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The main objectives of rhinoplasty in African descendants are to improve the definition and projection of the nasal tip, augment the dorsum, and reduce the alar base. Open rhinoplasty using costal cartilage graft, with lateral crural tensioning and septal extension graft associated with en bloc dorsal augmentation is the workhorse. Cartilage resections should be minimal. Oral isotretinoin and triamcinolone injection may improve tip definition. Surgical success ultimately depends on the ability of the surgeon to accurately identify the anatomic variables and reconcile these anatomic realities with the patient's aesthetic expectations and his or her sense of ethnic identity.

BACKGROUND Closure of the nasal skin defects that resulted from excision of the skin neoplasms represents a challenging problem in reconstructive surgery. Here, the use of the reading man procedure as a new alternative in reconstruction of the skin defects of the nose is presented. MATERIALS AND METHODS In this procedure, 2 local flaps designed in an unequal Z-plasty manner are used. Defect coverage is achieved by transposing the first flap to the defect area, whereas the second flap is used for closure of the first flap's donor site. In last 10 years, this technique has been used for closure of the nasal skin defects that resulted from removal of skin cancers in 28 patients (15 men and 13 women) aged from 45 to 98 years. The defects were ranging between 1.5 and 3.1 cm in diameter. RESULTS In all patients, a tension-free 1-stage closure was obtained. There was no patient with dog ear formation and/or distortion of the mobile anatomical structures, such as nasal tip, alar lobules, and nostrils. All patients healed without complications. A mean follow-up of 52 months (8 months to 6.5 years) revealed satisfactory cosmetic results in all patients. No tumor recurrence was observed. CONCLUSIONS Using the advantage of extra tissue relaxation provided by an unequal Z-plasty, the reading man procedure seems to be a useful alternative for the closure of nasal defects with alike local skin. As a critical achievement, this procedure does not require excision of additional healthy tissue. Borrowing tissue from multiple directions, it avoids dog ear formation and distortion of the mobile anatomic structures.

Aleksandra Bolewska,1 Monika Słowińska,1 Agata Błońska,1 Justyna Ceryn,2 Bartłomiej Grala,3 Joanna Narbutt,2 Magdalena Ciążyńska,4 Wojciech Małecki,5 Małgorzata Skibińska,2 Aleksandra Lesiak,2 Elwira Paluchowska,1 Witold Owczarek1 1Department of Dermatology, Military Institute of Medicine, Warsaw, Poland; 2Department of Dermatology, Pediatric Dermatology and Oncology, Medical University of Lodz, ŁÃ³dź, Poland; 3Department of Pathology, Military Institute of Medicine, Warsaw, Poland; 4Department of Proliferative Diseases, Nicolaus Copernicus Multidisciplinary Centre for Oncology and Traumatology, ŁÃ³dź, Poland; 5Department of Clinical Oncology and Chemotherapy, Poddębice Health Centre, Poddębice, PolandCorrespondence: Aleksandra Bolewska Tel +48 261 816 241; +48 604 783 340Email aleksandra.bolewska@wp.plAbstract: Lung cancer most often metastasizes to the central nervous system, bone and liver. Although metastases to the skin are quite rare, it is estimated that they may be the first clinical manifestation of this disease in 0.7%– 12% of cases. Metastases to the skin are caused by adenocarcinoma (about 30%), squamous cell carcinoma (30%) and undifferentiated carcinoma (40%). Nasal tip metastases are extremely rare. They can be confused with more common skin problems, including non-melanoma skin cancers, rhinophyma, inflammatory tumors or infectious diseases. We report two patients with a tumor on the nose, which proved to be the first sign of the metastatic lung cancer.Keywords: lung cancer, skin metastasis, ulceration, tumor

Despite the great demand of aesthetic rhinoplasty in Asian population, it is difficult to obtain the lasting ideal tip projection along with lengthening of the nose due to the small and weak nasal septum. The shortage of available septal cartilage to work with is another major obstacle. A retrospective study was conducted between January 2017 and December 2019 in Seoul, Korea. A total of 774 patients underwent septorhinoplasty using polycaprolactone (PCL) mesh for the cosmetic enhancement of the nasal tip and the projection. Comparisons of aesthetic outcomes, patients' satisfaction surveys, and complications were performed between PCL mesh-only group and composite PCL group. Of all the patients, 97.5% of the patients in composite PCL group were rated more than 3 scores in aesthetic outcomes, whereas 90.4% in mesh-only group (p-value = 0.0002). About 96.7% of the patients with composite PCL rated their satisfaction level as more than satisfied, whereas 94.3% in mesh-only group (p-value = 0.0365). Overall, there were 17 patients in composite PCL group who exhibited complications including decreased tip projection, deviated nasal tip, mesh infection, and mesh exposure. However, there were two patients who had mesh injection in mesh-only group. Septorhinoplasty with septal extension graft using composite PCL graft provides robust support to the aesthetically modified projection and the lengthened nose without obvious complications on the nasal tip. Such technique allows surgeons to overcome the nature of Asian nose that is weak and small, and also provides satisfaction to patients who desire ideal tip projections and dramatic changes.

