Mark and connect three dots in an inverted V shape on the narrowest area of the columella and make an incision with the #11 blade (Fig. 2A). Extend the markings to the left and right corners at the bottom of the inverted V and then mark3 mm medially from the lateral side of the columella for the lateral columellar incision (Fig. 2B). Note that the caudal margin of the lower lateral cartilage (LLC) is located more in the posterior and cephalic directions on the lateral side. Incise the vestibular skin along the caudal margin using blade #15 along the outline. The marginal incision should be made close to the caudal margin of the LLC in order to avoid postoperative hypertrophic scarring (Fig. 2C) [1]. A lateral columellar incision is made along the medial crus of the LLC from the incision line marked on the lateral side of the columella (Fig. 2D). Be careful not to cut the medial crural cartilage. The lateral columellar incision is connected to the previously performed marginal incision. Two methods are available for mid-columellar incision according to the order of the procedures.

1) Insert converse or iris scissors, pass through both lateral columellar incisions, and pass them through to the opposite side as guide scissors. An incision is made on the mid-columella skin using a #11 or #15 blade, or converse scissors, and connected to the lateral incision. For a stable connection, fix the tip with the thumb or index finger of the opposite hand, or hook the Cottle elevator and slightly pull it upward to fix the columella area. The columellar flap is carefully elevated over the medial crus through the supra-perichondrial plane.

2) Starting from the inverted V region in the middle, incisions are made to the left and right corners at the bottom to the extent of the lateral columella area. The columellar flap is carefully elevated along the medial crus from the lateral region through the supra-perichondrial plane. Perform a relatively deep incision because there is no cartilage in the center of the inverted V region [2] to ensure that the skin edge is not beveled at the corner to achieve a clean margin. Likewise, this incision should be performed while being fixed with the opposite finger or instrument.

While elevating the columellar flap to the infratip lobule, dissect toward the lateral crus after identifying the intermediate crus and dome of the LLC. Using a two-prong retractor, the assistant counter-tracts the flap upward. While performing supra-perichondrial dissection, the lateral crus is dissected along the previously made marginal incision [3]. During this process, 3-point traction around the LLC helps with the dissection [4]. Afterward, the soft tissue on the dorsum is elevated to minimize bleeding by dissecting below the superficial musculoaponeurotic system (SMAS) layer (Fig. 3A). At this time, the method of pushing the soft tissue in the cephalic direction using a cotton swab or gauze and hanging the retractor under it makes elevation easy without bleeding because the surgical plane below the SMAS layer is avascular. The bony hardness can be felt using a Freer elevator or Joseph elevator (Fig. 3B). The bony area has a slightly rough feeling, whereas the cartilaginous area feels soft. The periosteum is incised with a #15 blade (or Joseph knife) and elevated with a Joseph elevator. When planning for radix augmentation, particularly using alloplastic implants, the dissection pocket should be made according to the size of the implant. Soft tissues should not remain inside the pocket. After creating the pocket, it becomes difficult to remove the remaining tissue. Both sides should be elevated symmetrically so as not to tilt to one side. Otherwise, implant mobility can occur later [5].

The anterior septal angle could be the landmark for the open dorsal approach in rhinoseptoplasty [6]. Therefore, the membranous septum between the dome of the LLC is first dissected, and the caudal septum is dissected and exposed through the anterior septal angle. The sub-perichondrial plane can be easily found by dissecting the exposed caudal margin of the septum cartilage while rubbing it with scissors (Fig. 3C). Dissection between the septal cartilage and mucoperichondrium with the Freer elevator (or converse scissors) is done to incise the connected area between the septum and the upper lateral cartilage (ULC) from bottom to top. To harvest the septal cartilage, leave the L-strut, mark the cartilage to be excised, and harvest the central part using a #15 blade, D-knife, or Freer elevator (Fig. 3D) [7]. Partial resection of the connected area between the ULC and nasal septum enables harvesting in a wider field of view. Resection is performed to protect the contralateral septal mucosa using a long nasal speculum.

