Abstract
Background:
Nasal tip refinement remains one of the most challenging aspects of rhinoplasty. Traditional closed rhinoplasty techniques often limit precise manipulation of the lower lateral cartilages due to restricted visualisation and tissue mobility. The Arumugam Technique addresses these limitations through complete lower lateral cartilage liberation via a closed approach, offering open-rhinoplasty-level control without external incisions.
Methods:
A retrospective cohort study was conducted at Apollo Hospitals, evaluating 150 patients who underwent primary rhinoplasty with tip correction using the Arumugam Technique between January 2016 and May 2025. The technique involves rim incision, hydrodissection, and complete release of lower lateral cartilages from both vestibular mucosa and dorsal skin attachments, allowing bilateral cartilage externalisation, modification, and repositioning. Patient demographics, surgical procedures, complications, and patient-reported outcomes using the Rhinoplasty Outcome Evaluation (ROE) questionnaire were analysed. Inclusion criteria required patients aged 18–55 years undergoing primary rhinoplasty with tip correction indications and minimal septal work. Follow-up ranged from 6 months to 5 years.
Results:
The cohort comprised 77 males (51.3%) and 73 females (48.7%) with a mean age of 36.0 ± 11.1 years. The most common indications were cosmetic tip refinement (11.3%), minor dorsal hump with tip deformity (8.0%), and pinched tip (7.3%). The overall complication rate was 8.7% (13/150 patients), with prolonged oedema (5.3%), infection (2.0%), and mucosal perforation (1.3%) being the observed complications. All complications were minor and successfully managed. Mean preoperative ROE score was 32.02% ± 8.23%, improving significantly to 80.98% ± 8.96% postoperatively (mean improvement 48.96 percentage points, P < .001). Patient satisfaction was high, with 88.7% achieving ROE scores ≥70% and 38.7% achieving scores ≥85%. Outcomes were consistent across sex and age groups, with no clinically significant differences in improvement rates.
Conclusions:
The Arumugam Technique represents a significant advancement in closed rhinoplasty, providing surgeons with open-approach-level visualisation and manipulation of lower lateral cartilages while preserving the benefits of closed rhinoplasty, including no external scarring and faster recovery. The technique demonstrates an excellent safety profile, high patient satisfaction, and consistent outcomes across diverse patient populations. Complete lower lateral cartilage liberation addresses tissue memory and elastic recoil limitations inherent in traditional closed approaches, enabling precise bilateral tip refinement. This technique expands the indications for closed rhinoplasty to include complex tip deformities previously requiring open approaches.
Level of Evidence:
Level IV, therapeutic study.
Keywords
Introduction
Nasal tip refinement is a crucial aspect of rhinoplasty, significantly impacting the overall aesthetic outcome and facial feature harmony. Achieving optimal tip projection, rotation, and definition while maintaining naturalness remains a significant challenge for rhinoplasty surgeons. 1 Traditional closed rhinoplasty techniques, while offering advantages such as minimised external scarring, often present limitations in precisely addressing complex tip deformities due to restricted visibility and access to the lower lateral cartilages. 2 This constraint usually necessitates alternative approaches or limits the extent of achievable tip refinement in cases requiring substantial modification. The Arumugam Technique, however, offers a novel approach to overcome these limitations by facilitating complete lower lateral cartilage liberation, thereby enabling enhanced precision in tip manipulation within the confines of a closed approach. This technique extends the capabilities of closed rhinoplasty by providing surgeons with unprecedented control over the lower lateral cartilages, which are pivotal in shaping the nasal tip. 3 By allowing for comprehensive manipulation of these cartilaginous structures through internal access, the Arumugam Technique facilitates a degree of refinement previously associated primarily with open rhinoplasty, all while preserving the benefits of a closed procedure, such as reduced recovery time and absence of external incisions. 4 This innovative method addresses common challenges in tip rhinoplasty, such as achieving precise symmetry and optimal tip projection, without resorting to the more invasive open approach. We aim to delve into the long-term stability of the results obtained, considering factors such as scar tissue formation, cartilage memory, and patient satisfaction. Moreover, we will examine the demographic and anatomical factors that predict optimal outcomes, thereby establishing criteria for patient selection and technique applicability. Additionally, we will discuss potential complications and their management, alongside a comparative analysis with other established closed and open rhinoplasty techniques to highlight their unique advantages and limitations. This comprehensive examination aims to position the Arumugam Technique as a significant advancement in closed rhinoplasty, offering a refined solution for intricate nasal tip reshaping. This technique specifically addresses the intricate interplay between cartilage integrity and soft tissue envelope redraping, crucial for durable aesthetic results.