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 .

Nasal tip deformities after primary rhinoplasty may occur, including the formation of bossae, a pinched nasal tip, and nasal tip ischemia. Because of the central location in the midface, even minimal nasal tip deformities (small bossa) may be noticed and upsetting to the patient. This is in addition to more severe nasal tip deformities, including nasal tip ischemia, that are easily visible to any viewer. Prevention, early recognition, and, depending on the case, intervention are critical in minimizing these complications. If complications do occur, regular communication with the patient and follow-up are crucial.

Dermoid cyst is a congenital and benign disease with most occur on the head and neck. It is rarely that occur on the nasal tip and nasal septum at same time and rarely repair of using nasal septum mucosa. The authors treated a child with dermoid cyst in the nasal tip and septum. Only the dermoid cyst at the tip of the nose caused the change of appearance. Dermoid cyst of nasal septum did not cause any clinical symptoms. She underwent excision of the dermoid cyst at the tip of the nose and endoscopic surgery for the dermoid cyst in the nasal septum and used the nasal septum mucosa for repair at the same time. After 6 months of recovery, the appearance of the nasal tip recovered well without obvious scar, the nasal septum area recovered well, and the local stoma was unobstructed without recurrence. The authors found that this kind of nasal septal cyst with no clinical symptoms can achieve good therapeutic effect through endoscopic surgery and repair of using nasal septum mucosa, with less damage, rapid recovery, and good prognosis.

The autologous conchal cartilage of good elasticity is easy to harvest, thus is often used in nasal tip plasty of East Asians. However, the operation techniques vary a lot among different surgeons. This article aims to introduce 3 techniques commonly used in clinical practice.One hundred three patients were included in this study and divided into 3 groups according to the shape of the nasal tip during 2017 to 2019. The patients were followed up for at least 6 months. All patients were measured with Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). ImageJ software was used to measure and calculate the projection ratio for lateral position standard image, and columella-labial angle (CLA) was measured.In group 1, SCHNOS for nasal obstruction (SCHNOS-O) score were 13.23 ± 7.61 and 14.49 ± 10.55 (P0.05); SCHNOS for nasal cosmesis (SCHNOS-C) score were 66.55 ± 31.23 and 21.73 ± 18.91 (P0.001); projection ratio were 0.51 ± 0.04 and 0.57 ± 0.05 (P0.001); CLA were 91.02° ± 5.67° and 93.55° ± 4.64° (P0.05), preoperative and postoperative, respectively. In group 2, SCHNOS-O score were 16.76 ± 13.44 and 15.44 ± 9.26 (P0.05); SCHNOS-C score were 61.87 ± 44.14 and 19.16 ± 29.37 (P0.001); projection ratio were 0.50 ± 0.05 and 0.58 ± 0.03 (P0.001); CLA were 92.32° ± 6.39° and 94.86° ± 5.96°(P0.05), preoperative and postoperative, respectively. In group 3, SCHNOS-O score were 15.25 ± 7.83 and 17.73 ± 11.66 (P0.05); SCHNOS-C score were 52.03 ± 33.38 and 17.73 ± 11.66 (P0.001); projection ratio were 0.53 ± 0.05 and 0.57 ± 0.02 (P0.001); CLA were 91.65° ± 5.75° and 93.21° ± 5.38° (P0.05), preoperational and postoperational, respectively.None of these 3 techniques cause or aggravate nasal obstruction, and all of them can achieve high cosmetic satisfaction. Technique 1 and technique 2 are suitable for the patients with moderate and moderate to severe short nose that is common in East Asia, which can better increase the protrusion of the tip and length of the nose. Technique 3 is suitable for the patients with better shape of the nose, who need to slightly increase the protrusion of the nasal tip and increase the upward rotation.

Reconstruction of the tip of the nose following the excision of skin cancer is a cosmetic and surgical challenge. We propose using a crescentic nasojugal flap, also known as a perialar crescentic advancement flap, to repair such defects. We present a series of 13 cases in which cutaneous carcinoma (mostly basal cell carcinoma) was excised from the lateral nasal tip with clear margins and the defect repaired with a crescentic nasojugal flap. The technique was successful in all cases. None of the patients developed notable surgical complications and the postoperative outcomes were satisfactory, with no significant functional or cosmetic problems. The crescentic nasojugal flap is therefore a good option for repairing medium-sized defects on the tip of the nose.

Head and neck injury as a consequence of in utero pressure and birth trauma is a rare event. We report a case of a patient who was born full-term via vaginal delivery and presented soon after birth with skin changes over the nasal tip consistent with a pressure-related injury that progressed to a stable eschar. Conservative management with close clinical monitoring resulted in a well-healed wound over the nasal tip. A detailed discussion regarding the diagnosis and management of head and neck lesions after birth is provided.

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 .