Infiltrative injection of local anesthesia is performed before the suture, and then the vestibular skin below the LLC is dissected. A horizontal mattress suture is applied to the dome and lobule of the middle crura on both sides (Fig. 6A). Depending on the case, it may be performed on only one side. It is cosmetically preferable that the caudal portion is slightly longer than the cephalic portion of the transverse axis passing through the LLC. It is better to make the knot on the medial side rather than on the lateral side. If the knot is too tight, the tip becomes too sharp and unnatural; therefore, it is advisable to consider the angle and shape of a normal dome and tie it with appropriate strength. Because Koreans often have a weak LLC, tip asymmetry may occur following transdomal sutures. In addition, due to the thick skin, it is often difficult to improve the tip definition using the suture technique alone. Therefore, before the procedure, the cartilage strength and skin thickness should be well evaluated to decide whether to perform the suture technique [14]. Furthermore, since convexity can occur after transdomal suture, it is sometimes necessary to perform cephalic resection of LLC additionally from an esthetic point of view [15].

Interdomal suture binds to both domes of the LLC after transdomal suture: this can provide symmetry and stability to the LLC. Interdomal suture can be performed after transdomal suture or alone [16]. The knot is made to the cephalic end of the middle crura just behind the dome (Fig. 6B). If a columellar strut is performed, the needle enters just below the left transdomal suture knot and passes directly above the middle columellar strut. It is then sutured with the same site on the opposite right middle crura, just below the transdomal suture knot. It is usually performed 2–3 mm behind the caudal border of the crura. It is paramount not to suture too tightly to avoid pinching deformity of the tip. Decide the tip width to make it diamond-shaped.

Although easy to perform, onlay graft often become the cause of revision surgery [17]. It can be performed to increase the projection of the nasal tip with multiple stacked onlay grafts (Fig. 7A). In addition, it can smooth the pinching deformity of the nasal tip or protect the skin of the nasal tip from the implant. Generally, it is performed at the end of the entire rhinoseptoplasty procedure. If a shield graft is used, onlay graft can be omitted. The septal cartilage is often used for onlay grafts, and the conchal cartilage can also be performed using natural curvature. Tip onlay grafts often become transparent over time, requiring revision surgery. Hence, the edges should be beveled and trimmed well to avoid postoperative visibility, especially in cases of hard graftings, such as the septal cartilage. In contrast, even in the case of soft graftings, such as the conchal cartilage, the shape of the grafts could be visible on the skin. In particular, this occurs more often if the cartilage supporting the tip is strong, such as in the costal cartilage. In any case, if the skin is thin, the graft is often visible on the skin, and it is often necessary to reinforce the dermis or fascia during revision surgery. It is essential to inform patients of these characteristics preoperatively. For a patient with thick skin, if the width of the implant is wide, the nasal tip can easily be bulbous. For a patient with thin skin, and if the width of the implant is too small, the nasal tip tends to be pinched. Therefore, if the skin is thick, it needs to feel sharp. If the skin is thin, the implant should not be high, but in cases of inevitable augmentation, the implant should be strengthened with fascia or soft tissue. When augmenting the nasal tip with multiple onlay grafts, the implant may move downward over time and cause tip ptosis; therefore, it is critical to fix stacked grafts well with a suture.

Carve a shield-shaped tip graft using harvested septal cartilage. The width of the superior margin should be approximately 6–8 mm, and the margin should be beveled to make it smooth in appearance. After placing the grafts in the correct position by considering the height and angle, four or more places are fixed to the medial crus of the LLC with 5-0 polydioxanone (PDS) (Fig. 7B). After placing the grafts in the correct position while considering the height and angle, the grafts are sutured to the medial crus of the LLC with four to six stitches using 5-0 PDS. To avoid tilting back and cephalic rotation, the back-stop graft could be placed in the rear part of the shield graft [18,19]. Shield grafting is a sophisticated technique that can increase the tip projection in Asians, while the grafts could be palpable in the margin or tilted in many cases due to its hardness. Therefore, ensure that there is not much difference in height between the newly created dome and lateral crus of LLCs.

