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I did a pretty good podcast already on this subject many, many months ago, but it is probably the single most important evolution that is occurred in rhinoplasty in the last five years and I want to discuss it again as well as talk about some refinements in this concept. So this is the caudal septal extension graft. Essentially it’s a cartilage graft that is sutured to the septum on the bottom of the nose to support the nasal tip during rhinoplasty. The biggest reason to do this is that when you’ve opened a nose or when you’ve done anything to make a cut in the nose, you will lose tip support and the tip will fall. And in the old days when I did Calumellar strut placing a small strut graft into the nose the tip would fall if ever so slightly to dramatically over a week to a month and it was very very unreliable and also as we age the nose also tends to drop or fall. The Huddle septal extension graft is essentially taking a very mobile tip and securing it to an anchor point fix anchor point, which is the septum so that the tip doesn’t have that degree of imprecision and I hate and precision with rhinoplasty. It also secures that tips over five years so nose doesn’t collapse. And so if at 60 years of age 20 years later 30 years later the nose should not collapse. Now the nose does evolve over time, but the nose is so secured that it should not fall over timing. Of course, there’s no guarantees in life. But in general that’s the principle of what a caudal septal extension graft is gives you a very very firm anchoring. The other thing that the concept is besides tip stability predictability are some maneuvers that are very unique to a caudal septal extension graft. So with an Asian nose the biggest concern is when you try to refine the tip. You tie the tips together and you route then it will cause rotation. If you do that the nose tip will actually go upwards and look like a pig which you want to avoid. So what the caudal septal extension graft does is allow you to create tip definition without undo rotation. You can rotate the nose how you want to rotate the nose because you have so much predictability and securing the tip to where the position should be. The other benefit especially in broader ethnic noses is since your anchor point now is fixed and strong. When you refine that nasal tip going forward not only do limit the risk of that nasal tip rotating when you tie the tips together, which is what you want to avoid, especially in ethic noses. But also when you pull that tip forward again that’s very hard to describe without a visual but you actually secure the tip and it actually takes the convexity out of the side of the nose and it flattens it is called a lateral tensioning maneuver. You’re actually pulling it forward and anchoring it so that the whole nostril sort of straightens out. You don’t you can’t really get that effect, especially in week ethnic nose cartilage has by just short of tying it together or you know, tying the tips that you just cannot do that. With this you’re actually with a fixed anchor point. you’re actually creating incredible strength and recurvature or loss of that over convex side by pulling it to a fixed anchor point so you can actually take the flare off a nose incredibly well with this technique. Along those lines, you can listen to my podcasts on a lateral turning flap where the old days when I had a bulbous nose I would just cut out the extra cartilage throw it away and be done with it. The problem with that is you weaken the nose. And so what a little turn and flap is just as a quick summary you score the cartilage you fold the cartilage into itself and that does several things. Now what you’re doing is you’re thinning the cartilage but you’re saving all that cartilage is making it now much firmer. And then also what happens is that that by flipping a convex piece of cartilage it already flattens it now you take that move and you combine it with this caudal septal extension graft, which is causing this lateral tensioning anchor point and now you’ve got an incredibly strong tip. That is better shape to find and predictable. So there’s a probably a billion other things. I can talk about the caudal septal extension graft, but this is such an important concept that it is worth another podcast special if you missed my first I’m from a few months ago.