Background
Evolution of Nasal Tip Refinement Techniques
Historically, nasal tip refinement has evolved from rudimentary excisional methods to sophisticated cartilage-sparing and reconstructive approaches, driven by a deeper understanding of nasal anatomy and aesthetic principles. Early interventions often involved aggressive resection of cartilaginous structures, leading to compromised structural support and undesirable long-term aesthetic outcomes, such as pinched or amorphous tips. This led to the development of more conservative techniques focusing on cartilage modification and suturing to achieve desired tip aesthetics while preserving structural integrity. 5 The integration of grafting techniques further advanced tip surgery, allowing for augmentation and structural reinforcement using autologous tissues like septal or costal cartilage. 6 The evolution continued with an emphasis on functional outcomes, recognising that aesthetic alterations should not impede nasal airflow, especially in cases involving internal nasal valve stenosis or septal deviations. 7 Recent advancements have also focused on preserving the natural integrity of the nasal dorsum, thereby mitigating the need for extensive structural alterations and minimising potential complications associated with dorsal reduction techniques. 8
Limitations of Traditional Closed Rhinoplasty
Despite its advantages, such as reduced oedema and a quicker recovery, traditional closed rhinoplasty often presents inherent limitations in managing complex tip deformities due to restricted direct visualisation and manipulation of the lower lateral cartilages.5,9 This indirect approach can complicate the precise reshaping and repositioning required for significant tip refinement, particularly when addressing issues like asymmetry or inadequate projection. 5
Rationale for Complete Lower Lateral Cartilage Liberation
The rationale for complete lower lateral cartilage liberation stems from the necessity to overcome these inherent limitations, providing surgeons with enhanced control over tip dynamics previously afforded only by open approaches. 10 This approach allows for meticulous sculpting and repositioning of the cartilages, addressing issues such as malposition, asymmetry, and inadequate projection with greater accuracy and predictability within a closed framework. 10
Materials and Methods
This is a retrospective study conducted at Apollo Hospitals over a 10-year period (February 2016-May 2025), examining patient outcomes following the Arumugam Technique for nasal tip refinement. During that period, a total of 150 patients who matched the patient selection criteria were included in this study, with follow-up periods ranging from 6 months to 5 years.
Inclusion Criteria
Patients were included in this study if they met all of the following criteria:
Age requirements: Patients aged 18 to 55 years at the time of surgery.
Primary rhinoplasty: Only primary cases were included to ensure a homogeneous cohort.
Tip correction indications: Patients presenting with nasal tip deformities requiring surgical correction. Acceptable indications included bulbous tip, tip ptosis, pinched tip, boxy tip, bifid tip, wide nasal tip, nasal tip asymmetry, under/over-projected tip, hanging or retracted columella, tip rotation deficit, tip definition deficit, supratip fullness, lack of tip projection, and cosmetic tip refinement.
Minimal or no septal work: Patients requiring either no septal intervention or only minimal septoplasty, including minor septal deviation correction, septoplasty for graft harvesting, or minimal septal adjustments to facilitate tip work.