Background The tongue in groove technique (TIG) is a useful technique for the correction of the nasal tip projection and the nasolabial angle. The purpose of this study was to determine the utility of this technique for nasal tip rotation and projection correction in the Iranian society. Methods This is a retrospective clinical trial study of 20 patients undergoing open septo-rhinoplasty using TIG technique from January 2017 to August 2019 at the oral and maxillofacial unit of Bu Ali Hospital and private sector. Preoperative and postoperative profile view photographs were compared to assess the changes in tip projection and rotation. Results Fifteen patients (75%) had normal angular size, and 5 of them (25%) were not within the normal range after the surgery. The Fisher exact test showed that this success was statistically significant (P = 0.006). Ten patients (50%) had normal projection size, postoperatively. The Fisher exact test showed that this effect was statistically significant (P < 0.01) Conclusion The study demonstrated the benefit of TIG on the correction of nasal tip projection and rotation.

Arteriovenous malformation is a vascular malformation with fast-flow shunt from the artery to the vein. Extracranial arteriovenous malformation in the head and neck area is rare disease compared to other vascular malformations such as venous malformation or lymphatic malformation. Extracranial arteriovenous malformations especially on face can cause aesthetic problems, therefore surgeons should consider an importance of cosmetic outcome and choose appropriate treatment plan. We report a case of 51-year-old male who presented with enlarged nasal tip diagnosed arteriovenous malformation. This case showed successful outcome after combination therapy consisted of superselective embolization and surgical resection.

Background Nasal skin defect closures are challenging because the nose is a complex anatomic structure with several subunits, and the nasal tip and ala represent particularly difficult subunits to reconstruct. The traditional full-thickness skin graft (FTSG) is an easy and well-established method, but often results in undesirable outcomes in terms of the nasal contour caused by a lack of dermal tissue. Aims The purpose of the study is to report the outcomes of the simultaneous application of the acellular dermal substitute (Matriderm® ) with FTSG in the treatment of nasal skin defects. Patients/methods Five patients with various nasal skin defects were treated with multilayered Matriderm grafts followed by FTSGs harvested from the pre- or postauricular region. Graft survival, scar quality, and patient satisfaction were evaluated and compared with 10 patients treated with conventional FTSGs. Results One-stage Matriderm-aided FTSGs were well-taken in all cases. Scar quality in the Matriderm group (8.0 ± 1.9) was statistically superior to that in the FTSG only group (10.8 ± 1.7). The Matriderm-aided graft was also superior in patient satisfaction. Conclusions The multilayered application of Matriderm in combination with FTSG is a reliable method for covering nasal skin defects, especially in the thick skin zone of the tip and ala.

Resumen Objetivo: describir los resultados que se obtienen con el uso de ortopedia prequirúrgica NAM, Dynacleft y componente nasal en relación a estética, alimentación y brecha entre segmentos maxilares. Método : Se realizó un análisis de la literatura publicada utilizando bases de datos Pubmed y SCIELO, además de una búsqueda manual de libros y artículos científicos. Después de aplicar los criterios de inclusión y exclusión, se analizaron 25 estudios. Resultados : La literatura indica que NAM y Dynacleft mejoran la estética y disminuyen la brecha entre los segmentos maxilares, con respecto a la alimentación se necesita mayor evidencia. Conclusión: los resultados obtenidos con la ortopedia prequiríurgica son mejores si se empieza los primeros días de nacimiento. Dentro de la estética destaca la simetría labial y nasal, proyección de la punta de la nariz y cicatriz post operación primaria.

Septal extension graft is a unique technique for controlling nasal lengthening and tip projection, rotation, and shape by which a graft is fixed to the septum, leading to a strong and stable supporting structure. Nasal tip three-dimensional positioning is a vital and difficult component in the overall appearance of the tip. A total of 12 Middle Eastern patients with thick nasal envelope skin were subjected to rhinoplasty using the septal extension graft (SEG) method. Eleven out of the 12 patients, had pleasing results after primary rhinoplasty with SEG, while only one patient had SEG as a secondary procedure. In conclusion, septal extension graft in rhinoplasty is an effective technique for achieving a strong supporting force of the nasal tip for adequate projection. Keywords: Nasal tip, surgery, septal extension, graft, rhinoplasty

Frontonasal dysplasia is an uncommon congenital anomaly with diverse clinical phenotypes and highly variable clinical characteristics, including hypertelorism, a broad nasal root, median facial cleft, a missing or underdeveloped nasal tip, and a widow’s peak hairline. Frontonasal dysplasia is mostly inherited and caused by the ALX genes (ALX1, ALX3, and ALX4). We report a rare case of a frontonasal dysplasia patient with mild hypertelorism, a broad nasal root, an underdeveloped nasal tip, an accessory nasal tag, and a widow’s peak. We used soft tissue re-draping to achieve aesthetic improvements.

