nasolabial region. In order to evaluate the nasal morphological changes which would result following anterior maxillary segmental osteotomy (superior and posterior repositioning), four angles, namely nasolabial, nasal tip projection, columellar labial and supra tip break angle, were evaluated. In ten selected subjects who have undergone anterior maxillary segmental osteotomy with superior and posterior repositioning, preoperative (T1) and postoperative (T2) lateral cephalometric parameters pertaining to the four angles were analyzed using Wilcoxon’s signed-rank test. A significant increase in nasolabial angle and mild changes in nasal tip projection, columellar labial angle and supratip break angle were observed. The results of this study emphasize the need for the presurgical evaluation of nasal morphology in every individual planned for anterior maxillary segmental osteotomy.

Asian noses are mainly characterized by a low nasal dorsum, a short nose and an underprojected nasal tip due to underdeveloped (short and weak) alar cartilages. The goals of the surgery are to increase the tip projection, elongate the nose and augment the dorsum. In Asian noses the structural approach helps strengthen the weak cartilages and add definition to the nasal tip. There are various methods to increase tip projection and definition. Columellar strut, caudal septal extension graft, tip grafts and lateral crural grafts in order to elongate the upper legs of the nasal tip tripod can be used. The method described in this article seems a useful solution in Asian rhinoplasty patients who do not want to use rib cartilage. The "Skiff Graft" functions similar to caudal septal extension graft with its elongation and raise effect at the caudal septum. However in cases which need significant increase in tip projection and nose elongation, this method may be insufficient. In such cases, stronger structural grafts prepared from rib cartilage will give a better tip definition and more predictable outcome.

Among the greatest challenges in rhinoplasty are setting the nasal tip contour and projection, and avoiding excessive upward rotation of the nose. Many suture and graft fixation techniques have attempted to achieve this result but may still produce results lacking in refinement. This study aims to describe in detail a new approach to stabilize the nasal tip for a durable and more predictable result.Twenty-eight surgeries were performed by the author, following a standardized technique which included: a modified distal onlay dorsal graft, a modified columella strut, and bilateral caudal septal sliver grafts. Follow-ups were conducted with all patients for at least 365 days. Twelve patients had follow-ups ranging from 456 to 619 days.At the nasal tip there was no loss of projection or rotation. One patient had a traumatic nasal fracture and left the study. Two patients had unilateral alar retraction not related to the technique described. One patient with thin nasal skin was submitted to a surgical revision to thin the caudal septal extension grafts and improve the nasal airflow.The Multi-Lock System for rhinoplasty is a good option to assure nasal length as well as projection and rotation of the tip. Also, it seemed to decrease the dead space of the supra-tip area which avoided pollybeak deformity.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The aim of this study was to compare Goode’s and Byrd’s method in objectively assessing nasal tip projection. This study included 20 patients from the ENT outpatient clinic, Cairo university hospital, who underwent augmentation tip rhinoplasty, closed technique, using Sheen graft, during the period from January 2008 until December 2011. Two objective methods, Goode’s method and Byrd’s method, were used to assess nasal tip projection preoperatively and postoperatively. There was statistically significant difference between the gain in projection by Goode’s method compared with Byrd’s method. The mean gain in projection was 11.6 using Goode’s method, whereas it was only 9.55 when measured by Byrd’s method. Goode’s method correlated more with patients’ and surgeon’s subjective assessment and satisfaction. In our study, Goode’s method proved to be more accurate in representing the final outcome compared with Byrd’s method in the Egyptian population.

Reconstruction of the nasolabial columella complex is a technical challenge for which many solutions have been suggested. The peri-alar hatchet pedicle flap, herein described, allows the transposition of a well-matched tissue to reconstruct columellar and nasal tip defects while preserving the alar and nasolabial crease. This procedure did not require a columellar strut or a finishing touch-up procedure for sufficient columellar projection and achieved excellent cosmetic results. Level of Evidence: Level V, therapeutic study.

Background Lipoma in nasal region in a case of Pai syndrome is very rare. Very few cases of Pai syndrome with columellar lipoma with extension to septum and tip have been reported till date. Case presentation We report a very rare form of nasal lipoma in a case of Pai syndrome with extension to septum and tip in a 4 year old female child. Conclusions Pai syndrome with columellar lipoma with septal and tip extension should always be kept in mind when evaluating a swelling in the region of nasal tip, collumella and septum with notch in upper lip and corpus callosal lipoma.

