Nasal tip sutures part I: the evolution

Suture techniques for reshaping the nasal tip have been in use for many decades. However, the past two decades have been the most influential in the advancement of the procedures commonly used today. This report details the origin of the major tip suture techniques and tracks their evolution through the years. The early techniques in tip rhinoplasty share a basic principle: the sacrifice of lateral crus integrity to augment the middle and medial crural cartilage to gain tip projection and height. These techniques often disrupt the support mechanisms of the tip lobule, leading to undesirable postoperative results, including supratip fullness, tip asymmetry, tip drop, and an overoperated appearance. Modern nasal tip surgery is founded on the philosophy that suture placement does not simply secure partially excised sections of alar cartilage; rather it aims to directly reshape and reposition the various nasal tip components. The principal suturing methods available in the repertoire of today's rhinoplasty surgeon are the medial crural suture, the middle crura suture, the interdomal suture, the transdomal suture, the lateral crura suture, the medial crura anchor suture, the tip rotation suture, the medial crura footplate suture, and the lateral crura convexity control suture. This report acknowledges past contributions to nasal tip surgery and looks at the recent evolution of techniques commonly used today.     

The nasal tip: anatomy and aesthetics.

New anatomic observations and expanded aesthetics are presented based on an in-depth analysis of 50 patients undergoing primary open rhinoplasty. The alar cartilages can be conceived of as three crura (medial, middle, and lateral), each composed of two segments, plus distinct intervening junction points of aesthetic importance. The classic four-dot tip aesthetics can be expanded and wrapped around the nasal lobule in a three-dimensional fashion. Three nasal tip angles are easily defined (angle of tip rotation, angle of domal definition, and angle of domal divergence) and can be created surgically.     

The two essential elements for planning tip surgery in primary and secondary rhinoplasty: observations based on review of 100 consecutive patients

Nasal tip surgery has become significantly more complex since the introduction of tip grafting and the many suture designs that followed the resurgence of open rhinoplasty. Independent of the surgeon's technical approach, however, is the need to identify the critical anatomical characteristics that will make nasal tip surgery successful. It is the author's contention that only two such features require mandatory preoperative identification: (1) whether the tip is adequately projecting and (2) whether the alar cartilage lateral crura are orthotopic or cephalically rotated ("malpositioned"). Data were generated from a review of 100 consecutive primary rhinoplasty patients on whom the author had operated. The results indicate that only 33 percent of the entire group had adequate preoperative tip projection and only 54 percent had orthotopic lateral crura (axes toward the lateral canthi). Forty-six percent of the patients had lateral crura that were cephalically rotated (axes toward the medial canthi). Both inadequate tip projection and convex lateral crura were more common among patients with malpositioned lateral crura (78 percent and 61 percent) than in patients with orthotopic lateral crura (57 percent and 20 percent, respectively). Tip projection can be reliably assessed by the relationship of the tip lobule to the septal angle. Malposition is characterized by abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities, and associated external valvular incompetence. The data suggest that the surgeon treating the average spectrum of primary rhinoplasty patients will see a majority (61 percent) who need increased tip support and a significant number (46 percent) with an anatomical variant (alar cartilage malposition) that places these patients at special risk for postoperative functional impairment. Correction of external valvular incompetence doubles nasal airflow in most patients. As few as 23 percent of primary rhinoplasty patients (the number with orthotopic, projecting alar cartilages in this series) may be proper candidates for reduction-only tip procedures. When tip projection and lateral crural orientation are accurately determined before surgery, nasal tip surgery can proceed successfully and secondary deformities can be avoided.     

