Tip Definition Research Articles

Use of lateral alar caudal graft to increase nasal tip definition in rhinoplasty

ObjectiveThe aim of this study is to demonstrate use of Lateral Alar Caudal Graft to increase nasal tip definition in primary or revision rhinoplasty cases. MethodLateral Alar Caudal Graft was used in 24 patients who underwent open technique septorhinoplasty between 2019 and 2023 years. Fourteen of the patients were female and 10 were male. This technique was applied in revision or primary cases where the caudal part of the lateral alar crura of the lower lateral cartilage was lower in the vertical plane than the cephalic part. The Lateral Alar Caudal Graft was sutured over the caudal edge of the lateral alar crura of the lower lateral cartilage. ResultThe mean age of the patients was 23. The mean follow-up time of the patients was between 6 and 18 months. No complications were observed due to this technique. Satisfactory results were obtained in the postoperative period after surgery. ConclusionWe have successfully demonstrated that in primary or revision rhinoplasty cases, nasal tip definition will be enhanced by positioning the caudal level of the lateral alar crura of the lower lateral cartilage higher than the cephalic level using an onlay lateral alar crural graft and eliminated the need for alar rim graft.

New Concept for Articulated Alar Rim Graft Positioning.

The articulated alar rim graft (AARG) proposed by Davis is a simple and effective method for avoiding and correcting most alar rim deformities in rhinoplasty. In addition to its benefit for the nasal ala, the position suggested herein allows for a precise definition of the facet polygon and infratip lobule. A retrospective series of 317 patients surgically treated with the modified AARG positioning were evaluated. The height of the septal extension graft was always a few millimeters above the new dome, without demanding excessive lateral crural tensioning (LCT), and the AARG itself was fixed more on the facet polygon and infratip than in the standard procedure. The results were favorable after 1 year of follow-up. The proposed AARG modification yielded good nasal tip projection and definition without excess LCT, enhanced the facet polygon and supra-alar sulcus, and stretched the skin downward. Functional gain was reported by most patients. Few minor and common complications were reported. The use of this modified AARG position can avoid and correct most alar deformities, with the added benefit of providing better control over tip definition without the need for excessive LCT or overprojection of the nose.

Tip Definition in Cleft Rhinoplasty Assessment and outcomes meta-analysis

Tip Definition in Cleft Rhinoplasty Assessment and outcomes meta-analysis

High-fidelity simulations of low-velocity impact induced matrix cracking and dynamic delamination progression in CFRP beams

A high-fidelity finite element model is constructed to simulate the low-velocity line-impact experiments conducted by Bozkurt and Coker on [05/903]s CFRP beams. The simulations utilize a user-implemented three-dimensional continuum damage model with the LaRC05 criterion for matrix cracking, and a built-in cohesive zone model for delamination in ABAQUS/Explicit. The significant influence of boundary supports on the global impact response leads to proposing a heuristic boundary conditions approach using spring elements that replicate the experiment boundaries. Results then demonstrated an excellent agreement with the experiments in terms of the global impact response, the strain field, and damage pattern and sequence. Simulations reveal intersonic delamination with crack tip speeds around ∼5000 m/s, while the experimental crack speeds were measured as sub-Rayleigh speeds reaching ∼1000 m/s. When a crack tip definition based on the crack tip opening is introduced in the simulations, crack tip speeds in the range of 490–1500 m/s are measured which are within the range of experimental speeds, suggesting that the sliding mode might be physically hidden in the experiments. The potential use of delamination crack tip speeds as a benchmark for refining numerical simulations is demonstrated by increasing the effective interface toughness leading to a decrease in crack tip speeds with no noticeable effect on the global responses.