Severe lateral crura concavity (LCC) can lead to an important deformity of the nasal tip and to external nasal valve insufficiency. The lower lateral crural reverse plasty represents a valuable technique for the correction of severe LCC, but often requires additional cartilage to gain more alar rim support. We describe a modified version of the reverse plasty, in which a polydioxanone plate is sutured as a strut at the dome junction to increase alar rim support. We report our experience with this technique in 10 women (age range 24–56 years). The procedure was performed in eight primary rhinoplasties and in two cases alone without rhinoplasty. All patients had aesthetic complaints, whereas three had obstructive symptoms. Eight patients had unilateral problems. A one-year follow-up was completed in 100 % of patients. There were no surgical complications and all patients had optimal short and long-term aesthetic and functional results. Acikel C (Aesthetic Plast Surg 36:862–865, 2012) The adjunctive use of a polydioxanone plate during lateral crural reverse plasty was feasible and led to satisfying functional and cosmetic long-term results in patients with severe LCC. This surgical maneuver appears reproducible and emerges as an alternative way of gaining stronger support during lateral crura reverse plasty while avoiding additional tissue. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Anterior septal height is an important determinant of nasal tip projection. Accordingly, the anterior septal extension technique has proven itself to be a powerful tool for achieving long-lasting nasal tip projection in rhinoplasty. However, anterior septal extension does not protect against postoperative loss of nasal tip rotation unless an additional suspension strategy is used. A tip-suspending transfixion suture is the authors’ strategy for supporting nasal tip rotation whenever an anterior septal extension technique is performed. Of 156 rhinoplasties performed by the authors between 2010 and 2012, a cohort of 22 droopy-tip rhinoplasties was extracted in which the described technique was used. The patients in this cohort were included in a retrospective nasal tip projection and rotation analysis. The nasolabial angle (NLA) and Goode ratio measurements were compared between preoperative, 3-week postoperative, and 1-year postoperative profile-view photographs. The NLA and the Goode ratio measurements were significantly higher in the 3-week postoperative group than in the preoperative group, indicating an effective gain in both tip projection and rotation. The NLA and the Goode ratio measurements did not differ statistically between the postoperative 3-week and postoperative 1-year groups, indicating long-term maintenance of nasal tip position. A tip-suspending transfixion suture is an easy method for securing nasal tip rotation when used in conjunction with an anterior septal extension. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The aim of this study was to compare the degree of nasal tip rigidity from different techniques for increasing nasal tip projection. Retrospective records of patients who had undergone rhinoplasty were reviewed at the tertiary referral center. 81 patients who had undergone suturing of the medial crura to the extension graft or to the long septum were selected. In group A, fixation was performed at the same level compared to before surgery. In group B, tip grafting was performed to gain 3 mm or more in projection after fixation as done in group A. In group C, the same tip projection was provided by advancing the medial crura on the caudal septum or extension graft. Patients were evaluated with a visual analog scale, based on the rigidity of the nasal tip (0 = very flexible, 10 = very rigid). When the preoperative and postoperative VAS scores of all groups were compared, postoperative scores were significantly higher than the preoperative scores (p