Background Primary rhinoplasty outcomes may not meet individual expectations. Consequently, reoperation may be advocated to improve results. This study examines the prevalence of individuals considering revision rhinoplasty, while identifying the main cosmetic and functional complaints and factors associated. Methodology This is a cross-sectional study conducted in Saudi Arabia using a self-reported online questionnaire distributed through social media channels. The sample included 1370 participants who were all Saudi nationals over the age of 16 who had undergone primary rhinoplasty at least 1 year prior. Results The prevalence of individuals considering revision rhinoplasty was 44.7%. The primary reason for considering it was the desire for further esthetic improvement in an already acceptable result (50.16%). The most common cosmetic complaints subjectively reported were poorly defined nasal tip (32.35%). The most prevalent nasal function symptom was nasal obstruction (56.9%). Significant factors associated with considering revision rhinoplasty included the physician not understanding the patient’s complaints, short consultation time, low monthly income, inadequate information about the expected results, not using computer imaging to predict outcomes, lack of rapport with the surgeon, and inadequate information about the risks and complications. Conclusions A thorough understanding of patient concerns and expectations, as well as thoughtful consideration of risk factors, may help surgeons achieve more successful outcomes and potentially reduce the incidence of revision rhinoplasties. Level of evidence III

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.

Summary Dorsal augmentation using silicone and tip plasty with autogenous cartilage is commonly performed in Asians. No study has investigated the classification pattern and step-by-step procedure for tip plasty using silicone implants. Therefore, this study classified cartilage grafts using silicone implants in Asians and developed a step-by-step procedure for their implementation. The study included 39 patients who had undergone augmentation rhinoplasty with a silicone implant combined with a conchal cartilage graft as a shield, an onlay graft, or both. We classified the implant-conchal cartilage complex into two main types (edge and no-edge types). In the edge type, the shield graft tip was located 1–2 mm above the silicone implant or onlay graft. In the no-edge type, it was located at the same level as the silicone implant or onlay graft. Each type was classified into three groups depending on the number of onlay grafts: group I, 0; group II, 1; and group III, ≥2. The cartilage complex was placed on the dorsum. The conchal cartilages were harvested through a post-auricular incision while preserving the radix helicis as cartilage bars. The donor site was closed primarily without a tie-over dressing. Of the 39 patients, 35 were satisfied with the outcome. Three revision operations for implant displacement and one revision for a patient who changed her dorsal height preference were performed. No donor site morbidity occurred. This method may be safe and reliable, with minimal morbidity associated with graft harvesting for tip plasty in Asians.

Background:. One of the faced difficulties of nasal tip surgery is progressive loss of nasal tip projection and rotation postoperatively. Nasal base stabilization by septal extension grafts has shown to improve this loss over time. The aim of this study was to demonstrate that a modified septal extension graft can provide the required tip rotation/derotation by changing the angle of the graft’s insertion. In addition, it maintains nasal tip projection without creating a rigid tip. Other than that it avoids the requirement of a large amount of cartilage. Materials/Methods:. This study involves a retrospective review of 37 patients who underwent open rhinoplasty for primary or secondary cases over a period of 12 months. The average age of the patients was 28 years (range = 20–43 years), and all patients were of Middle Eastern origin. Subjective evaluation based on photographic analysis was used pre and postoperatively. Results:. All cases included in this study maintained their operative results of tip rotation. Two cases showed a minimal decrease in tip projection documented upon review 6–12 months postoperatively. No patient needed secondary revision surgery due to changes in tip projection or rotation. The objective pre and postoperative findings were satisfying for the patients and surgeons. Conclusions:. The modified septal extension graft is an effective tool for rotation of the nasal tip as well as derotation of an over rotated tip. It is also capable of maintaining nasal tip projection.

OBJECTIVE The reshaping of the nasal tip in rhinoplasty according to the expectations of the patient and the surgeon is called tip plasty. In this article, the onlay rotated flap (ORF) is presented as a new technique for reshaping, supporting, and projecting the nasal tip without any resection or grafting. METHODS Thirty-two patients (26 female and 6 male) were included in the study retrospectively. Primary rhinoplasty with ORF was performed to all patients. The follow-up period was between 9 and 12 months. The nasal tip projection (NTP) with Goode method and nasal tip rotation (NTR) according to nasolabial angle were calculated in standardized preoperative and postoperative(6th month) photographs with Image J. SPSS Version 21.0 was used for statistical analysis. RESULTS There were no complications resulting from our procedure. There were no visible tip flaps, no distortion, no asymmetry, and no alar retraction. Revision surgery was not required in any patient. The preoperative and postoperative means of nasolabial angle (Mean ± SD) were 92.06 ± 7.73° and 99.71 ± 6.06°, respectively. The preoperative and postoperative means of NTP (Mean ± SD) were 0.535 ± 0.041 and 0.57 ± 0.386, respectively. The postoperative nasal tip rotation and NTP values of the ORF procedure were found to be statistically significantly higher than the preoperative values (P

Introduction The predictability of nasal tip projection and rotation after aesthetic surgery is a challenge. Tongue-in-groove (TIG) is an effective technique to control tip projection and rotation, but there may be a small loss of projection and rotation of the tip lobe due to lack of support between the anterior septal angle and the domus, since this region is sustained by medial crusts suture-linked and interdomus sutures. Objective To describe a new surgery technique in an attempt to correct the lack of support for the nasal tip after lowering the nasal dorsum. Methods The horn technique consists in preserving a square of cartilage during the removal of the nasal dorsum and septum excess in patients with long and projected nose. This piece will give greater support to the TIG technique and greater predictability of the rotation and projection of the nasal tip. Results Between 2016 and 2018, 50 patients with long and projected noses were submitted to the “horn technique” surgery. They were submitted to the TIG technique associated to the horn technique. A retrospective review of the preoperative and postoperative photographs (3 months to 1 year) of these patients treated with the horn technique were analyzed and showed better support of the nasal tip. Conclusion The horn technique provides greater support to the projection and rotation of rhinoplasties in patients with long and projected nose.