Vertical Alar Lengthening technique in correcting short noses

BackgroundIt is crucial that the nose length must be compatible with the face in order to obtain beautiful results that suits the face. Shorter and upturned noses appear as if the tip of the nose is cut from the front and gives a piggy appearance to the patient's face. ObjectiveThe aim of this study is to obtain longer noses with increased tip definition by effectively lengthening the medial and lateral crura's in patients with short nose and Asian noses. Materials and methodsVertical Alar Lengthening (VAL) technique was applied to 17 revision and 12 primary Asian noses. VAL technique consists of three steps. In the first step, the medial crus were lengthened by stealing from the lateral crus. Later, a lateral crural extension graft was applied to the shortened lateral crus, and the lateral crus was lengthened and sutured to the medial crus. In the final stage, a subdomal graft was placed and supported in the space formed underneath the alar tip between the mucosa and the new dome. They were followed in average 12 months (between 6 and 18 months). ResultsVAL technique was applied to 17 revision and 12 primer Asian noses. Suggested surgical technique move the tip forward and downward reduced its cephalic rotation and lengthened the nose. Targeted tip point, rotation and projection results were achieved in all patients. All patients had satisfactory esthetic results. ConclusionsIn revision cases and short nose deformities in Asian noses, the nasal tip point was extended forward and downward with the VAL technique, reducing its rotation and lengthening the nose.

Intradermal Hyaluronidase: The Answer to Treatment in Softening a Fibrous Thick Supratip Skin in Rhinoplasty?

ABSTRACT
 It is a common goal for rhinoplastic surgeons to make the best-looking tip with proper projection, maintaining the tip lobule appearance with a supratip break. (Figure 1) However, a fibrous thick skin with fullness may not achieve the ideal tip. It is one of the nuisances in rhinoplasty that makes tip definition surgery difficult. The supratip area remains firm and convex causing a wide bulbous feature of the tip. Several techniques have been introduced with good results however some may still result in supratip fullness because of the firm fibrous nature of thick skin.1-3 Hyaluronidase is an enzyme that depolymerizes hyaluronic acid which is present in the epithelium.4 The use of intradermal hyaluronidase for thick skin was discovered by the junior author (JMP) in one of his rhinoplasties when he injected hyaluronidase in a nose with fillers containing hyaluronic acid. The fillers not only instantly dissolved but the skin also softened, so he tried injecting intradermally in his subsequent rhinoplasties on non-filler noses with fibrous thick skin and indeed found the same effect of softening of the fibrous supratip skin. We here describe the technique used in this preliminary clinical series.
 METHODS
 A vial of 1,500 I.U. of hyaluronidase (Liporase, Skin Lab Medical, Essex, UK) is mixed with 1.0 ml of Normal Saline Solution (NSS) and 0.1 - 0.2ml (150u – 300u) is aspirated and may be diluted with 0.8ml of PNSS in a 1 cc tuberculin syringe or given as concentrated dose. Intradermal injection into fibrous thick skin can be performed intraoperatively before incision or after closure when defatting and tip grafts are put in place but still with supratip fullness. The areas to be injected are the supratip and its sides. (Figure 2).
 A disposable hypodermic needle gauge 30 is used to inject intradermally or subdermally in minute amounts until blanching is noted. These injections are given at equally random spacing. Immediately after injection, finger pressure massage is applied at the supratip area for 1-3 minutes to soften the skin and allow redraping of the skin and soft tissue envelope (SSTE).

Controlling Supratip Break and Tip Rotation and Projection with Preservation of the Pitanguy Ligament.

In this article, the author describes a new closed rhinoplasty technique in which the Pitanguy ligament was protected, ultimately resulting in better supratip break, tip projection, and tip rotation. Based on the inclusion and exclusion criteria, the records of 156 patients who underwent surgery with this "Pitanguy ligament protection and suturing" technique were evaluated retrospectively. In this novel technique, the Pitanguy ligament was dissected from the proximal and distal points with scissors in the lower third, and it was left intact. There was no need for revision operations in any patient. Twelve months after surgery, the Rhinoplasty Outcome Evaluation scores ranged between 80 and 100 points. The median score was 86.5 points. Patient satisfaction was excellent in 90% of the included cases. Protection of the Pitanguy ligament and attachment of this ligament to the nasal tip create better tip definition and generate several aesthetic and functional advantages. Therapeutic, IV.

