The tip also needs to be supported so it does not droop back down and also does not get droopy with age. The technique that I'm showing you now is called a tongue-in-groove maneuver. What I'm doing is I'm taking the medial crura of the left lower lateral cartilage, suspending it with a suture or a stitch to the caudal edge of the septum, and then taking a bite of the right medial crura of the lower lateral cartilage and sandwiching it together. This is called a tongue-in-groove technique. Essentially, the groove is the space between the left and the right medial crura of the lower lateral cartilages and the tongue is the caudal edge of the septum.

There's some preparation work that's necessary before this maneuver can be done. The two cartilages have to be separated from each other and rotated into the better position and the caudal edge of the septum has to be exposed. Some of the mucosa from the left and the right side of the septum has to be elevated so that it can shrink-wrap back down without any bleeding or excess. Permanent sutures can be used for this technique, but as I have mentioned before, I do not like anything permanent that's a foreign substance in the nose. I don't like any pieces of plastic, implants, sutures, or anything of that nature inside the nose, because they do have a propensity for infection, even though it may be rare; they can become infected. So you may end up with a beautiful nose job result and several months or several years later, you may end up with a bad infection and have to go fishing out, trying to find a piece of plastic or piece of implant or piece of stitch. So I much prefer absorbable sutures.

What I'm using is a plain gut suture and my assistant is just cutting it there for me. Again, this technique, in this patient, is relevant. This is not a technique that I use in all patients by any means, but in a situation where the tip of the nose needs to be shortened, needs to be rotated, and needs to be suspended, this is a very powerful technique. And it's not something that's commonly used; it's more of an advanced technique in rhinoplasty. These sutures that are placed in a mattress fashion will support the nose in place, but as in any rhinoplasty, the tip initially for the first few weeks to a few months, will be slightly higher than it eventually will be. Over the next several days to several weeks to several months, the tip does settle down into its ultimate position.

Doctor POV: Open Rhinoplasty (Part 7)

An advanced tongue-in-groove technique is demonstrated on a particular patient whose nose tip requires shortening and additional support.