BACKGROUND: Control of nasal tip position is critical to final rhinoplasty outcomes. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft (SEG). Past work has demonstrated that SEG are better able to preserve tip position. However, there is no quantitative data describing long-term projection and rotation. The purpose of this study was to analyze long-term maintenance of tip projection and rotation following SEG.
METHODS: A retrospective study of adult patients undergoing open rhinoplasty was conducted. Three-dimensional photogrammetric evaluation of nasal tip position was performed. Anthropometric points were analyzed preoperatively and postoperatively. Outcome variables were tip projection, tip rotation, and nasal length.
RESULTS: Twenty patients were included with an average follow-up time of 3.3 years (2.0 - 6.6 years). From postoperative week 1 to 6, there was a statistically significant decrease in rotation (-4.3%, p<0.01). There were no statistically significant decreases in projection, rotation, or nasal length from 6 weeks postoperative to 2 years postoperative, or from 6 weeks postoperative to final follow-up (2.0 - 6.6 years).
CONCLUSIONS: Nasal tip projection and rotation appear to decrease from the immediate postoperative position, likely due to resolving edema. In this study, patients that underwent open rhinoplasty with SEG experienced modest loss of projection and rotation until 6 weeks postoperative, but projection and rotation were maintained from 6 weeks postoperative to 2 years and beyond. This study provides evidence that SEG maintains long-term changes in tip projection and rotation.
METHODS: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Different techniques exist to provide tip support in rhinoplasty. There is little evidence to provide a consensus on the most effective choice.
Evaluating columellar strut graft (CSG) and septal extension grafts (SEG) for their influence on airway function, patient satisfaction and tip support.
A retrospective cohort study was undertaken on 165 adult patients who underwent open rhinoplasty with either a CSG or SEG, from February 2012 to August 2019 in a single tertiary facial-plastic practice in Sydney, Australia. Operations were for both cosmetic and functional indications, and both primary and revision cases were assessed. Airway testing and patient-reported outcomes (PROMs) were performed preoperatively and at least 6 months following the procedure. Photographic tip analysis was taken from approximately 4 and 12-month postoperative photographs.
Nasal peak inspiratory flow (NPIF) and total nasal airway resistance (NAR) were the primary airway functional outcomes. The primary PROMs analysed were a visual analogue scale (VAS) for nasal obstruction and 13-point Likert scale for global cosmesis, the Nose Outcome Symptom Evaluation (NOSE), and the nasal obstruction score. Tip support was determined by the nasolabial angle (NLA) and Simon\'s ratio as assessed by Rhinobase developed by Apaydin et al. on lateral Frankfort plane photographs. Data normalised as an improvement over preoperative baseline, accounting for individual variability.
A total of 165 patients was assessed (35.2 ± 12.9 yrs, 72% female), 100 (61%) of which received SEG. There were similar nasal airway assessments between CSG and SEG groups, with ΔNPIF (20.0 ± 42.1 L/min v 19.9 ± 44.9 L/min, p = 0.983) and Δ \"obstructed\" NAR (-1.13 ± 1.90 v -1.02 ± 4.33 Pa/cm3/s, p = 0.849). Amongst PROMs, a greater cosmetic outcome was seen in the SEG group (7.20 ± 2.97 v 5.69 ± 3.45, p < 0.01) with all other assessments similar between CSG and SEG techniques. Photographic analysis of tip projection showed reduced NLA distortion in the SEG.
While greater patient-perceived cosmesis was seen in patients with a SEG, there were similar airflow and patient-reported nasal function between groups. Photographic analysis of tip projection showed SEG patients additionally benefited from less NLA distortion and greater tip maintenance.