Complete ROE assessment: Patients with documented Rhinoplasty Outcome Evaluation (ROE) scores obtained preoperatively (within 4 weeks before surgery) and postoperatively (minimum 6 months post-surgery).
Adequate follow-up: Minimum follow-up period of 6 months postoperatively to allow for resolution of oedema and assessment of final outcomes.
Exclusion Criteria
Patients were excluded from this study if they met ANY of the following criteria:
Revision Rhinoplasty
Complex or extensive septal work: Patients requiring major septal reconstruction, extensive septoplasty, septal perforation repair, severe septal deviation requiring extensive cartilage removal, or major inferior turbinate surgery.
Cleft lip/palate rhinoplasty: Excluded due to fundamentally different anatomical challenges and surgical techniques.
Post-traumatic Reconstruction
Syndromic or Congenital Deformities
Uncontrolled medical comorbidities: Patients with poorly controlled diabetes, bleeding disorders, immunosuppression, or conditions substantially increasing surgical risk or impairing wound healing.
Surgical Technique: The Arumugam Technique
Pre op assessment: clinical examination and routine pre op assessment. Detailed photographic analysis, including standardised views, was taken.
Patients who completed the ROE questionnaire 11 preoperatively were utilised to assess patient satisfaction and aesthetic outcomes following the surgical procedure.
Anaesthesia and Surgical Setup
Anaesthesia
Only tip correction: Local, 2%lignocaine with adrenaline (injection at rim incision, tip, mucosal plane overlying the cartilage for hydrodissection).
Full rhinoplasty: Local with IV sedation or General anaesthesia Supine, Neck extension, adequate lighting.
Detailed Surgical Steps
A rim incision is marked along the caudal margin of the alar cartilage, and local anaesthetic is injected along the incision line and around the alar cartilage to facilitate dissection (Figure 1). Incision is made. The skin is dissected free from the lower lateral cartilage. If sufficient soft tissue is available for defatting, the dissection plane is kept closer to the skin to preserve as much soft tissue on the cartilage as possible. The rim incision is placed 1–2 mm beyond the cartilage margin. The mucosa is grasped with two baby haemostats near the dome, and a plane is developed between the cartilage and mucosa using a fine-tipped tenotomy scissors. This step is facilitated by hydrodissection with lidocaine, with care taken to avoid any tears in the mucosa. The lateral attachments are then released, freeing the cartilage entirely from both the skin and mucosa. A similar procedure is performed on the contralateral side, exposing both lower lateral cartilages with the domes in their anatomical positions. Any excess soft tissue left behind initially is now completely removed to fully expose the cartilage. Cephalic resection is performed as planned, preserving approximately 4–5 mm of cartilage width on each side (Figure 2). Irregularities in the caudal margin are trimmed. Blunt double hooks are placed to lift the tip, allowing assessment of the remaining alar cartilage lengths on each side (Figure 3). A tunnel is created over the domes to ensure the area is completely free from the overlying skin. Interdomal sutures are placed as required (Figure 4), and the lower lateral cartilages are repositioned in their pockets.
Initial Exposure and Liberation. (A) (Operative Image): Baby Hemostats Holding Edges of Mucosa and the Cartilage Are Being Freed from the Cutaneous Side. (B) (Illustration): Schematic Representation of the Bilateral Liberation. The Lateral Attachments Are Released, Freeing the Cartilages Entirely from Both the Skin and Mucosa While Maintaining Their Anatomical Positions for Assessment.
Cartilage Modification and Refinement. (A) (Operative Image): Cephalic Resection Being Done Under Direct Vision. (B) Schematic View: Detailed View of the Cephalic Resection. Note: The Preservation of Approximately 4-5 mm of Cartilage Width on Each Side to Maintain Structural Integrity.
Post-trimming and Cartilage Refinement. (A) (New Photo): Intraoperative View of Alar Cartilage Following Cephalic Resection and Defatting of Overlying Soft Tissue. (B) (Schematic): A Basal-view Illustration Highlighting the 4–5 mm of Preserved Cartilage Width. This Illustrates the Structural Stability Maintained Despite the Total Liberation from the Mucosal and Skin Planes.