The delivery approach, though very appropriate for remodeling the tip of the nose, has been overlooked in recent years and has often been passed over for the open approach. One reason for this is the intercartilaginous incision used for the delivery approach, which may cause scarring at the nasal valve area, leading to postoperative functional obstruction of the nose. The delivery of the alar cartilages is another negative, as this maneuver will disrupt the collagen fibers that attach the upper lateral cartilages to the cephalic margin of the alar cartilages, leading to a weakening of the tip's support. We propose a modification to the traditional delivery approach by using a transcartilaginous instead of an intercartilaginous incision to prevent damage to the valve area. We also suggest taking advantage of the interference to the tip's support caused by the disruption of the collagen fibers of the scroll area. The purpose of this article is to describe this modification of the delivery approach and to emphasize the advantages that this controlled interference to the tip's support may have in selected cases.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Recently, rhinoplasty techniques have advanced significantly and are frequently combined with columellar struts using conchal cartilage grafts to sufficiently reshape the nasal tip. For this reason, auricular keloids following harvesting of conchal cartilage grafts are expected to occur with greater frequency. The aim of this study was to share our experiences with auricular keloids and to suggest possible risk factors.We conducted a retrospective review of patients with pathologically confirmed auricular keloids that were surgically excised with primary closure after conchal cartilage grafts were harvested. Starting between days 21 and 28 postoperatively, patients were instructed to use magnets for approximately 12 h a day for 6 months until adjuvant pressure therapy was completed. Recurrence after treatment was recorded. In all patients, a follow-up period of 18 months was required.Auricular keloids were successfully treated in 93.3 % of the cases and 6.7 % of the cases had recurrence. The postoperative course was uneventful without exception. There was a male predominance of auricular keloids after conchal cartilage graft harvesting. In addition, a high growth rate as a result of the short duration of the keloid before treatment was seen.Adjuvant pressure therapy using magnets is useful for treating auricular keloids following conchal cartilage graft harvesting. In addition, surgeons should be careful when performing conchal cartilage harvest to avoid needless injury to the adjacent skin flap.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A case of severe alar retraction and underprojected nasal tip due to hypoplastic lateral crura was successfully treated using a columellar strut graft, lateral crus replacement graft, and lateral crus caudalization graft and Medpor implant. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

To evaluate the effects of open rhinoplasty incisions on tip projection using digitized photographs. Thirty-one patients, who underwent open technique rhinoplasty were prospectively included in the study. The lateral aspect photographs were taken before the operations. Following midcolumellar incision septal elevation was done until septal cartilage was shown. After replacing the skin totally back and suturing midcolumellar incision, the intraoperative photographs were taken. The projection indexes were measured by Goode method from the photographs and the measurements were compared. A statistically significant decline of the nasal projection was established after open technique approach. Open rhinoplasty approach led to the decrease of the nasal tip projection. This result was thought to be the effect of ligamentous disruption.

Excessive concavities of the lower lateral crura can lead to heavy aesthetic disfigurement of the nasal tip and to insufficiencies of the external nasal valve. This study reviewed experience with the lower lateral crural reverse plasty technique that uses the existing cartilage to create the desired lower lateral cartilage contour and provides sufficient alar rim support. A retrospective review was conducted with a follow-up period ranging from 9 to 33 months. The technique was applied in primary (n = 13) and secondary (n = 3) open rhinoplasties to correct severe concavities of the lower lateral cartilages. Two case examples and intraoperative photographs are presented to illustrate the technique and its results. The lower lateral crural reverse plasty proved its applicability for the functional and aesthetical correction of severe lower lateral crura concavities. By dissecting the distorted lateral crus, turning it around, and suturing it back in place, surgeons can “reconstruct” a new lateral crus with existing cartilage. No additional cartilage is needed, and no harvesting at a different location needs to be performed. After rhinoplasty, no alar rim instabilities were observed. In three cases, even preexisting instabilities were corrected. Aesthetically enduring results were observed, and no overcorrection or alar retraction was seen. With the lower lateral crural reverse plasty, severe concavities of the lower lateral crura can be corrected. This technique is a useful and reproducible procedure, performed without additional tissue to achieve functionally and aesthetically satisfying and enduring results.

In this article the onlay folded flap (OFF) is introduced as a new technique for reshaping, refining, supporting, and projecting the nasal tip by remodeling the cephalic portions of the lateral crura rather than canceling them. The surgical technique and the long-term outcomes are described. The indications, contraindications, advantages, and disadvantages are defined.Forty patients were operated on for hypoprojected nasal tips. They had been followed for from 6 to 35 months (average = 13 months). None of the patients had thin skin, and none of them had previously undergone a rhinoplasty. Two symmetric lateral flaps are taken from the cephalic portions of the lateral crura and attached to the domal segments. The flaps' internal edges are carefully sutured together to form one flap. This is then rotated anteriorly over the original domes and fixed to them, before its distal portion is turned posteriorly over the first layer and fixed to it. The nasal tip projection was calculated for all patients before and 6 months after surgery using a personal method as a means of evaluating the gain in nasal tip projection in the postoperative period.Revision was necessary in only one patient to fix an unpleasant columellar scar. The average nasal tip projection gain 6 months after surgery was approximately 4 mm (range = 3-5 mm). The nasal tips were fine and stable in all patients.The OFF technique is recommended in primary rhinoplasty for reshaping, refining, and supporting the nasal tip and for increasing nasal tip projection (from 3 to 5 mm maximum) but only for people with normal or thick skin. It has many advantages and good postoperative results.