Nasal tip sutures part II: the interplays

The achievement of consistently superior results in rhinoplasty is rendered difficult in part by a number of complex interplays between the anatomical structures of the nose and the techniques used for their alteration, such as tip sutures. The effects of sutures depend largely on the magnitude of suture tightening, the intrinsic forces on the cartilages, cartilage thickness, and the degree of soft-tissue undermining. The tip complex is perhaps the most intricate of the nasal structures, exhibiting subtle but evident responses to manipulations of the lower lateral cartilages. The three-dimensional effects of nine suture techniques that are frequently used in nasal tip surgical procedures are discussed and illustrated. (1) The medial crura suture approximates the medial crura and strengthens the support of the tip. The suture also has effects that are less conspicuous immediately. There is slight narrowing of the columella, caudal protrusion of the lobule, and minimal caudal rotation of the lateral crura. (2) The middle crura suture approximates the most anterior portion of the medial crura. There is greater strengthening of the tip and some approximation of the domes with this suture. (3) The interdomal suture approximates the domes and can equalize asymmetric domes. However, the entire tip may shift to the short side if there is a significant difference in the heights of the domes because of short lateral and medial crura. (4) Transdomal sutures narrow the domal arch while pulling the lateral crura medially. The net results are increased tip projection, alar rim concavity, and the potential need for an alar rim graft. In addition, depending on suture position, cephalic or caudal rotation of the lateral crura may be observed. (5) The lateral crura suture increases the concavity of the lateral crura, reduces the interdomal distance, and may retract the alar rims. Perhaps the most significant inadvertent results of this suture are caudal rotation of the tip and elongation of the nose. This is important because patients who undergo rhinoplasty would often benefit from cephalic, rather than caudal, rotation of the tip. (6) The medial crura-septal suture not only increases tip projection but also rotates the tip cephalically and retracts the columella. (7) The tip rotation suture shifts the tip cephalad while retracting the columella. (8) The medial crura footplate suture approximates the footplates, narrows the columella base, and improves undesirable nostril shape. (9) The lateral crura convexity control suture alters the degree of convexity of the lateral crura. The nuances of these sutures and their multiplanar effects on the nasal tip are discussed.     

Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty

Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain, but frequently the alar cartilages are missing--unilaterally, bilaterally, completely, or incompletely--with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised, or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columellar retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance, or malposition have been noted. Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear, and rib cartilage, fixed to the residual medial crura and/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair. Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to the surgeon's advantage. A rigidly supported framework with a nasal shape can mold a covering forehead flap or the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal. Anatomic alar cartilage reconstructions were used in eight reconstructive and eight secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized.     

Open rhinoplasty without skin-columella incision

For the last 4 years, the author has been using the open lower cartilaginous vault rhinoplasty, making an external cutaneous incision on the columella. After observing the improved results in patients with nasal tip, lateral crura, and medial crura difficulties, the author widely recommends the use of this procedure in selected patients. In addition to multiple advantages which have been reported useful in open-tip rhinoplasty in the past, the author has contributed two additional advantages: that it avoids scarring columella skin and that it can be extended to cope with defects of the entire lower cartilaginous vault. Disadvantages are some residual edema in some patients over a 6-months period and prolongation of operating time.     

The Goldman tip in secondary rhinoplasty

The ingenious division and suture of the mesial crura of the lower lateral cartilages devised by Goldman has found little utilization in recent years, even by surgeons familiar and experienced with this procedure. However, in secondary rhinoplasty, many of the disadvantages inherent in the Goldman tip can be turned to the surgeon's advantage and used to correct nasal tip defects which might otherwise prove refractory to treatment. Cartilage deficit, tip asymmetry, unacceptable bifidity, excessive tip elevation, hanging columella, and insufficient bulk are readily corrected with the Goldman tip and variations on its basic theme. This report covers the authors' 20-year experience with the Goldman tip, including a recent increase in the utilization of this procedure for secondary rhinoplasty.     

Extended incision in open-approach rhinoplasty for asians

The purpose of this study was to introduce an extended incision in open-approach rhinoplasty for obtaining greater satisfaction in aesthetic rhinoplasty for Asians. This incision is the same as for the usual open rhinoplasty incision, but it is extended along the caudal border of the footplates of the medial crura onto the floor of the nasal vestibule to access the footplates of the medial crura more easily. This simple extended incision enabled the authors to achieve further tip projection because the pressure of the skin flap on the tip was reduced. By approximating the lateral curves of the medial crural footplates, the width and the length of the columella were narrowed and lengthened, respectively. The columella was also advanced caudally; thus, the shape of the nostrils could also be elongated. In addition, a cartilage graft or an implant insertion for alar base augmentation could be performed through this extended incision without an additional incision. Another advantage was that in correction of caudal septal deviation, displaced septal cartilage could be repositioned by suturing to the periosteum or soft tissue around the anterior nasal spine without drilling into it through an intraoral incision. Fifty-one consecutive patients who underwent this extended open-approach rhinoplasty between August of 1999 and September of 2000 were included in this study. A total of 40 patients had an adequate follow-up time of over 6 months. Patient satisfaction and postoperative complications were recorded. The majority of the patients (35 of 40) were satisfied with the results of the procedure. Two patients had complications of nostril-scar contracture requiring close follow-up. There were no cases of implant extrusion, displacement, or infection. No patients experienced transcolumellar or extended-incision scarring. Although further studies and longer follow-up are needed to determine the value of this incision, the authors believe that the addition of the extended incision in open-approach rhinoplasty is safe and reliable for effecting better results for Asians.     

