At surgery although I noted he had particularly large tip cartilages they were positioned too far up the nose away from the nostril edges. This causes unnatural, bulbous curvature in the nasal tip and is associated with weak support to the nostril margins particularly when breathing in. I therefore used an open approach freed up the tip cartilages and swung them down to lie along the nostril rims. I strengthened them with struts of cartilage taken from the nasal septum. Rollin Daniel and I have discussed this technique before and recognise that it must not be considered lightly as a change in one part of the nasal tip cartilages can lead to abnormal changes in other areas which have to be counteracted with stitches and grafts. I saw Rollin use this technique in California 3 weeks ago which helped me think about my own technique more and it was good to have such a case to do when I returned home. I think the key is to fix the dome areas and the medial crura first before repositioning the lateral crura. After repositioning the lateral crura the infra tip lobule position must be reassessed as there is a tendency for the tip to rotate and turn up. This may need to be balanced with an infra tip lobule add on graft.