Separate the perichondrium of the septum and the ULC. After preparing the spreader graft by cutting the cartilage horizontally, place it into the space where the septum and ULC are separated in line with the top of the septum and temporarily fixed with a #26-gauge needle (Fig. 7C). A needle of adequate size (such as 4-0 PDS) facilitates engaging all structures in a single pass (for instance, right ULC, right spreader graft, septum, left spreader graft, left ULC) [20].

Create a pocket for inserting the columellar strut by dissecting the soft tissue between the medial crus and the anterior nasal spine. Before fixing the columellar strut, temporarily place the columellar strut between the separated medial crus and hold it with a #26-gauge needle, and suturing the medial crus and columellar strut on both sides in several places. Then, secure it to the medial crus with several mattress sutures placed through the vestibular skin. Position the columellar strut slightly above the anterior nasal spine without tight sutures as in the floating type (Fig. 7D) [21].

These grafts are designed according to the intended purpose, such as lengthening, projection, and rotation, using the harvested septal cartilage. Before fixing the septal extension graft (SEG), if the caudal septum deviates, it should be corrected first. Otherwise, the tip might be misaligned long-term. If the caudal septum is weak, SEG is applied after strengthening the caudal septum with a spreader graft or batten graft. If the harvested cartilage is large enough, it can be broadly overlapped with the caudal septum to strengthen and extend simultaneously when designing the SEG (Fig. 7E) [22]. It is essential to position the SEG on the midline and fix it firmly with 3–4 sutures on the caudal septum. After pulling both LLCs to the desired position, they are sutured together with the intermediate crus of both LLCs (Fig. 7F). If necessary, the membranous septum and SEG are penetrated and sutured together to secure the SEG. Additional grafting can be performed at a new location of the tip if needed.

According to the esthetic purpose, such as dorsal height or shape, determine the implant thickness and type. The implant is thoroughly disinfected from time to time using betadine solution and saline to minimize the risk of inflammation. While silicone implants can be trimmed using a sterilized razor blade, #15 blade, U-shape knife, or iris scissors (Fig. 8A), various ready-made products are available in terms of height and shape. Therefore, it is advisable to select an appropriate implant and reduce manipulation during surgery as much as possible. In the radix area, ensure that the upper end of the implant is exactly placed at the deepest part of the nasofrontal angle, and no dead space is created. The nasal starting point varies from patient to patient, but the length of the implant is usually adjusted to the height of the eyelashes [23]. If there is a mild hump, the lower surface of the silicone implant is slightly trimmed at the rhinion area to match the height. The implant area corresponding to the tip area is appropriately cut. If the height of the dorsum does not match, additional grafting can be added to the lower surface of the thin side.

If the silicone implant is inserted too superficially into the supra-periosteal plane in the radix area, the silicone implant can be visible and move later. It is beneficial for the pocket size for insertion to be slightly wider than the size of the silicone. Nevertheless, if it is too wide, there is concern about implant movement, and if it is too narrow, an insertion is difficult during the surgery. Therefore, a suitable size is recommended. Even if the pocket size is judged to be adequately adjusted from the top and the bottom, the size of the rhinion, which is in the middle position, is narrower than expected, making implant insertion difficult in many cases. This area should be dissected widely on both sides with a Freer or Joseph elevator. When holding the implant for insertion, it is grabbed at once using a long instrument such as Bayonet or Jung’s forceps (Fig. 8B). After confirming that the end of the instrument is positioned at the end of the radix, percutaneous needling is applied for transient holding, and then the instrument is removed. The forceps are removed while fixing the needle and implant well so that the implant is not removed while removing the instrument. In order to prevent implant movement, it is better to fix the caudal end of the silicone implant on both sides of the ULC. For more secure fixation, it can be suture-fixed with the septum at the anterior septal angle. The caudal end of the silicone places the supratip area, and it should be beveled and relatively low so that the supratip area does not become bulky and is naturally smoothed with the tip area [24].