Four common anatomic variants that predispose to unfavorable rhinoplasty results: a study based on 150 consecutive secondary rhinoplasties

A retrospective study was conducted of 150 consecutive secondary rhinoplasty patients operated on by the author before February of 1999, to test the hypothesis that four anatomic variants (low radix/low dorsum, narrow middle vault, inadequate tip projection, and alar cartilage malposition) strongly predispose to unfavorable rhinoplasty results. The incidences of each variant were compared with those in 50 consecutive primary rhinoplasty patients. Photographs before any surgery were available in 61 percent of the secondary patients; diagnosis in the remaining individuals was made from operative reports, physical diagnosis, or patient history. Low radix/low dorsum was present in 93 percent of the secondary patients and 32 percent of the primary patients; narrow middle vault was present in 87 percent of the secondary patients and 38 percent of the primary patients; inadequate tip projection was present in 80 percent of the secondary patients and 31 percent of the primary patients; and alar cartilage malposition was present in 42 percent of the secondary patients and 18 percent of the primary patients. In the 150-patient secondary group, the most common combination was the triad of low radix, narrow middle vault, and inadequate tip projection (40 percent of patients). The second largest group (27 percent) had shared all four anatomic points before their primary rhinoplasties. Seventy-eight percent of the secondary patients had three or all four anatomic variants in some combination; each secondary patient had at least one of the four traits; 99 percent had two or more. Seventy-eight percent of the primary patients had at least two variants, and 58 percent had three or more. Twenty-two percent of the primary patients had none of the variants and therefore would presumably not be predisposed to unfavorable results following traditional reduction rhinoplasty. This study supports the contention that four common anatomic variants, if unrecognized, are strongly associated with unfavorable results following primary rhinoplasty. It is important for all surgeons performing rhinoplasty to recognize these anatomic variants to avoid the unsatisfactory functional and aesthetic sequelae that they may produce by making their correction a deliberate part of each preoperative surgical plan.     

The true hanging columella: simplified diagnosis and treatment using a modified direct approach

An imbalance between the alar rim and the columella border can be a disturbing aesthetic deformity. If the cause is a pseudohanging columella, the therapy should be directed to the alar rims. When the deformity is a true hanging columella with unusually wide medial crural cartilages, balance can be restored by excising a C-shaped crescent of cartilage from the cranial border of the medial crura of the alar cartilages in a direct approach. This condition was present in approximately 15 percent of the patients reviewed. The treatment of a true hanging columella adds a subtle beneficial enhancement to the results of a rhinoplasty. The authors describe a simplified diagnostic method and present their experience treating the true hanging columella using a modified "direct approach" through a closed endonasal rhinoplasty.     

The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty

One of the most common problems affecting both the primary and secondary rhinoplasty patient is deformity of the alar rim. Typically, this deformity is caused by congenital malpositioning, hypoplasia, or surgical weakening of the lateral crura, with the potential for both functional and aesthetic ramifications. Successful correction and prevention of alar rim deformities requires precise preoperative diagnosis and planning. Multiple techniques of varying complexity have been described to treat this common and challenging problem.Over the past 6 years (1994 through 2000), the authors have employed a simple technique in 123 patients for alar retraction that involves the nonanatomic insertion of an autogenous cartilage buttress into an alar-vestibular pocket. Among the 53 patients who underwent primary rhinoplasty in this study, 91 percent experienced correction or prevention of alar notching or collapse. However, correction was achieved for only 73 percent of the patients who underwent secondary rhinoplasty; many of whom had alar retraction secondary to scarring or lining loss. In patients with moderate or significant lining loss or scarring, a lateral crural strut graft is recommended. The alar contour graft provides the foundation in the patient undergoing primary or secondary rhinoplasty for the reestablishment of a normally functioning external nasal valve and an aesthetically pleasing alar contour. This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indications and the surgical technique for the alar contour graft.     

