Tip-Oriented Closed Rhinoplasty Built on Septocolumellar Suture and a New Caudal Septal Graft Techniques

1. Introduction: The Importance of the Nasal Tip in Modern Rhinoplasty

In modern rhinoplasty surgery, the paradigm has evolved from merely reducing the bony structure toward positioning the nasal tip as the central anchor of aesthetic balance. The "tip-oriented" surgical philosophy that Prof. Dr. Erdem Tezel has contributed to the literature argues that the nasal tip is the most critical focal point of the face. In this approach, unlike traditional methods, resection of the dorsal hump is not the primary procedure; rather, it is a secondary step that establishes the ideal balance between the nasal tip and the nasal dorsum. Once the tip is given the correct projection and rotation, the amount of bony intervention required is reduced, yielding far more conservative and natural results.

The core objectives of this modern approach are:

• Dynamic Naturalness: An appearance that integrates with the facial features, in which the nasal tip does not droop downward while smiling.

• Functional Restoration: Preservation of the nasal valve angle and improved breathing quality through enhanced tip support.

• Minimal Trauma: Structural reinforcement using the "endonasal extramucosal" technique without severing the natural connections of the tissues.

2. Open vs. Closed Rhinoplasty: Why the Closed Approach?

In traditional open rhinoplasty, the incision made across the columella (the central pillar of the nose) severs the natural bonds between the skin and the cartilage. This brings with it significant edema during healing, the formation of fibrosis (hardened tissue) between skin and cartilage, and the risk of a permanent scar. In the closed rhinoplasty technique performed by Prof. Dr. Erdem Tezel, however, all procedures are carried out through the nostrils, with no external incision whatsoever.

Comparison of Open and Closed Rhinoplasty

Criterion — Open Rhinoplasty — Closed Rhinoplasty (Tezel Approach)

Scar Risk — A permanent, externally visible suture scar on the columella. — Incisions are entirely inside the nose; no external scar remains.

Healing Time — Edema is prolonged (6–12 months) due to complete separation of tissues. — Edema is minimal because tissue integrity is preserved; rapid healing is achieved.

Tissue Damage — Skin–cartilage connections are severed; stability may be compromised. — Natural bonds are preserved with the "endonasal extramucosal" approach.

Predictability — Because the skin is lifted during surgery, the final shape is masked by edema. — Because the skin stays in place, the surgeon sees the result instantly and fixes it.

3. The Septocolumellar Suture System: The Invisible Architect of the Nose

The Septocolumellar Suture (septocolumellar suture system), contributed to the literature by Prof. Dr. Erdem Tezel and forming the cornerstone of this technique, functions as a load-bearing and stabilizing mechanism for the nasal tip. This suture fixes the tip cartilages (medial crura) onto the septal cartilage in a "rider" position, giving the nasal tip its final shape. The expert surgeon manages this system not as a single suture but as a four-stage suture architecture applied in a specific sequence:

1. Pivot Suture: Determines the height of the nasal tip (projection) to the millimeter.

2. Rotation Suture: Adjusts and fixes the upward rotation angle of the nasal tip.

3. Support Suture: Controls the footplates of the tip, widening or narrowing the columella–lip (nasolabial) angle.

4. Interdomal Suture: Eliminates the divergence between the tip cartilages to create a more refined and defined tip.

Advantages provided by the system:

• Permanent Stabilization: Prevents the nasal tip from dropping over time.

• Precise Projection Control: In humped noses, raises the tip and thereby reduces the amount of bone to be removed.

• Smile Aesthetics: Creates a strong lock that prevents the upper lip muscles from pulling the nasal tip downward.

4. Caudal Septal Graft (Cartilage Patch) Techniques

For the septocolumellar suture to succeed, the "pillar" it anchors to — that is, the septal cartilage — must be straight, strong, and of sufficient length. In cases where the septum is weak, deviated, or short, the Caudal Septal Graft (Cartilage Patch) comes into play. In this technique, a patch prepared from the patient's own cartilage is carved in a "stair-step" pattern and fitted with a perfect, puzzle-piece interlock onto the end of the existing cartilage in the sagittal plane.

Caudal Septal Graft (Patch) Designs:

1. Type 1 (Height Augmentation): Used to provide more projection to the nasal tip when the vertical height of the septum is insufficient.

