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Patel et al. Plast Aesthet Res 2024;11:20 https://dx.doi.org/10.20517/2347-9264.2024.17 Page 7 of 14

[23]
the nose must be released to give the greatest degree of freedom in the cartilage . This includes
ligamentous attachments at the piriform and the medial crural insertion at the columella base. Release of the
scroll ligaments may also be necessary to separate the lower lateral cartilage from the upper lateral cartilage.
Beyond setting the nasal domes and the medial crura to the midline septum or septal extension graft, it is
important to address the lower lateral cartilage position and alar margin. Lengthening the nasal dorsum
without addressing the nasal sidewalls of the nose can cause distortion of the alar-columellar relationship, a
retracted alar margin, and increased columellar show. Alar support and positioning should be considered
prior to setting the nasal domes to the appropriate position.

When the lower lateral cartilage is mobilized caudally, gaps between the upper and lower lateral cartilage
can result. While adequate fixation of the domes to the septum will prevent retraction, postoperative
contracture can cause rotation of the domes with loss of nasal length. This resembles the outcome observed
in aggressive cephalic resection of the lower lateral cartilage in attempts to refine and narrow the nasal tip.
In patients who require a combination of tip refinement and lengthening of the nose, cephalic reduction of
the lower lateral cartilage should be done cautiously. When a gap between the upper and lower lateral
cartilages exists, bilateral interposition cartilage grafts can be placed between the upper and lower lateral
cartilages, resulting in caudal displacement and derotation of the nasal tip . This can be particularly useful
[4]
when the nasal sidewalls are retracted or shortened along with the dorsum. These grafts can be fashioned
from cartilage, or in some instances, where mucosal deficits exist, a composite auricular cartilage graft can
be used.

Our preference is complete repositioning with the use of lateral crural strut grafts [Figure 7] [24-26] . While this
technique is commonly employed in the setting of cephalically malpositioned lower lateral crura, it can be
useful in the foreshortened nose. Hydrodissection with local anesthetic can facilitate the elevation of the
thin vestibular mucosa off the underside of the lower lateral cartilage, which enables complete mobilization
of the alar sidewall. Placement of a lateral crural strut under this cartilage and into a precise pocket that is
inferiorly oriented allows for repositioning of the cartilage. If the cartilage is atrophic or unusable, it is
discarded. The most critical portion to conserve is the tip, as it is the most challenging to reconstruct
[Figure 8]. Placement in precise pockets is critical to ensure elongation, and thus, suture stabilization is
[25]
useful [Figure 9]. We have reported good aesthetic and functional outcomes with this technique .
Examples of patients who underwent this type of nasal lengthening are shown in Figures 10-16.

Anchoring of the domes to the newly positioned nasal septum or extension graft can be accomplished with
a variety of methods. A tongue-in-groove technique with fixation of the medial crura to the midline
cartilage structures of the nose will set the nasal tip rotation and projection . This has been shown to be a
[27]
powerful and reproducible technique in elongating the nose while aligning the tip with the rest of the nose
and minimizing tip rigidity . Alternatively, the apex of the domes can be sutured to a septal extension graft
[28]
at the desired location. Placement of an alar spanning suture also enables a means for approximating the
[29]
domes while stabilizing the lateral crural position and eliminating dead space in the supratip .
Despite the above maneuvers, it is possible that the desired nasal length is not achieved. In this scenario, the
cautious use of shield-type tip grafting can add volume to the infratip and lower the tip defining points [30,31] .
These grafts are placed such that the superior wider portion of the graft sits at the tip defining points. They
can be sutured in place at the nasal domes. Grafts can be multilayered to provide additional derotation and
lengthening as needed. The use of tip grafting can also help with the projection of the nasal tip, which may
be necessary for an over-rotated and shortened nose. However, we strongly recommend avoiding tip grafts
as a maneuver for nasal lengthening for two reasons. First, in patients with thin skin (and even in those