Lengthening the nose with a tongue-and-groove technique

Lengthening the short nose is often a major task. The ability to maintain proper alignment between the nasal base and dorsum may prove difficult without sacrificing the suppleness of the former. In this article, the authors introduce a technique of nose lengthening that ensures alignment of the tip with the rest of the nose yet avoids tip rigidity, unless a significant increase in tip projection is also planned. Two spreader grafts are placed, one on either side of the septum, and are extended beyond the caudal septal angle proportional to the planned nasal lengthening. A columella strut, with the cephalocaudal dimension equaling the combination of the width of the existing medial crura plus the amount of planned nasal lengthening, is placed between the medial crura in continuity with the caudal septum and is fixed to the medial crura using 5-0 clear nylon or polydioxanone suture. If additional projection beyond what is achievable by mere placement of a columella strut is required, the strut is fixed to the spreader grafts in a more projected position. Otherwise, the columella strut is simply positioned between the extensions of the spreader grafts. It is necessary to mobilize the lower lateral cartilages to prevent excessive columella show. This procedure has been performed on 23 patients over the past 12.5 years, with 20 patients enjoying good-to-excellent results. The advantages of this technique include its predictability and reproducibility, and the ability to elongate the nose with a mobile nasal base that is in line with the rest of the nose. If suture fixation is used to gain more projection, the technique proves dependable but the nose will become more rigid than is optimal. The requirement of three pieces of properly shaped septal cartilage, which might not be available when a secondary rhinoplasty is performed, is the major disadvantage of this operation. Furthermore, the procedure is, to some degree, labor-intensive.     

A new technique in nasal-tip reduction surgery.

This article presents a technique for the reduction of the overprojected nasal tip with a proportional reduction of the nostril-margin circumference. To achieve these reductions, a modified open rhinoplasty technique is used, which is unique in that it involves the total transection of the columella through the medial crura of the alar cartilage. The alar cartilage is raised with the flap.The technique was first developed and introduced by the senior author (R.A.S.) 25 years ago and has since been refined through the execution of several thousand rhinoplasties. The results continue to be consistent and pleasing from both the patients' and the surgeon's points of view.     

An algorithm for correcting the asymmetrical nose

Correction of the twisted nose forms the watershed of aesthetic and reconstructive rhinoplasty, combining and requiring elements of each. Faced with this formidable task, surgeons have fashioned a great number of techniques, many of which rely for their cardinal step on cutting, fracturing, or scoring the dorsal septal strut. While highly satisfactory results have been achieved with these methods, the constant problem of loss of dorsal support remains. It is possible in many cases to align the crooked nose while leaving intact osteocartilaginous dorsal support. The key determination to be made is the preoperative aesthetic balance, itself a product of bridge height and nasal base size. Once nasal aesthetics have been established, the algorithm proceeds as follows: First, resect the dorsum in the area of the deviation until the dorsal septal edge is sufficiently close to the midline to allow camouflage of the remaining asymmetry. Second, perform the septal resection necessary for the airway, preserving a continuous dorsal strut. Third, augment according to (a) the support needed for the dorsum, middle vault, columella, and tip and (b) the aesthetic balance that must be restored.     

Rhinoplasty and endoscopic surgery for functional and inflammatory nasal/sinus disorders

The rhinoplastic surgeon when faced with nasal sinusitis has traditionally delayed aesthetic treatment of the nose, referring the patient to the ear, nose, and throat consultant until complete resolution of the inflammatory condition. Often, under such a scenario, the patient found the ear, nose, and throat procedure to be a traumatic experience that discouraged further surgery of an aesthetic nature. The advent of functional endoscopic sinus surgery has significantly modified the management of paranasal sinus disorders. This minimally invasive, sophisticated procedure can easily be combined with rhinoplasty. More recently, an endoscopic approach has been advocated for management of the septum and lower/middle turbinates. The authors call this functional endoscopic nasal surgery. Functional endoscopic nasal surgery allows a clearer view of the operative field (septum and turbinates), a more accurate correction of nasal obstruction, and better control of bleeding. Thus, endoscopic techniques permit the treatment of functional and inflammatory nasal disorders in a single stage, along with aesthetic improvement. Only the patient with severe sinusitis is unsuitable for combined therapy. The authors present their experience based on 72 consecutive cases of combined functional endoscopic sinus surgery/functional endoscopic nasal surgery with aesthetic rhinoplasty. Complications were minimal and functional failures were limited to 4 percent, whereas aesthetic outcomes remained uncompromised.     