Chondroid syringomas of the nose are rarely encountered. We present a novel case of a patient who developed a chondroid syringoma of the nose after paramedian forehead flap reconstruction. Furthermore, we discuss complete excision by external rhinoplasty approach.

Background: Alar rim collapse is an agonizing problem that has both cosmetic and functional sequalae. It has been usually addressed with batten grafts. In this study, we are describing a simple technique for insertion of alar rim grafts to fix external nasal valve collapse.Patients and Methods: Between January 2018 and October 2020, eighteen patients with alar rim collapse or deformities were addressed using alar rim septal cartilage grafting.Results: All patients who underwent alar rim grafting for external nasal valve collapse were evaluated functionally and aesthetically with post-operative follow up ranging from 12 to 24 month. During which, they showed marked improvement in their nasal airway patency with complete satisfaction for the aesthetic outcome. No complications were encountered.Conclusion: Alar rim grafting is a simple and effective approach to provide support for the external nasal valve and alar contour. In cases of malpositioned lower lateral cartilage, alar flaring, nasal tip deformities, mild retraction, or contour asymmetries, these cartilage grafts showed good outcomes in primary or revision cases.

BACKGROUND Based on previous reports, in comparison with Caucasian, nose anatomy has features that have to be considered by surgeons during the tip augmentation in Asian patients. Weak alar cartilages, thick soft-tissue envelope, and bifid-like tip in most cases. This case report demonstrates our experience of using ball-shaped diced conchal cartilage during the tip plasty in Asian patients. CASE REPORT Twenty-seven-year-old female patient underwent tip plasty augmentation with ball shaped diced cartilage wrapped with dermofat. There were no complications in postoperative period. DISCUSSION Based on the Asian nasal anatomy features, surgeons commonly use septal extension graft in tip projection and derotation. However, it is still challenging to perform it in patients with septal cartilage insufficiency. In this case report, the authors introduce the alternative surgical option for nasal tip augmentation. The ball shaped cartilage autologous implant can be successfully used in tip plasty.

Background:. Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery, the incidence of which has increased up to approximately 1 million cases in 2016 according to the recent International Society of Aesthetic Plastic Surgery survey. This study aimed at defining the importance of each sequential procedure within the same surgery, the extent to which a procedure can be performed, and those that can be omitted. Methods:. In this descriptive study, 27 candidates (18 women; nine men; age range, 20–48 years) for primary rhinoplasty between September 2016 and September 2019 were included. All had long noses, their main concern was reduction of nasal tip projection and all were seeking cranial tip rotation to enhance their tip aesthetics. Those who required revision rhinoplasty or who had nasal deformities due to congenital defects, and those older than 60 or younger than 18 years of age, were excluded. Results:. The average nasolabial angle in women preoperatively was 88.2 ± 6.6 and postoperatively 102.8 ± 5.6. In men, the average average nasolabial angle preoperatively was 79.6 ± 5.4 and postoperatively 92.3 ± 2.3. In both men and women, the P value was

Infantile hemangioma is the most common pediatric vascular tumor, with the following risk factors: low birth weight, prematurity, white skin, female gender, multiparity and advanced maternal age. The use of oral and topical beta-blockers, although recent, has emerged as the first line of treatment, with superior safety and efficacy to previously used therapies, such as corticosteroids and surgeries. This report describes two cases of nasal tip infantile hemangioma, treated with oral propranolol. Both presented excellent therapeutic responses.

The nasal tip projection and rotation to be obtained with tip plasty play a key role in achieving successful results. Cartilage sparing techniques provide extra ease to reshape the cartilage in revision rhinoplasty. Freed dome cartilage eliminates the restricting forces of mucosa. The authors recommend to free the dome cartilage from mucosa during the tip plasty which ensures the desired dome shape and extra projection. A total of 218 patients who were operated between the dates of January 2017 and August 2018 were included in this study. About 3 mm parts of the marked domes toward medial and lateral crurae were dissected from the mucosa. New domes were created with bilateral hemitransdomal sutures. The outcome of the operation was asked to the patients verbally and answers were recorded. Of 218 patients who were included in the study, 182 were females and 36 were males. Patients had a mean age of 26.5 years. The length of follow-up was 11.8 months. About 205 patients had primary rhinoplasty while 12 patients had secondary rhinoplasty and 1 patient had revision rhinoplasty. Of the patients, 89.9% (196/218) were very satisfied with the result and 7.4% (16/218) were satisfied, whereas 2.7% (6/218) were dissatisfied. Only 5 patients who were dissatisfied with the result underwent revision rhinoplasty operation. The combination of the modified free dome suture with the mucosal dissection in dome area provides achieving the desired tip projection and symmetry.