Skin Contour Sutures in Rhinoplasty.

The skin-soft tissue envelope (STE) is a critical component of rhinoplasty and can have a significant impact on the final result. Skin contour sutures (SCSs) can be used to prevent potential complications related to skin detachment and to improve rhinoplasty results. The aim of this study was to assess the efficiency of SCSs for nasal skin approximation. SCSs involve the use of external sutures to stabilize the STE flap based on the principle that the pressure of the sutures helps to approximate the STE to the underlying nasal skeleton. The first study group demonstrated the utilization of SCSs in 459 consecutive rhinoplasty cases between December 2016 and April 2022 which were retrospectively reviewed. The second study group consisted of 30 patients with thick skin who had insertion of SCSs with ultrasonic evaluation both preoperatively and postoperatively. The average postoperative follow-up period in the first study group was 41 months (range, 12-64 months). Any suture site that was visible after removal of the suture disappeared completely after 6 weeks in most patients. No complications were reported. In the second group the ultrasound data indicated that STE healing was faster as its thickness returns to its preoperative state earlier in the healing process when SCSs were used. SCSs appear to help to decrease severe nasal edema, hematomas, loss of tip definition, fibrosis, and pollybeak deformity, thereby improving the results and predictability of rhinoplasty surgery.

Extended Lateral Crural Overlay for Lateral Crural Tensioning.

An extended lateral crural overlay with substantial overlapping of the two cartilaginous edges combined with fixation of the lower lateral cartilages (LLC) to a septal extension graft is an efficient technique for tensioning and flattening the lateral crura of the LLC. This technique can be used to improve tip definition and to create a smooth and strong transition between tip lobule and alar lobule without producing a tendency for over projection of the nasal tip.

Fine-Tuning of the Supratip in Rhinoplasty: An External Approach.

Supratip deformity, also known as the pollybeak deformity, accounts for one of the most common iatrogenic deformities requiring revision surgery in rhinoplasty. We aimed to present a novel technique to prevent supratip deformity and increase the tip definition, especially in patients with thick skin. A total of eighty-three patients were included in the study. In control group, thirty-three consecutive patients with thick skin underwent structured primary rhinoplasty without any additional maneuvers. In study group, thirty-one consecutive patients with thick skin underwent the same operation with an additional "External supratip suture (ESS)." Nineteen patients with moderate skin were also operated using the ESS to accentuate the supratip break and control the soft tissue response. Patients' supratip regions were analyzed with reference to a tangent line from the tip defining point to the nasion. Two independent blinded plastic surgeons rated the supratip aesthetics on a 5-point scale. The ESS maneuver had better results in the supratip region according to the two parameters which were statistically significant (p < 0.05). No ischemic complications were observed. This simple and reliable external approach is a powerful maneuver which can be an effective technique not only in patients with thick skin, but also in moderate skin patients who requires better supratip definition. It enables surgeon to reduce the nasal volume efficiently in patients with noncompliant skin by controlling skin redraping by adhering to Auersvald's hemostatic net principles. We believe that this approach will find a place in the armamentarium of rhinosurgeons. 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.

Frequency, Indications and Intraoperative Dynamics of Repositioning of the Lateral Crura of the Lower Lateral Cartilage: A 35-Year Experience.