Hispanic rhinoplasty in the United States,with emphasis on the Mexican American nose

Because an increasing number of Hispanic patients are seeking nasal surgical treatment, a critical analysis of 25 consecutive Hispanic rhinoplasties was performed. After a review of the patient data and preoperative photographs, a new classification was developed, based on the type of deformity rather than geographical origins (as previously used). A treatment paradigm is offered for each type of deformity. Type I involves a high radix, a high dorsum, and a nearly normal tip and is often referred to as a Castilian nose. Treatment consists of a closed functional reduction rhinoplasty, with dorsal reduction and minor tip changes. Type II involves a low radix, a normal dorsum, and a dependent tip and is a new designation. Treatment consists of a finesse rhinoplasty with a radix graft, minimal dorsal changes, use of a columellar strut for support, and open tip suturing. Type III involves a broad base, thick skin, and a wide tip deformity, with its worst expression in the mestizo nose. Treatment consists of a balanced rhinoplasty with minimal dorsal alteration but maximal lobular reduction and an open-structure tip graft. The following conclusions with respect to Hispanic rhinoplasty in the United States are important: (1) an enormous anatomical diversity of deformities is present, in contrast to Asian and black noses; (2) three distinct types of deformities have been identified, each of which requires a different surgical approach; (3) a wide variety of surgical techniques are necessary, in contrast to other ethnic noses; (4) conservative dorsal reduction is essential for type II and III noses; and (5) limitations imposed by the skin envelope are far less than presupposed, and the results are better than generally recognized. As the Hispanic population grows and becomes more prosperous, plastic surgeons in the United States can expect to encounter an increasing number of Hispanic patients requesting rhinoplasty.     

The "iatrogenic-hanging columella": preserving columellar contour after tip retroprojection

This article discusses a method for treating the ultraprojecting tip by the resection of columellar skin in open rhinoplasty. Lack of postoperative contraction of columellar skin and soft tissue may result in an "iatrogenic-hanging columella." Columellar skin resection frequently produces its own deformities because of a discrepancy in the width of the columellar base side and the infralobular flap side. The ultraprojecting tip was present in 56 of 660 consecutive rhinoplasty patients (8 percent) over 8 years (1991 to 1998). Of these 56 patients, 48 underwent partial resection of the infralobular skin flap. Of these 48 patients, eight (17 percent) required secondary skin revision of the columellar resection area. The technique was then modified since 1998. Over 2 years, 13 of 129 consecutive rhinoplasty patients (10 percent) were judged to have an ultraprojecting tip. Of these, eight patients were treated with a modification in the technique by resecting skin on the posterior columellar base. No resection areas were revised in the second series. Of the 789 patients in both series, 647 (82 percent) underwent primary rhinoplasties, 126 (16 percent) had secondary rhinoplasties, and 16 (2 percent) had tertiary rhinoplasties. The treatment of excess columella skin adds a subtle aesthetic improvement to the postoperative nasal contour. By resecting skin on the posterior columellar base or the posterior columellar base and, rarely, the anterior flap, an iatrogenic-hanging columella can be avoided.     

Dynamics of rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the result revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on front view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.     

鼻中隔软骨联合耳软骨雕塑鼻尖在假体隆鼻中应用效果

目的:探讨假体隆鼻时应用鼻中隔软骨联合耳软骨雕塑鼻尖的临床效果。方法:选取2013年1月至2014年3月在我院进行隆鼻术的患者98例,按照随机数表法将其分成对照组和实验组,每组49人。对照组患者采用单纯的假体隆鼻,实验组患者采用假体隆鼻并使用鼻中隔软骨联合耳软骨雕塑鼻尖。评价手术的满意程度及手术前后患者的鼻长、鼻尖高度、鼻尖角的变化情况。结果:实验组患者的治疗满意度为91.84%,明显高于对照组的40.82%,差异具有统计学意义(P0.05)。实验组患者术后鼻长、鼻尖高度、鼻尖角均优于手术前(P0.05),且显著优于对照组,差异均有统计学意义(P0.05)。结论:应用鼻中隔软骨联合耳软骨雕塑鼻尖在假体隆鼻中具有良好的应用效果,满意度较高,值得在临床上推广使用。     

Dynamics in rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the results revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on frontal view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.