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

Background: Nasal tip surgery is regarded as the most challenging aspect of plastic surgery. Control of nasal tip contour has always been a key component of a successful rhinoplasty. Creating a natural-appearing nasal tip contour is a complex task and requires a 3-dimensional approach.Aim of Study: In this study we aimed to study and imple-ment the different non-destructive surgical techniques for the management of the various nasal tip deformities.Patients and Methods: Fifty patients with various tip deformities were operated by an open approach either by sutures, various grafts or both.Results: Decreased need for irreversible techniques, with a concurrent increase in conservative techniques as sutures and grafts techniques that had been done in most of our patients for each.Conclusion: We concluded that management of nasal tip deformities with both suture and grafting provides best results.

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 Middle crura support deficiency and short middle crura can usually cause insufficient definition and projection of the tip and can sometimes result in a flat tip. The aim of this study was to investigate the effectiveness of a new technique involving a tip reinforcement flap to strengthen the middle crura and to achieve a well-projected and defined tip. Methods Twenty-nine patients who underwent primary open-approach rhinoplasty that included the use of tip reinforcement flaps were included in the study. Cartilage flaps that had been created from the excess cephalic portion of the lateral crura were prepared as medial crura-based cartilaginous flaps. Results There were 29 patients (17 women, 12 men) aged 18 to 44 years (mean age, 31 years). Follow-up time ranged between 3 and 25 months (mean, 21 months). Preoperative and postoperative average of nasal tip length was 10.84 (±1.07) mm and 14.32 (±2.34) mm, respectively (P = 0.0214). Preoperative and postoperative average of nasolabial angle was 97.42° (±9.84°) and 107.99° (±12.16°), respectively (P = 0.0344). Preoperative and postoperative average of nasal projection ratio was 0.53 (±0.04) and 0.57 (±0.03), respectively (P = 0.4347). The tip reinforcement flap technique provided strengthening and extra support for the middle crura and increased definition, projection, and stability to the domal area. Conclusions The tip reinforcement flap technique offers advantages for tip plasty in those cases with middle crural deficiency, short middle crura, and middle crural weakness. The technique also provides an additional projection, stabilization, and definition to the nasal tip while reducing lateral crural cephalic excess. This technique improves nostril-lobular disproportion and has the advantage of hiding extra support grafted into the folded flap. Complications such as graft visibility, malposition, and asymmetry, which may occur with the use of classic tip grafts, can be eliminated with the tip reinforcement flap technique.

INTRODUCTION This study aimed to evaluate postsurgical changes of nasal tip and lateral nostril characteristics after semi-tongue-in-groove (TIG) technique in open rhinoplasty surgery. MATERIALS AND METHODS This prospective observational study was performed in a before-after setting on 22 patients who underwent open rhinoplasty surgery using semi-TIG technique. Postoperative photographs were analyzed for nasal tip and lateral nostril changes at several time points (1, 4, and 12 weeks after surgery) and were compared with preoperative photographs. Nasal tip support change after the surgery was also assessed using a purpose-designed device. RESULTS In total, 22 patients were studied (20 females, 2 males). The tip support increased by 98%, 291.8%, and 377% at certain time points after the surgery. The tip rotation increased significantly at all measuring time points, postoperatively. The length of upper lip increased at all time points after semi-TIG technique. Columellar show and nostril length and height decreased significantly after the surgery. CONCLUSION The characteristics of the nasal tip and lateral nostrils along with nasal tip support showed significant improvement after the semi-TIG technique. Therefore, this technique is recommended in selected rhinoplasty cases to achieve more favorable objective results.

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.

BACKGROUND Although columellar strut grafts (CSGs) are considered among the fundamental steps for providing nasal tip support, a downward rotation of the nasal tip in patients with strut grafts can still be encountered. Patient-related factors such as nasal skin thickness can allow the plastic surgeon to anticipate certain drawbacks that can be encountered in the healing phase, but patient-based differences of nasal cartilage and the resulting impact have yet to be investigated. The purpose of this study was to evaluate the effect of the biomechanical properties of CSGs on late postoperative nasal tip position and support. METHODS The study was undertaken with the participation of 20 patients undergoing closed-technique primary rhinoplasty with CSGs. Each cartilage specimen was biomechanically analyzed to calculate the modulus of elasticity. Preoperative and postoperative images were obtained to determine nasal tip position and rotation with quantitative measurements. Postoperative 3- and 12-month measurements were evaluated according to their relationship with the elasticity modulus of the utilized cartilages. RESULTS The evaluation demonstrated that the elasticity modulus can impact the long-term support of the nasolabial angle in which an increase in the coefficient of elasticity can result in a decrease in long-term nasal tip support. CONCLUSION The results of the study reveal a new objective variable that can impact nasal tip dynamics and patient-related differences following rhinoplasty. This study not only brings forth a different perspective in the evaluation of nasal tip dynamics but can also provide data for determining ideal values for cartilage prefabrication.

