I have enjoyed listening to and talking about this problem with Ira Papel in Rome in May at the International Federation of Facial Plastic Surgery Societies meeting and in Las Vegas at the Multifaculty Cosmetic Surgery meeting last week. I have long felt that stitches in the nasal tip cartilages to make them less round and bulbous sometimes do things that are unpredictable and difficult to see even at the time of surgery. Millimetre variation in the placement of the suture or unknown differences in stiffness or immobility in different parts of the tip cartilage introduce unpredictability in the effect produced. The sutures can achieve lovely results with a slimmer tip but sometimes also cause movement of the cartilage that might pull up the nostril rim or cause notching, or they conversely might fill out the infra-tip lobule which is the under part of the tip. Ira and also in Las Vegas Bahman Guyuron discussed these risks and sometimes unwanted effects in relation to where the stitches are placed in the cartilage. Frustratingly despite trying to recognise and understand these things more, we can’t always explain unexpected changes. Cartilage grafts can also be used under the tip cartilages to make them less curved and bulbous. Unfortunately these too don’t always achieve just what we hope for either. The skin does not always adapt to the new shapes created in the cartilages and as Jay Calvert pointed out, grooves at the edge of a round tip may be due to the shape of the skin and these cannot be changed. Steve Pearlman also mentioned that these grafts can add bulk too. As we all recognised – nothing is perfect. I will continue to strive not just to look but to “see” what happens using these techniques during surgery. Making teaching videos for others is invaluable in helping me understand more profoundly what happens with our surgical techniques.