Plastic surgeons have long recognized the long nose or dependent ptotic tip is a powerful stigma of aging and an unattractive feature in youth. A plethora of techniques are employed to rotate the nose. Some such as caudal septal excision require considerable experience and a formula to be predictable. Others such as cephalic trim described for this purpose are more likely to cause alar retraction or internal valve collapse than rotate the nose at all. Lower lateral fixation to the septum directly or indirectly through a septal extension graft has been our preferred technique of rotation for 16 years. We employ Byrd's measurement from a forehead reference point (1) intermittently throughout surgery. We have found a range of numbers that bring about very gratifying amounts of rotation for the patient and avoid the much feared too much change to nasal length. 121 charts and electronic records of rhinoplasty patients undergoing rotation in five years were pulled. 55 charts in which the amount of rotation was recorded were reviewed, finding the amount varied from 1to 8mm with the larger numbers for nasolabial angles of 90 degrees or less. Follow-up was from 5 years to 3 months. Nasal length remained stable and all patients were pleased with their degree of rotation except one patient that had only 2mm of rotation, too conservative for an angle of 90 degrees. Some patients in their own words express the desire for nasal shortening or rotation. Many others are unaware of the potential aesthetic benefits of this change and need to be educated about the choice. The fear of over rotation is common among all. Our experience is very clear. Persevere with the patient that this is an extremely important aesthetic parameter that should be included with their other rhinoplasty changes. Then have confidence that the preoperative planned mm's of change will be appropriate and rigid techniques extremely reliable long term to hold the tip to that planned amount. Patients are aware of more nose stiffness but all have felt this to be a very small tradeoff.

1. Byrd HS, et al Septal Extension Grafts: A Method of Controlling Tip Projection, Rotation, and Shape, 1999 Dallas Rhinoplasty Symposium