The present article describes the anatomy, surgical technique and outcomes for nasal dorsal augmentation. The various materials available for augmentation are outlined, including polytetrafluoroethylene (PTFE), autogenous costal cartilage graft and irradiated costal cartilage. In addition, appropriate surgical guidelines for successful augmentation are given. The correct height of the nasal dorsum is determined according to the position of the nasion and the nasal tip, whereby the desired height may also be influenced by the sex of the patient as well as his/her notion of an aesthetic ideal. Access is chosen according to the extent of the planned correction; external access is advisable in the case of extensive correction. Osteotomies should only be undertaken where unavoidable, e. g. in the case of concomitant nasal misalignment. Patient results, complications and future directions are presented.

Recontouring the nasal tip in rhinoplastic procedures has generated a wide range of surgical techniques. These range from aggressive cartilage resection, division, grafting, or suture methods. Each of these categories contains many variations described in hundreds of publications. The goal of this communication is to describe a predictable, reproducible technique that can be used in a wide variety of rhinoplasty operations. Based on pre-existing anatomy variations of this technique can be adopted. The author described the basic technique in 2004 [1].The cornerstone of the technique is a predictable method of narrowing the interdomal space utilizing a suture technique. This procedure employs a pair of permanent sutures designed to minimize distortion, valve impingement and overcorrection. It can be performed through intranasal or external approaches. This paper will define the wide interdomal space, describe the technique, and demonstrate the efficacy of the technique in 250 rhinoplasty procedures. In addition, variations of the technique for specific goals will be shown.

Bei Rhinoplastiken erfordert die Korrektur der Nasenspitze die groste Erfahrung. Sie entscheidet in vielen Fallen erst uber das Gelingen einer Nasenkorrektur. Es ist sinnvoll, einen gewissen Algorithmus bei der Korrektur der Nasenspitze zu befolgen: ausgehend vom anatomischen Befund uber das Operationsziel bis hin zu den Operationstechniken, den operativen Zugangen und letztendlich den Inzisionen. Neben In- und Exzisionstechniken und der Anwendung von Knorpeltransplantaten haben sich in den letzten Jahren vor allem Nahttechniken etabliert, die eine weitgehende strukturerhaltende Rhinoplastik ermoglichen. Wahrend bei geringfugigen und mittelgradigen Nasenspitzendeformierungen Nahttechniken zu bevorzugen sind, bleiben die beiden anderen Techniken hauptsachlich den ausgepragten Varianten unproportionierter Nasenspitzen vorbehalten. Man kann fur alle Techniken sowohl den geschlossenen als auch den offenen Zugang wahlen; mit der „offenen Rhinoplastik“ sind aber alle Techniken ubersichtlicher und praziser durchzufuhren. Zuletzt ist es auch eine Frage der personlichen Erfahrung, die entsprechenden Techniken, Zugange und Inzisionen auszuwahlen.

Tip surgery, the most important part of the rhinoplasty procedure, has entered a new era in the past few decades. Various treatment protocols have been attempted. To date, however, opinions on the management of the Asian tip have not been solidified. To generalize and provide appropriate guidelines for the treatment of typical Asian tips, an English literature search from 1977 to March 2007 was conducted. Finally, a total of 26 papers were selected for review. The full text of each paper was read carefully, and data were extracted. Then all extracted information was imported into Microsoft Excel. Nine articles treating 11 groups of patients described the suitable techniques for Asian nasal tips, with 81.8% of the groups advocating that the protocol include a grafting technique, 64% reporting use of the grafting technique alone, and 9% applying cartilage reduction and a suturing technique. Of the 11 (18%) groups, 2 attempted more than one technique. Because of the Asian nasal tip's innate qualities, success with nasal tip plasty for Asians depends on the combined application of appropriate suturing, grafting, and defatting, with grafting techniques contributing the most.

