1.  Cadaver with a preferably well projected nose.
 

 
2.  An ink pen used to mark an inverted “V” incision on the columella.

3.  Using a Bard-Parker #15 blade, a 2 mm vertical incision is made behind the shining light reflex on the columella.
 

 
4.  The incision is repeated on the opposite side.
 

 
5.  Pass the fine curved scissor through the incision in front of medial crus of the lower lateral cartilage and elevate the skin and soft tissue over the inferior crura of the lower lateral cartilages.
 

 
6.  The columellar skin is incised with a Bard-Parker blade as marked with the the ink pen. 
 

 
7.  The skin over the lower lateral cartilage is dissected and elevated.
 

8.  Elevate the skin on the dorsum and on the side of the dorsum with fine curved scissors.  The dorsum of skin will be retracted with a skin hook and later with an Aufricht’s retractor and a lid retractor.
 

9.  Removing the hump:  Remove the cartilaginous hump using a Bard-Parker #15 blade and remove the bony hump using an osteotome.
 

10.  An open roof deformity is formed after the hump removal
 

11.  A spreader graft is placed between the upper lateral cartilage and the nasal septum.

Cut the attachment of the upper lateral cartilage with the septal cartilage with a #15 Bard-Parker blade.  Trim the harvested septal cartilage into thin strips and place one on either side of the septal cartilage and suture the entire assembly together.   The spreader graft opens up the nasal valve area.  It also provides support to the dorsum.
 

12. Columellar strut:  Cut the harvested piece of the septal cartilage into a strip and place between the two medial crura as a strut and suture it.  Before suturing, fix the assembly of the medial crura of both the lower lateral cartilages with the columellar strut with a 26 gauge needle.  The columellar strut provides tip support (Tip recoil test).
 

13.  Shield graft placement:  Harvested septal cartilage is used as a shield graft over the medial crus of the lower lateral cartilage and is sutured into place.   The shield graft provides columellar show.
 

Tip Surgery:

14.  Dome splitting:  Cut the junction between the medial crus and lateral crus of the lower lateral cartilage, i.e., the dome.  The dome splitting is for reconstruction of the nasal tip.
 

15.  Resection of cephalic portion of lateral crura of lower lateral cartilages. 

The resection of cephalic portion of lateral crura of lower lateral cartilages.  This reduces the bulbous nasoalar groove.
 

16.  Spanning sutures:   Pass the sutures from the cephalic end of one lower lateral cartilage to the other lower lateral cartilage on the opposite side.  The knot is buried between the two lower lateral cartilages.  The spanning suture deepens the nasoalar groove and makes it prominent.
 

17.  Tip accentuation suture:  To create a new dome, pinch the dome of one lower lateral cartilage crus with smooth forceps and fix it with a #26 gauge needle.   Repeat the procedure on the opposite side.  Fix the entire assembly with two #26 gauge needles.
 

 
Suture the entire assembly (the two new artificially created domes) together for tip accentuation.  This will accentuate the tip.
 

 
18.  Tip anchoring sutures:  Using a fine needle, pass the suture through the dorsum, i.e., junction of both upper lateral cartilage and septal cartilage.  Use a through-and-through stitch and place a knot.  Without cutting the stitch take the suture to the center of the spanning suture and tie it tightly as much as is required for tip elevation.  This suture will elevate the tip right in front of your eyes.
 

19.  Augmentation:  Place the resected cartilage over the dorsum and suture with a fine stitch to avoid displacement of the graft.
 

20.  Inter Domal Suture:   Resect the soft tissue between the two dome areas of the two lower lateral cartilages.   Suture the dome area together or suture it after performing the dome splitting steps, depending upon the individual case.  Inter domal sutures are required for the correction of a bifid tip. 
  

21.  Medial Osteotomy:  If a bony hump has been removed, it's removal detaches the bony attachment of the nasal bone from the septal bone (perpendicular plate of ethmoid). In this situation, a medial osteotomy is not required.  The osteotomy is performed by placing a sharp osteotome at the junction between the nasal and septal bones.  The starting point is at the “step” created after cartilage hump removal.  The sharp tap tap movement of the mallet advances the osteotome until it reaches the point just below the nasion.  The change of sound as the mallet taps the ostotome guides the surgeon when to stop.  The medial osteotomy is completed and the nasal bone is detached from the septal bone.
   

22.  Lateral Osteotomy:   Select the midpoint between the medial canthus of eye and lowermost point of the nasoalar groove.  At the nasal process of the maxilla (the point where the side of the nose just starts projecting up), perform a deep stab incision down to the bone using a Bard-Parker #15 blade.   Insert a 3 mm sharp osteotome through the incision and move it up and down (cephalic and caudal direction) to lift up the periosteum.  Next, make multiple perforations at an interval of 2-3 mm (external perforating digital osteotomy).   If the osteotomy is not done at this level and instead is performed at a higher level nearer to the nasal bone, an ugly step deformity will be created.
 

23.  Horizontal Osteotomy:  Select the midpoint between the medial canthus and the nasion.  Perform the osteotomy as described in step number 22 (above).   (The medial osteotomy, lateral osteotomy and horizontal osteotomy completely mobilizes the nose.  In real surgery, the stab incision may cause brisk bleeding, but if it is pressed firmly with the finger for two minutes, the bleeding stops.  It is very important to use a normal saline ice pack after performing an osteotomy to prevent edema. If edema occurs, it may mask minor irregularities and gives the false impression of a good correction.)
 

24.  Conchal cartilage harvesting: The cartilage can be harvested from the cavum concha region of the pinna.  An incision can be made on the posterior side of pinna (More preferred) or on the anterior side (Less common).  If the antihelix fold is not violated, the shape of the pinna is not altered.  It is important to place a bolster dressing on the pinna for a long period of time to prevent hematoma formation.  The natural curve of harvested conchal cartilage makes it perfect for the tip graft.
  

25.  Marking for the harvesting of the costal cartilage.