Lower lateral cartilage repositioning (LLCR) is an effective technique that places the lateral crus in a newly created caudal pocket, and is utilized for a variety of indications including cephalic malposition, alar asymmetries and tip rotation/projection alteration. However, there is a relative sparsity in the literature regarding this procedure and the dynamic changes that it produces. In this study, we report our experience with LLCR in regard to its indications and related interplays. Data from our institution were collected from the most recent 100 primary rhinoplasties, most recent 100 secondary rhinoplasties and all LLCRs performed. For each LLCR, patient demographics and concurrent surgical techniques were compiled. A descriptive analysis was performed for all cohorts, while Fischer's exact test was performed to compare the associations of categorical data for the respective sample sizes of the primary and secondary rhinoplasty cohorts. Overall, 127 patients underwent LLCR, with eleven (11%) LLCRs in the primary rhinoplasty cohort and twelve (12%) LLCRs in the secondary rhinoplasty cohort. The most common indication for LLCR was cephalic malposition, followed by over-projection and asymmetry of the lower lateral cartilages. Intraoperative observation of dynamic changes included invariable cephalic rotation of the tip, ability to precisely control the tip projection, drastic narrowing of the domal arch often minimizing the need for the transdomal suture, alar repositioning caudally, correction of alar retraction and more elegant tip definition. However, the external valve lost its strength on majority of LLCR patients, which required almost routine use of Gunter lateral crus strut. LLCR is a powerful and versatile tool that can be utilized in either primary or secondary rhinoplasty. Its transposition results in cephalic rotation of the tip, narrowing of the domal arch, caudal reposition of the alar rim and superior tip definition. 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 Onlay Rotated Flap (ORF): An Original Technique for Nasal Tip Plasty.

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. 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 12months. 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. 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 < 0.05). The ORF technique is another alternative for achieving adequate nasal tip definition and projection and has many advantages and very successful postoperative results. The alar retraction was not encountered in our technique and this is the superior aspect of our technique over similar methods described in the literature.

Cephalic lateral crural advancement flap

BackgroundIn lower lateral cartilage (LLC) surgery, cephalic trimming poses risks for the collapse of the internal and external nasal valves, pinched nose, and drooping deformity. The cephalic lateral crural advancement (CLCA) technique presented herein was aimed at using a flap to increase nasal tip rotation and support the lateral crus, in addition to the internal and external nasal valves, by avoiding grafts without performing excision.MethodsThis study included 32 patients (18 female and 14 male) and the follow-up period for patients having undergone primer open rhinoplasty was 12 months. The LLC was elevated from the vestibular skin using the CLCA flap. A cephalic incision was performed without cephalic trimming. Two independent flaps were formed while preserving the scroll ligament complex. The CLCA flap was advanced onto the lower lateral crus while leaving the scroll area intact. The obtained data were analyzed retrospectively.ResultsThe mean age of the patients was 31.6 years (range, 20–51 years). The Rhinoplasty Outcome Examination scores after 12 months varied from 90 to100 points, and 93% of patients reported perfect satisfaction. At a 1-year follow-up, the patients’ nasal patency (visual analogue scale) rose from 4.56±1.53 (out of 10) to 9.0±0.65 (P<0.001).ConclusionsThe CLCA flap led to better nasal tip definition by protecting the scroll area, increasing tip rotation, and supporting the internal and external nasal valves without cephalic excision.

Evaluation of Modified Unilateral Nasoplasty in Patient with Post Operation of Unilateral Labioplasty at Malahayati Hospital Banda Aceh: Cohort Study from 2017 until 2019

Background : Nasal deformity associated with cleft lip has been viewed as one of the most challenging reconstructive problems in rhinoplasty.(1) The common clinical features associated with cleft lip nasal deformity are its lack of symmetry, alar collapse on the affected side, short nasal length, loss of tip definition, obtuse nasal labial angle, and altered columella show among others.(2) The complexity of cleft lip rhinoplasty is demonstrated by the abundance of technique that is available for its correction.(3) In this case we used the technique that modified by Dr. Muhammad Jailani, SpBP-RE in Aceh.Methods: We conducted a retroperspective study involving 139 patients who is done the rhinoplasty unilateral operation at Malahayati Hospital from January 2017 to November 2019. Demographic information was recorded such as ratio between pre – operation and post – operation, gender and age.Results : Our results has shown the result of comparison between cleft nose before rhinoplasty and cleft nose after rhinoplasty is ±0.26 : ±0.58, and the patients who came to the hospital to do the rhinoplasty unilateral surgery are 81% from 139 patients. Woman (61.2%) experience rhinoplasty more dominant compare to man (38.8%), and the highest age average is between 1 years old until 7 years old (71%)Conclusions: Improvement in procedure’s duration and better positioning of both nasal tip and nostril. Expected improvements in terms of aesthetic and functions were observed but further documentations still needed.