For defining the shape and projection of the nasal tip, the bilateral and symmetric batten-type septal extension grafts proposed by Byrd and colleagues have drawbacks. The main problems are stiffness of the nasal tip and thickening of the septum in the nasal valve area.Since 1998, unilateral single-batten grafts, and more frequently, bilateral asymmetric batten grafts as compared with Byrd's bilateral symmetric application, have been used for 72 patients in our facility.At the 6-month postoperative follow-up assessment, tip projection was found to be satisfactory in 61 patients. Less than desired projection occurred in three cases and overprojection in two cases. Nasal lobule deviation was evident in one patient. The loss of the columellar break point was evident in five cases.Unilateral or asymmetric bilateral batten grafts facilitate adjustment of the nasal tip intraoperatively. This technique results in a more pliable nasal tip in the horizontal plane. Construction of a three-layered cartilage in the nasal valve area is not needed, and the nasal airway is preserved. With this modification, a reliable and predictable nasal tip location is obtained with a minimum of graft usage.

Haemangiomas are the most common tumours of infancy. They typically proliferate then involute with considerable variation as regards to their rates of proliferation and involution. Haemangioma of the nasal tip is a lesion of special characteristics. During proliferation, it expands, contracts and deviates the nasal cartilages. Particularly, it regresses slowly and frequently involutes incompletely. That is why excision of the lesion is frequently suggested. The present study was conducted to evaluate open rhinoplasty after initial non-excision treatment modalities namely, intra-lesional corticosteroid injections and laser treatment, as a protocol of treatment for nasal tip haemangiomas. Twelve patients with nasal tip haemangiomas were included in the present study. Patients of both sexes, of different ages, with deep and mixed haemangiomas were studied. Disfigurement was the constant presenting symptom. Initial non-excision treatment reported different responses as denoted by the regression of the lesions’ size. Haemangiomas constantly extended between the medial crura of the alar cartilages as noted by the constant widening of the columella pre-operatively and the obvious separation of the nasal cartilages intra-operatively. This separation was constantly found to require approximation by sutures. The results of the present study concluded that whenever an early presentation with nasal tip haemangioma could be established, initial non-excision treatment followed by open rhinoplasty could be a useful protocol of treatment. Within the limitations of the present study, this protocol could achieve an early, safe and effective treatment for nasal tip haemangiomas with provisionally acceptable cosmetic outcomes so far.

The past two decades have ushered in a new era of nasal tip surgery. The new philosophy focuses on preserving and reorienting nasal tip structures. Modern suture techniques can give predictable results because of more precise suture placement. Only a few reports, however, have objectively evaluated the suture techniques for Asians. Accordingly, the authors aimed to assess the efficacy of the tip suture technique through projection and rotation analysis. We focused on transdomal sutures because they involve one of the most popular suture techniques. Preoperative and postoperative photographs of 85 patients who underwent rhinoplasty at Inha University Hospital between June 2002 and June 2004 were analyzed. The patients were categorized into four groups according to the techniques used. Tip projection was measured by the modified Heuzinger's method and tip rotation by the nasolabial angle. The pre- and postoperative indexes were compared within each group and among the four groups. Paired and unpaired t tests were used for statistical analysis. When the pre- and postoperative indexes were compared within each group, only the combined technique (transdomal suture with onlay graft) showed significant tip projection improvement. All tip surgeries resulted in insignificant tip rotation increase. Comparison among the four groups showed no significant difference based on the type of tip surgery performed. The suture technique has many advantages, although it has some limitations with Asian noses, especially if used alone. Therefore, we recommend using the suture technique in combination with other tip surgical procedures, such as onlay grafts, to achieve significant tip projection.

Management of nasal tip projection and support for positioning of the tip represent an important part of rhinoplasty operations that must be handled properly for a final satisfying result. Manipulation of the nasal tip is complex and variable. Plastic surgeons use many techniques to achieve this goal.The authors propose that the caudal septal advancement technique be used to manipulate the positioning of the nasal tip, especially in cases of an underprojected tip and those requiring tip support. The authors prepare a rectangular septal cartilage, which after advancement carries the nasal tip to the desired position.This technique is easy to use, and the results are dependable. All the patients who underwent surgery with this technique were satisfied with the result.The caudal septal advancement technique presents another good and reliable alternative for managing nasal tip projection and support.