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 .

Background The alar and nasal tip are important subunits of the nose. Determining the optimal procedure for reconstructing a cutaneous defect in a nasal subunit depends on several factors including size, location, and involvement of deep underlying structures. We treated cutaneous defects after tumor ablation in the alar and nasal tip with a local flap, using an S-shaped design and a modified V-Y advancement flap with a croissant shape. Methods We analyzed 36 patients with skin tumors who underwent flap coverage after tumor ablation. Rotation flaps were used in 26 cases and croissant-shaped V-Y advancement flaps were used in 10 cases. The primary cause of the defects was skin cancer, except for one benign tumor. Results The mean patient age was 71 years. The size of the defects ranged from 0.49 cm2 to 3.5 cm2. No recurrence of skin cancer was noted and all flaps lasted until the end of follow-up. Partial desquamation of the epidermis was noted in one case. The postoperative appearance for most patients was excellent, objectively and subjectively. Conclusion For cutaneous defects of up to about 4.0 cm2 of the alar and nasal tip, local flaps using our methods offered a good cosmetic and therapeutic result. The main advantage of our flaps is the minimal dissection required compared to bilobed and other local flap methods. We believe our flaps are a suitable option for alar and nasal tip reconstruction.

Introduction and importance Reconstruction of the nasal tip is challenging, especially when large defects are associated with compromised nasal soft tissues and framework. The frontonasal flap is an axial-pattern myocutaneous flap from the glabella and nasal dorsum that allows for various modifications in flap design to cover medium sized defects of the nasal tip. Case presentation A 66-year-old male patient presented with a large and ulcerated squamous cell carcinoma of the nasal tip that was associated with substantial posttraumatic damage of the nasal soft tissue envelope and cartilaginous vault of the dorsum. Considering patient comorbidity, risk factors, and specific nasal condition, a single-stage tumor resection and reconstruction using a modified frontonasal flap was intended. While tumor excision resulting in a tip defect of 1.5 × 1.5 cm and flap coverage were initially achieved in a single stage, histologically incomplete tumor resection and individual patient requests mandated further surgery, including re-excision, cartilage grafting, and soft tissue contouring. Clinical discussion The frontonasal flap allows for single-stage reconstruction of moderate size tip defects. Even in the case of prior soft tissue damage and scarring, the flap may be used safely pending individual adjustments in flap design. However, additional measures may be employed as needed to optimize the functional and aesthetic outcome in cases of complex nasal pathology. Conclusion In a case with a combined tumor and posttraumatic nasal deformity, an individualized surgical concept incorporating a modified frontonasal flap with adjunct cartilage grafting and soft tissue contouring achieved an excellent functional and cosmetic outcome., Highlights • Nasal tip reconstruction can be performed with various grafts and flaps. • The frontonasal flap allows single-staged reconstruction of tip defects. • Previous nasal trauma can impair frontonasal flap reconstruction. • A modified frontonasal flap with adjunct procedures is presented. • The modified frontonasal flap obtained an excellent functional and aesthetic result.

Skin necrosis is one of the most severe complications following filler injections, and can result in permanent aesthetic defects. Although an increasing number of studies have addressed the management of dermal filler complications, no study has described the spectrum of microbial pathogens. The aim of this study was to delineate the bacterial profile and prognostic factors of filler-related skin necrosis by reviewing the clinical and microbiological features of these patients. A retrospective medical record review of patients undergoing treatment for skin necrosis induced by fillers was conducted. In total, 10 cases were identified, with injection sites being the nasolabial fold (70%; n = 7), nasal dorsum (20%; n = 2) and nasal tip (10%; n = 1). Reviewing the culture results, the true culture-positive rate was found to be 50% after cases of contamination were excluded. To avoid permanent sequelae, all physicians should be aware of possible secondary infections when treating filler-induced skin necrosis.

Introduction Congenital midline sinus over tip of nose is a rare clinical presentation. Accurate diagnosis should be done to rule out intracranial extension and to prevent recurrence. Appropriate surgical approach depends upon location, extent and degree of intracranial extension. Management entails complete surgical excision of sinus tract. We discuss a rare case, where external rhinoplasty approach was used for excising recurrent sinus and patient was disease free. Case Report A 29 year old male patient with midline nasal tip sinus presented in our institute with history of opening over tip of nose since childhood associated with recurrent episodes of discharge from opening. Our objective is to present clinic-radiological-pathological profile of congenital nasal sinus along with review of literature. Discussion Nasal dermoid is rare embryological anomaly of ectodermal and mesodermal origin. Radiological imaging should be considered to rule out any intracranial extension. Goal of management is complete surgical excision with meticulous pre-operative and surgical planning to avoid complications and recurrence. External rhinoplasty provides best surgical exposure and allows excision of sinus tract.