Combining Preservation and Structured Rhinoplasty: Septal Extension Grafts and the Interdomal Hanger.

Summary:Preservation rhinoplasty is a new philosophy in the field of rhinoplasty, focusing on preserving and reshaping nasal structures. However, the authors suggest some patients are not good candidates for preservation rhinoplasty. Patients with underprojected noses and thick skin need a septal extension graft for tip support and to achieve maximum tip definition. In this article, we describe a new technique to combine septal extension graft with the preservation of tip ligaments, called interdomal hanger. It allows the surgeon to benefit from increased tip support in rotation and projection. The technique consists of the preservation of the interdomal ligament, which is then stabilized above the septal extension graft working as a suspensory sling. With this technique, the surgeon can mix important steps of preservation rhinoplasty and benefit from the support of the septal extension grafts.

The Modified Sliding Alar Cartilage Flap: A Novel Way to Preserve the Internal Nasal Valve as Illustrated by Three-Dimensional Modeling.

Preservation of the scroll area is essential when performing rhinoplasty to achieve a good functional outcome. This is of particular concern with tip-plasty procedures. The objectives of this study were (1) to describe a novel tip-plasty procedure consisting of sliding the cephalic portion of the alar cartilage beneath its caudal portion to preserve the scroll area and (2) to present the authors' prospective case series, which includes Nasal Obstruction Symptom Evaluation and peak nasal inspiratory flow scores to objectively evaluate functional outcomes. The modified sliding alar cartilage surgical technique is described and illustrated by intraoperative photographs and videos and by three-dimensional modeling software. A prospective study of all patients undergoing tip-plasty with alar reduction by the sliding alar cartilage technique was performed from September of 2016 to December of 2017. Peak nasal inspiratory flow and Nasal Obstruction Symptom Evaluation scores were collected preoperatively and at 1 week and 6 months postoperatively. Twenty-five patients were included in the study. Aesthetic outcomes were good, with no major complications. The average preoperative peak nasal inspiratory flow score was 114 liters/minute (95 percent CI, 108.1321 to 119.8679 liters/minute), whereas the average score at 6 months postoperatively was 115.82 liters/minute (95 percent CI, 106.6241 to 125.0159 liters/minute; p = 0.513). The average preoperative Nasal Obstruction Symptom Evaluation score was 17.2 (95 percent CI, 15.99655 to 18.40345), whereas the average score at 6 months postoperatively was 15.2 (95 percent CI, 13.18131 to 17.21869; p = 0.08353), indicating no significant change. The sliding alar cartilage is a simple technique allowing tip definition while maintaining nasal airway function by preserving the crucial anatomical scroll area. Therapeutic, IV.

The Role of Lateral Crural Turnover Flaps in Enhancing the Supra-alar Crease in Middle Eastern Noses

Background: Middle Eastern noses are characterized bythick sebaceous skin and week alar cartilage, which may leadsto poorly defined nasal tip, depressed tip, poorly defined ala,ill-defined supra-alar crease, and external nasal valve collapse.Aim of Work: Is to investigate the lateral crural turnoverflap technique as a method to enhance the supra-alar creasein those patients, by strengthening the lateral crura of theweek lower lateral cartilage.Material and Methods: The study included 20 MiddleEastern patients, 14 females and 6 males, Age ranging from25-45 years, all patients underwent lateral crural turnoverflaps while doing their open rhinoplasties. We used this flapin our study to strengthen the lateral crura of the week lowerlateral cartilage in Middle Eastern noses, and at the same timeto gain the advantage of having the same effect of doingcephalic trim in these noses, but without excising the cartilage.This turnover flap results in tip definition, tip elevation, andit gives a well-defined supra-alar crease which results in amore alar definition and leads to a more narrowing of thecaudal part of the nose.Results: All of the study patients were satisfied with theaesthetic appearance of their noses postoperative.Conclusion: The turnover alar cartilage flap improves theesthetic appearance of the nasal tip by enhancing the the alarand supra-alar crease definition of Middle Eastern noses.