2. Type 2 (Support Patch): Strengthens thin and fragile septa, increasing stability.

3. Type 3 (Corrective Patch): Preferred for fixing a deviated septal cartilage to the midline.

4. Type 4 (Extension Patch): Corrects the "short nose" deformity (caudally deficient) by increasing the length of the septum.

5. Type 5 (Triangular Deficiency Completion): Fills the anatomical gaps in the anterior-inferior part of the septum, providing ideal columellar support.

5. The Surgical Process: Scarless, Strong, and Fast

The surgery is performed with the "endonasal extramucosal" method, in which the tissues are preserved by opening tunnels beneath the skin. In this way, the microcirculation between the tip cartilages and the skin is not disturbed.

Step-by-Step Surgical Flow:

• Assessment: The height, length, and thickness of the septum are examined by palpation and endoscopy.

• Incision and Access: The cartilage skeleton is reached through minimal incisions made entirely inside the nose.

• Caudal Septal Graft Application: If septal support is insufficient, the cartilage patch is sutured into place using the stair-step technique.

• Placement of the Septocolumellar Sutures: The pivot, rotation, and support sutures are placed in sequence, bringing the nasal tip into the "rider" position.

• Final Check: The results of the surgery are evaluated while the skin is in place (without the masking effect of edema).

• Duration: Cases requiring only tip intervention can be completed in as little as 20–40 minutes under local anesthesia.

6. Long-Term Results: An End to "Supratip" Deformity and Tip Drooping

The "tip drop" frequently seen after traditional surgeries — and the swelling at the tip end of the nasal dorsum (supratip deformity) associated with it — generally stems from the loss of nasal tip support. In this technique, because the tip cartilages are bound to the septum in a rigid (fixed) manner with sutures and, where necessary, caudal septal grafts, the risk of downward drooping during healing is eliminated.

Success Data

In Prof. Dr. Erdem Tezel's broad 14-year clinical series of 2,286 cases, this method has achieved a 98% rate of permanent success and patient satisfaction. The problem of the nasal tip drooping while smiling, in particular, is permanently solved with this technique iv.

7. The Recovery Period and Patient Expectations

The first 2 months after surgery are the most critical period for the cartilages to fuse together via a natural bonding tissue called the "biological cast." During this process, nasal tip massage must be strictly avoided, as massage can disrupt the position of the sutures.

Recovery Timeline and Recommendations:

• Upper Lip Movements: A temporary stiffness and restricted movement (hypokinesia) in the upper lip during the first 2–3 weeks after surgery is entirely normal. This returns to normal within 5–6 weeks.

• Nasal Tip Stiffness: The temporary sensation of stiffness in the nasal tip can last about 1 year; as the tissues soften, this sensation disappears.

Dos / Don'ts:

1. Do: Protect the nasal tip from impact and pressure throughout the first 2 months.

2. Do: Be patient during the healing process; the final shape will become more defined as the tissues settle.

3. Don't: Do not massage the nasal tip; it can damage the stabilization of the sutures.

4. Don't: Avoid contact sports and heavy exercise for the first 2 months.

8. Conclusion: Personalized Functional Aesthetics

Rhinoplasty is not merely a "filing-down" procedure but a functional restoration in which the internal architecture of the nose is rebuilt. Closed rhinoplasty performed with the caudal septal graft and septocolumellar suture system offers the patient a scarless, natural nasal structure that does not droop for a lifetime. However, "the learning curve for this technique is quite steep." For the most successful and lasting result, choosing an experienced plastic surgeon who has mastered all the details of the technique is of vital importance.

9. Frequently Asked Questions (FAQ)

Question: Is there a visible scar from the outside in closed rhinoplasty?

Answer: No. Because all incisions are made on the inside of the nostrils, no surgical scar visible from the outside remains.

Question: Will the nasal tip droop over time after surgery?

Answer: Because the septocolumellar suture system and caudal septal grafts lock the nasal tip in place, the kind of drooping seen in classic surgeries is not expected with this method.

Question: Can nasal tip surgery alone be performed under local anesthesia?

Answer: Yes. In cases where only the nasal tip is treated, the entire process — including preparation of the cartilage patch — can be completed under local anesthesia in approximately 20–40 minutes.

Question: Will there be a permanent change in my smile after surgery?

Answer: No. The restriction in upper lip movements is temporary (2–3 weeks). In the long term your smile becomes more aesthetic, because your nasal tip will not droop downward.