Closure and Postoperative Care
After verifying haemostasis, the rim incisions are closed with catgut sutures. Nasal taping is then applied, and splinting is performed where required (in case of concurrent osteotomy)
Postoperatively, the patient is nursed with the head end elevated, a drip pad is kept for 24 hours, and then removed. Tapes and splints are retained for 7 days and removed. Taping helps in maintaining the cartilages in their new position
Regular sunscreen usage is encouraged along with gentle tip massage and avoiding trauma.
Long-term Follow-up and Monitoring
Patients were followed up for a minimum of 6 months and a maximum of 5 years. The ROE assessment questionnaire 11 was administered again at follow-up of 6 months, and the pre- and postoperative scores were tabulated (Figures 4–6) showing pre- and 6-month postoperative images of patients included in the study. This allowed for a comprehensive evaluation of both objective aesthetic improvements and subjective patient satisfaction, providing a robust measure of surgical efficacy.
Checking for Symmetry. (A) (Operative Photo): Checking for Symmetry of Trimmed Alar Cartilages After Exteriorising. (B) (Schematic): Checking for Symmetry of Trimmed Alar Cartilages After Exteriorising.
Before and After Patient 1.
Before and After Patient 2.
Results and Outcomes
Demographics and Patient Characteristics
A total of 150 patients who underwent primary rhinoplasty with tip correction and minimal septal work between March 2016 and May 2025 were included in this study. The mean age was 36.0 ± 11.1 years (range: 18–55 years). The cohort comprised 77 male patients (51.3%) and 73 female patients (48.7%), demonstrating a relatively balanced sex distribution (Table 1).
Patient Demographics.
The most common indications for surgery were cosmetic tip refinement (n = 17, 11.3%), minor dorsal hump with tip deformity (n = 12, 8.0%), pinched tip (n = 11, 7.3%), bulbous tip with minor septal deviation (n = 9, 6.0%), and over-projected tip (n = 9, 6.0%). Other indications included tip ptosis, boxy tip, wide nasal tip, bifid tip, under-projected tip, hanging columella, retracted columella, tip rotation deficit, tip definition deficit, nasal tip asymmetry, drooping nasal tip, supratip fullness, and lack of tip projection (Table 2).
Most Common Indications for Surgery.
Surgical Procedures
All procedures performed were primary rhinoplasties with a focus on tip modification. The most frequently performed procedures were tip defining sutures (n = 14, 9.3%), primary endonasal tip rhinoplasty (n = 11, 7.3%), shield graft tip rhinoplasty (n = 10, 6.7%), primary closed tip rhinoplasty (n = 9, 6.0%), and primary open approach tip plasty (n = 9, 6.0%). Other techniques included cephalic trim with tip suturing, cartilage graft tip rhinoplasty, tip refinement with alar base modification, tip rotation and projection procedures, lateral crural strut grafting, tongue-in-groove technique, columellar strut placement, and minimal osteotomy when indicated (Table 3).
Most Common Surgical Procedures.
Complications
The overall complication rate was 8.7% (13/150 patients). Prolonged oedema was observed in eight patients (5.3%), representing the most common complication. Infection requiring antibiotic treatment occurred in three patients (2.0%), all of whom resolved without sequelae. Mucosal perforation was identified in two patients (1.3%) and was sutured intraoperatively on the table; both cases healed uneventfully without long-term consequences. The majority of patients (n = 137, 91.3%) experienced no complications (Table 4).
Complication Profile.