The long nose with a "plunging" tip is a deformity that involves an inferiorly rotated nasal tip, leading to an increase in the length of the nose. The anatomic basis of the long nose with a plunging tip may be divided into two types. Type 1 presents a normal alar-cartilage complex inferiorly displaced by a long nasal septum and long upper lateral cartilages. Type 2 is caused by a dislocation of the alar cartilages downward from the aponeurotic attachments to the septal angle. During the study period, the authors identified 60 patients with long noses and plunging tips. For 22 patients with type 1 long noses, the high septal incision technique was used in 12 cases and the step technique in 10 cases. The invagination procedure alone was used for 22 of 38 patients with type 2 plunging noses. Also, an extension graft with the invagination procedure was used for 6 patients, and a columellar strut graft was used for 10 patients. A high septal incision increased tip rotation without significantly changing the amount of tip projection. However, the step procedure, the invagination technique alone, septal extension graft with the invagination technique, and columellar strut grafts increased nasal tip rotation and projection. During the study period, 38 patients were identified as having a smiling deformity, which was improved using the authors' modification procedure. On the basis of the results, the authors recommend that the appropriate treatment for each patient with a long nose and a plunging tip must be determined by preoperative and intraoperative examination findings with the patient at rest and while smiling.

Rhinoplasty is one of the most common aesthetic surgical procedures in Korea today. However, simple augmentation rhinoplasty results often failed to satisfy the high expectations of patients. As a result, many procedures have been developed to improve the appearance of the nasal tip and nasal projection. However, the characteristics of Korean nasal tips including the bulbous appearance (attributable to the thickness of the skin), flared nostrils, and restriction of the nasal tip attributable to an underdeveloped medical crus of the alar cartilage and a short columella have made such procedures difficult. Currently, most plastic surgeons perform rhinoplasty simultaneously with various nasal tip plasty techniques to improve the surgical results. An important part of an aesthetically pleasing result is to ensure an adequate nasal tip positioned slightly higher than the proper dorsum, with the two tip defining points in close proximity to each other, giving the nose a triangular shape from the caudal view. From June 2002 to November 2003, the authors performed rhinoplasty with simultaneous nasal tip plasty using various techniques according to the tip status of 55 patients (25 deviated noses, 9 broad noses, 15 low noses, and 6 secondary cleft lip and nose deformities). The surgery included realignment of alar cartilage by resection and suture, fibroareolar and subcutaneous tissue resection, tip graft, and columellar strut. The postoperative results over an average period of 10 months were entirely satisfactory. There were no patient complaints, nor complications resulting from the procedures. Good nasal tip projection, natural columellar appearance, and improvement of the nasolabial angle were achieved for most patients. In conclusion, rhinoplasty with simultaneous nasal tip plasty, achieved by a variety of techniques according to patients' tip status, is an effective method for improving the appearance of the nose and satisfying the desires of the patients.

The wide exposition obtained with the open approach in rhinoplasty allows a precise evaluation of size, morphology, thickness, and position of the alar cartilages. This precise intraoperative diagnosis has permitted the development and improvement of surgical techniques in nasal tip sculpturing. At the same time, many surgical instruments have been adapted or created for the external approach. We describe our preferred and most commonly selected sequence in primary rhinoplasty with emphasis on the nasal tip work. A new, personally developed instrument, named the Delicate Alar Clamp, utilized to hold and stabilize the lateral crus during measurement and sculpturing of the cartilage, is presented with the description of its technical characteristics and practical application.

The method proposed is intended to reinforce the columellar support while simultaneously correcting the nasal tip and ala and improving the nostril symmetry in patients with secondary nasal deformities following cleft lip and palate surgery. It is based on using a bone cartilage autograft – a fragment that is taken from nasal dorsum and implanted into the nasal tip region. Very good aesthetic and functional postoperative results were reported in all 33 patients operated on so far (28 with unilateral and five with bilateral cleft lips).

Nasal tip hemangiomas may have deleterious effects on the psychosocial development of a child. Early surgical intervention has been shown to be beneficial. The technique discussed here is excision of a hemangioma via open rhinoplasty without resection of the excess skin. The excess skin is allowed to contract over time and in the majority of cases nasal tip projection is maintained. There have been no recurrences of the hemangioma.

