When it comes to rhinoplasty, nose reduction usually comes to mind, however, in recent years, patients with over reduced noses have been applying to us. A nose that is small compared to the patient's face looks worse than slightly large noses. Therefore, shrinked or innate small noses need to be extended to a size that is compatible with the face. We perform a significant number of nose lengthening and enlargement surgeries in our clinic. In nose enlargement surgeries, the skeleton needs to be extended, the mucosa and skin need to sufficiently cover the nose internally and externally. Nose lengthening usually involves more problems than reduction surgeries. With this video presentation, we want to share our methods for nose enlargement and overcoming the problems that arise with professionals.

This presentation will focus on the use of costal cartilage grafts in complex rhinoplasty and the complications that may occur during cartilage harvesting.

Three real surgical cases will be presented using intraoperative videos, demonstrating different complication scenarios encountered during costal cartilage harvest.

Each case will highlight the recognition of the complication, intraoperative decision-making, and surgical management, along with technical considerations for prevention.

Achieving durable nasal tip stabilization remains a central challenge in septorhinoplasty, particularly in patients with weak cartilage support, revision cases, or those requiring precise control of tip projection and rotation. Conventional septal extension grafts and suspension-based techniques often rely on indirect load transfer and lack intrinsic columellar support, which may limit long-term stability and predictability. These limitations highlight the need for a structurally integrated, load-bearing solution that provides direct and sustained support to the nasal tip framework.

This proposal presents the L-Shaped Septocolumellar Extension Graft (LS-SCEG) technique, a refined structural approach that combines the functions of a septal extension graft and a columellar strut into a single, integrated unit. The graft is designed in an L-shaped configuration and secured through multi-point fixation to four critical anatomical landmarks: the caudal septum, the spreader graft–septal junction, the medial crura, and the nasal tip framework. This configuration establishes a direct septocolumellar support column, allowing controlled distribution of mechanical forces across the nasal tip complex rather than reliance on suspension or single-point anchoring mechanisms.

The primary objective of this project is to describe the surgical design principles, fixation strategy, and technical steps of the LS-SCEG technique and to evaluate its effectiveness in providing stable nasal tip support in septorhinoplasty. The technique aims to improve control over nasal tip projection, rotation, and midline alignment while maintaining structural integrity over time. Secondary objectives include assessing the reproducibility of the technique, intraoperative handling characteristics, and early postoperative outcomes related to tip stability and alignment.

By functioning as a load-bearing septocolumellar unit, the LS-SCEG is expected to address key shortcomings of existing techniques, particularly in cases where durable tip support is essential. The anticipated outcome is the establishment of a clearly defined, anatomically grounded technique that offers predictable nasal tip stabilization and expands the surgical options available to rhinoplasty surgeons. This proposal seeks to contribute a distinct conceptual and technical framework to the septorhinoplasty literature, providing a foundation for further clinical evaluation and broader adoption of the technique.

Description: The preservation of the intercrural ligament during open technique rhinoplasty allows its re-fixation of to the medial crural complex, providing a fine tool to control tip rotation and projection in the long term after rhinoplasty, while avoiding rigidity of the tip complex. The author aims to illustrate this technique with a video presentation from multiple rhinoplasty cases with differing tip characteristics.

Outcome objectives: To suggest an effective alternative to nasal tip fixation that is closer to natural anatomy

Background: Septal extension grafting and alar cartilage fixation with rigid tongue-in-groove techniques has been widely used to ascertain long-term preservation of tip rotation and projection. In order to achieve a more natural, flexible but robust tip structure that withstands skin contracture, fixation of the medial crura to the intercrural ligament may be a sound alternative.

Overcoming difficulties in Frontal Sinus Surgery