ROE Scores
Patient-reported outcomes were assessed using the ROE questionnaire both preoperatively and postoperatively. The mean preoperative ROE score was 32.02% ± 8.23% (range: 17.1%–45.8%), indicating moderate baseline dissatisfaction with nasal appearance. Postoperatively, the mean ROE score significantly improved to 80.98% ± 8.96% (range: 60.0%–95.8%), representing a mean improvement of 48.96 percentage points. This improvement was statistically significant (paired t-test: t = 48.57, P < .001), demonstrating substantial enhancement in patient satisfaction following surgery (Table 5).
Patient Satisfaction
Using a threshold of ROE ≥70% to define patient satisfaction, 133 patients (88.7%) achieved satisfactory outcomes. Furthermore, 58 patients (38.7%) demonstrated ROE scores ≥85%, indicating high satisfaction with surgical results. These findings suggest that primary rhinoplasty with tip correction yields favourable patient-reported outcomes in the vast majority of cases (Table 5).
Overall ROE Scores and Patient Satisfaction.
Outcomes by Sex
Analysis of ROE scores stratified by sex revealed comparable outcomes between male and female patients. Male patients (n = 77) demonstrated a mean preoperative ROE of 31.80%, which improved to 80.09% postoperatively (mean improvement: 48.29%). Female patients (n = 73) showed a mean preoperative ROE of 32.26%, improving to 81.92% postoperatively (mean improvement: 49.66%). The slight difference in improvement between sexes was not clinically significant, suggesting that surgical outcomes are equally favourable regardless of patient sex (Table 6).
ROE Scores by Sex.
Outcomes by Complication Status
Patients without complications (n = 137) achieved a mean preoperative ROE of 32.02%, improving to 81.54% postoperatively (mean improvement: 49.52%). Patients who experienced complications (n = 13) had a mean preoperative ROE of 32.08%, improving to 74.31% postoperatively (mean improvement: 42.23%). While patients with complications showed slightly lower postoperative satisfaction scores, the majority still achieved good outcomes with ROE scores exceeding 70% (Table 7).
ROE Scores by Complication Status.
Age-stratified Analysis
Patients were stratified into four age groups for subgroup analysis. The 18–25 years group (n = 34) showed a mean ROE improvement of 48.6% (preoperative 32.4% to postoperative 81.0%). The 26–35 years group (n = 39) demonstrated an improvement of 48.0% (31.5% to 79.5%). The 36–45 years group (n = 39) showed an improvement of 47.8% (33.5% to 81.3%). The 46–55 years group (n = 38) exhibited the greatest improvement of 51.5% (30.7% to 82.1%). These findings suggest that age does not significantly impact surgical outcomes, with all age groups achieving substantial improvement in patient satisfaction (Table 8).
ROE Scores by Age Group.
Summary
This cohort of 150 patients undergoing primary rhinoplasty with tip correction demonstrated excellent outcomes with a low complication rate (8.7%) and high patient satisfaction (88.7% with ROE ≥70%). The mean ROE improvement of nearly 49 percentage points represents a clinically meaningful enhancement in patient-reported nasal appearance and function. Outcomes were consistent across sex and age groups, supporting the efficacy and safety of primary tip rhinoplasty in appropriately selected patients.