The Peng flap was originally described in 1987 as a viable option for re-creation of the convexity of the dorsum and nasal tip in a one step. Defects extending into the sidewall can result in multi-stage procedures. Beustes-Stefanelli in 2015 published a midline-based nasolabial transposition flap utilizing a single-stage repair for large defects of the nasal tip. There is minimal literature on large nasal tip defects repaired in a single stage and few modifications to the Peng flap. In this case, the sidewall involvement on top of the extent of nasal tissue removed limits the various different methods.

Postoperative dropping of the nasal tip after rhinoplasty is a known complication. Defining the position of the nasal tip begins with stabilizing the nasal base. To define the position of the nasal tip and stabilize the nasal base of the nose, the surgeon has three main options: tongue-in-groove maneuver, caudal septal extension graft, or columellar strut.

Patients with a droopy nasal tip, which occurs when the tip of the nose is more caudal than its ideal configuration, appear older than their biological age. Following post-surgical recovery, patients may begin to receive compliments from their friends on how much younger they look, which makes them feel better and more attractive, and helps them appreciate how negatively their droopy nose affected their lives prior to surgery. This is a common motivation for rhinoplasty. The success of droopy nasal tip surgery is also important for the surgeon; when less-experienced surgeons succeed in correcting a droopy nasal tip, they receive positive feedback from the patient and their colleagues, increasing their motivation and prestige. The success of the surgery depends on the surgeon’s anatomical knowledge, correct diagnosis of the underlying pathology, and selection of a surgical technique suitable for the patient. This chapter discusses droopy nasal tip, including the underlying pathology and treatment approaches (Fig. 11.1).

Since rhinoplasty surgery was first introduced, notable developments have been obtained in this field. In the last decades, surgeons aimed at improving the surgical procedure to achieve the long-term constant outcomes, avoiding postoperative complications, preventing nasal airway deficiency, making the operation less invasive and consequently lowering the possible damages to adjacent tissues, and finally proper management of the procedure to enhance the esthetic appearance of the nose. On the other hand, there is a significant change in people’s way of thinking toward having a nose with a natural appearance. Meanwhile, the emergence of grafting methods has led to disappearing of older invasive techniques. The present chapter attempts to have an overview of the novel techniques in rhinoplasty. The latest techniques in nasal tip surgery, lateral osteotomy, dorsal surgery, nasal base surgery, Asian rhinoplasty, and preservation rhinoplasty are discussed.

Infantile hemangiomas are common benign tumors of infancy with a predilection for the face. Nasal-tip hemangiomas, termed the "Cyrano deformity," can have especially devastating psychological effects. The ideal surgical approach and timing for these patients is unclear, as numerous designs have been reported in the literature. The authors present a novel approach to nasal tip reconstruction involving an algorithmic approach to incision selection and leaving a thin rim of hemangioma tissue under the dermis after debulking to minimize skin envelope atrophy. Nineteen cases were treated with the senior author's preferred method, with a mean age of 3.3 years and follow-up of 2.5 years. At follow-up, 10 patients were deemed by the senior author to have a very good aesthetic result, and the remaining nine patients were deemed to have an excellent one. The results of this study suggest that surgical intervention as early as 3 to 4 years of age is safe and provides good aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

"Subperichondrial-subperiosteal dissection technique (SSDT) decreases soft tissue injury to a minimum by protecting soft tissues from dissection and retraction traumas. The fact remains that dissecting the perichondrium of the nasal tip cartilages is not effortless. Cartilages may be harmed if dissection is not initiated at the right location. The aforementioned surgeons have routinely used the SSDT between the years 2008 and 2019 in more than 4000 rhinoplasties. The number of the surgeons making use of the SSDT will increase with the understanding of the key points in dissection, their ordering, and use of correct instrumentation."

To introduce an innovative refinement, the “double V cutting folded derotation graft” (DVCFD graft), which is a method for nasal tip lengthening in aesthetic rhinoplasty with strong holding force and efficient cartilage use. A retrospective study was conducted from January 2018 to July 2019 with 101 patients, including 11 males and 90 females with an average age of 36.87 ± 10.12 years, at Chang Gung Memorial Hospital; the patients received classic derotation grafts (n = 49, 17 of them were one layer and 32 of them were two layers) and DVCFD grafts (n = 52) for cosmetic tip plasty. The tip projection, columella labial angle and nasolabial angle were measured through clinical photography at three different times (T0: pre-operation, T1: two weeks post-operation and T2: five months post-operation). The differences between the original derotation graft and the DVCFD graft were identified using paired-t and independent-t tests. The final relapse ratios of the classic derotation graft and DVCFD graft were 36.78% versus 36.92% for tip projection, 40.65% versus 38.58% for columella labial angle and 45.00% versus 47.76% for nasal labial angle, respectively. The P values of the independent-t tests were 0.991, 0.564 and 0.439, respectively. Both the classic derotation graft and DVCFD graft possess similar stability in tip plasty. The novel modification of the DVCFD graft has more efficient cartilage usage and is a feasible and safe surgical option for patients with limited harvestable cartilage for tip lengthening. 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 .