Due to a paucity of subcutaneous tissue in the nose, mobilization of some flaps is impeded and large nasal defects are thus difficult to close with traditional V-Y flaps. The V-Y flap is modified by the addition of an amplified limb onto the advancing edge of the V-Y flap. This limb is located adjacent to the area requiring reconstruction and is hinged down on the end of the V-Y flap to close the distal portion of the defect. The amplified V-Y flap, a modified V-Y advancement flap, is very useful for the closure of relatively large defects on the nasal area. We have used this flap for nasal defects as large as 2.5 cm in diameter following excision of skin tumors on the nose in 11 patients. Most excised tumors were basal cell carcinomas. The results have been quite good, with only minor complications in two patients. Complications were encountered only in the nasal tip region, there was partial necrosis at the tip of the amplified portion of the flap. The modifications of the V-Y flap described has extended the application in closing nasal defects.

Reconstruction of the full-thickness defect of the tip of nose, columella, and ala has always been a challenge. Local flaps can be used, but this often results in a bulky nose with an unsatisfactory aesthetic appearance requiring secondary surgical procedures. The use of the ear as a donor site for a microvascular free flap, although not general consensus despite structural similarities between the nose and ear, offers a possibility of a good reconstruction for such patients. Five patients presented with composite tissue defects of the tip, columella and ala of the nose resulting from human bites. Reconstruction was performed early in order to avoid possible infection. The free flap was designed and elevated from the upper part of the helix and concha of the opposite ear; the flap matched the traumatic defect on the nose and was based on the anterior auricular branches of the superficial temporal vessels. The free flap was brought to the defect and sutured to the margins. Direct end-to-end anastomosis of both vessels was performed in four patients while a venous grafts was needed in one patient. The donor flap area was closed directly. The follow-up period ranged from six months to five years. The reconstruction was satisfactory as to contour, symmetry and colour match in four patients. The final aesthetic result was obtained by touch-up procedures under local anesthesia. The donor site deformity was minimal. In one patient, the free flap was lost due to venous thrombosis and late reintervention. The chondrocutaneous free flap represents a dependable vascularized composite tissue transfer that offers a straightforward one-stage reconstruction of tissue defects of the tip, columella, and ala of the nose. The additional advantages of freedom in the flap design and structural similarity between the nose and ear makes it an ideal choice for such defects.

The authors consider the morphology of alar lateral crus as a means of classification. Every variety of lateral crus has a peculiar property of shape and relationship with other elements that determines the course of therapy. Diagrams for explication, descriptions of surgical techniques, and clinical results are included here.

The procedure described here consists of a myocutaneous axial flap with lateral pedicle. It uses the transverse part of the nasal muscle that goes forward in rotation and the lateral and superior portions of the flap in the V-Y. The procedure is useful for repairing losses of nasal tip and the surrounding area. It is a simple method that can be used to reconstruct the brim near the tip of the nose, yielding an aesthetically and functionally efficient nose.

The Oriental nose is smaller and lower than that of Caucasians. The lobule, the movable lower third, is lower and wider when compared with the Caucasian nose, and this region, including the tip, is entirely round. Traditionally, the isosceles triangle of the basal view, which consists of the nasal tip, the columella, and the alae surrounding the nostril, has been used to show the differences between the two races. Alae form two sides of the isosceles triangle and have the greatest influence on the shape of the basal view. For Orientals, the distance between the sides of the alar base is large, and the alae themselves are round and extrude laterally. Aesthetically, this shape cannot be seen as beautiful, and various methods have been applied to correct these deficiencies. However, no one has ever reported a method that directly corrects the shape of alae that extrude laterally. The author has found the technique of correcting the middle part of the ala without leaving any external scars by performing some of the plasties from inside the ala or by grafting cartilages. Successful results have been obtained and are reported here.

The special anatomy of the supporting alar cartilage is described and compared with a tripod system. By shortening or lengthening the legs of this cartilaginous tripod system, the nasal tip can be changed and adapted to the facial features as desired. Different cases of nasal tip plasties are presented and the application of the tripod principle demonstrated.

BACKGROUND: Cleft lips are very common malformation and all patients present a typical feature of the nose. The correction of a cleft nose is the most important step in secondary rehabilitation of CLP patients. Adequate correction of the septum is a must for the functional as well as the aesthetic result. In many cases it will become necessary to take out the whole septum, to build up a straight septum plate and to replant it. To keep the replanted septum in the midline it is necessary to bring the dislocated anterior nasal spine into the correct position. After closure of the lip, the deformity of the nasal tip and the nostrils preserve the stigma of the CLP patient. To achieve symmetry of the cartilagenous structures and the deformed soft tissue, a triple swing flap technique is recommended, which we have up to now used in 261 patients.