Postrhinoplasty fibrotic syndrome.

Over the years there have been numerous anecdotal reports of nasal tip enlargement and loss of tip definition post rhinoplasty. Subsequent revisionary procedures not only failed to reduce the tip size but aggravated the problem causing an even larger and less defined nasal tip. The final result was often worse than the preop condition and uncorrectable. Six patients who demonstrated an aggravation of the postop result with subsequent revisionary or secondary surgeries were evaluated to find common causes or circumstances. All patients had 1)worsening of nasal tip result with subsequent procedures, e. g., nasal tip enlargement and/or loss of tip definition with subsequent procedures 2)exhibited substantial postop edema at one or more surgeries and 3)extensive subcutaneous fibrous tissue noted at revisionary procedures. The nasal scenario described is referred to as postrhinoplasty fibrotic syndrome. It is recommended that if revision surgery is necessary by asurgeon, the scale of the surgery should be smaller than that of the primary operation. If yet another revision is necessary that surgery should be of an even smaller scale than the prior surgery. Augmentation rather than reduction rhinoplasty is clearly abetter approach. With the surgical philosophy of smaller and/or less surgery with each revision (should it be necessary) the irreversible condition of postrhinoplasty fibrotic syndrome should be avoidable.

Association of Skin Thickness With Alar Base Reduction in Patients Undergoing Lateral Crural Repositioning and Strut Grafting.

Knowing the operation plan is important for rhinoplasty surgeons to prevent unpredictable results. To investigate the frequency of alar base resection in patients with different skin thickness who underwent lateral crural repositioning and lateral crural strut graft and to evaluate the results in the context of the current literature. This retrospective case series study included 621 patients who underwent primary open septorhinoplasty by the same surgeon between January 1, 2012, and June 30, 2015. From the surgical notes, operation type (lateral crural repositioning [LCrep] with lateral crural strut grafting [LCSG] and with or without alar base resection) and skin type were recorded. Study participants' skin types were determined intraoperatively and divided into 3 groups: (1) thick skin (the tip definition was limited by skin thickness and subcutaneous tissue), (2) thin skin (the tip cartilage was visible and could be observed despite overlying soft tissue and skin), and (3) normal skin (the tip cartilage during the procedure had no effect on the tip definition). The rate of alar base resection according to the type of operation performed and patient skin thickness. Of the 621 patients in the study, 95 (15.3%) were men and 526 (84.7%) were women. Lateral crural repositioning with LCSG was performed in 319 surgical procedures (51.4%), and alar base reduction was performed in 329 (53.0%). The rate of alar base resection differed significantly on the basis of whether LCrep with LCSG was performed (odds ratio [OR], 1.82; 95% CI, 1.32-2.50; P < .001). In patients with thin skin, there was no significant difference in the incidence of alar base resection associated with LCrep with LCSG (OR, 2.034; 95% CI, 0.912-4.539; P = .08). In patients with thick skin, a significant difference in the frequency of alar base resection was associated with the application of LCrep with LCSG (OR, 1.995; 95% CI, 1.228-3.241; P = .005). In patients with normal skin, LCrep with LCSG had no significant association with the frequency of alar base resection (OR, 1.557; 95% CI, 0.930-2.607; P = .09). The necessity of alar base reduction after LCrep with LCSG is greater in patients with thick skin than in patients with thin and normal skin. This study is the first to our knowledge to examine this topic in rhinoplasty. 3.

Commentary on 3D Photogrammetric Analysis of the Nasal Tip Projection and Derotation Based on the Nasal Tip Quadripod Concept.

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.