Discussion
Challenges in Nasal Tip Refinement
Despite significant advancements in rhinoplasty, achieving consistently precise and aesthetically pleasing nasal tip refinement remains one of the most challenging aspects of the procedure, primarily due to the intricate anatomical relationships and biomechanical properties of the lower lateral cartilages. 12 These cartilages, responsible for the shape, support, and functional integrity of the nasal tip, demand meticulous manipulation to avoid complications such as bossae, alar retraction, or functional compromise. 13 The variability in cartilage thickness, resilience, and individual patient healing responses further compounds these challenges, necessitating highly individualised surgical strategies.14,15 Traditional excisional techniques, while once prevalent for refining wide nasal tips, often destabilise the tip complex and can lead to progressive cephalic retraction of the alar margin due to scar contracture. 16 Conversely, modern cartilage-sparing approaches, such as the complete liberation of the lower lateral cartilages, aim to maintain structural integrity while achieving optimal tip aesthetics. 17 The challenges are further amplified in revision cases, where prior surgical interventions may have altered the native anatomy, leading to unpredictable tissue responses and diminished cartilage availability. 13
Comparison with Existing Techniques
The Arumugam Technique distinguishes itself from traditional closed rhinoplasty by enabling full liberation and externalisation of the lower lateral cartilages for direct visualisation and precise adjustments—capabilities typically associated with open rhinoplasty but achieved without external incisions.5,9 Unlike other closed methods involving limited cartilage modification or partial detachment,5,18 it supports intricate manoeuvres such as cephalic resection (preserving 4–5 mm width), caudal margin trimming, and interdomal suturing to refine tip projection, rotation, symmetry, and structural integrity, while allowing direct assessment of the intrinsic spring to reduce postoperative deformities. 19
Conventional closed rhinoplasty often relies on the bipedicle technique via rim, intercartilaginous, or transcartilaginous incisions, creating a chondromucosal flap that inverts the cartilage and demands mental reorientation. 5 This works well for thin-skinned patients but challenges precise resection visualisation in thicker-skinned individuals, such as those of Indian descent.
In contrast, open rhinoplasty elevates the skin-soft tissue envelope while preserving vestibular mucosa, offering excellent visualisation, yet is limited by mucosal attachments, causing elastic recoil and restricted repositioning. 18 The Arumugam Technique overcomes this by fully detaching the LLCs from both skin and mucosa via rim incisions (1–2 mm caudal to cartilage), hydrodissection, and lateral release—maintaining anatomical positioning for unrestricted manipulation, especially in complex cases. 18
This approach provides open-like exposure for remnants, grafts, or asymmetries, while retaining closed rhinoplasty’s advantages, like no columellar scar and faster recovery. 5
Advantages of the Arumugam Technique
Enhanced Anatomical Visualisation and Precision
This approach affords direct visualisation of the LLCs in situ while retaining the inherent merits of closed rhinoplasty. In contrast to traditional techniques, where incomplete exposure is hindered by persistent soft tissue adhesions, total liberation facilitates meticulous evaluation of cartilage morphology, symmetry, and structural properties. Consequently, it enables superior surgical planning and execution, particularly for optimising tip projection, rotation, and definition.
Moreover, simultaneous bilateral dome visualisation in their native anatomical orientation represents a substantial advancement over standard closed methods. This exposure permits a precise appraisal of interdomal dynamics and symmetrical adjustments, which are frequently impeded in alternative approaches. Thus, the technique effectively narrows the visualisation disparity between restricted closed rhinoplasty and extensive open approaches, eschewing the latter’s transcolumellar scarring.
Superior Tissue Mobility and Surgical Freedom
Full release of all tissue attachments—including the frequently underemphasised lateral crura connections—yields exceptional manoeuvrability for LLC repositioning. This mitigates the elastic recoil and tissue memory that commonly compromise durability in conventional closed rhinoplasty, thereby promoting more reliable healing and sustained aesthetic outcomes unencumbered by residual soft tissue tethering.
Furthermore, tunnel dissection overlying the dome helps in better repositioning and retention and also facilitates dome suturing and placement of cartilage grafts wherever necessary. Such mobility is especially efficacious for substantial tip modifications, where traditional closed techniques are constrained by inherent tissue limitations.
Optimised Soft Tissue Management
The method optimises soft tissue preservation by initially maintaining perichondrial attachments during skin envelope elevation—employing a subepidermal plane for defatting when indicated—followed by targeted excision of superfluous tissue after liberation. This strategy ensures adequate redraping and contour refinement while averting over-resection and fostering consistent envelope adaptation to the reconfigured framework, outperforming conventional approaches encumbered by suboptimal exposure.
Improved Surgical Outcomes and Predictability
The synergy of augmented visualisation and enhanced mobility engenders greater outcome predictability. Direct, concurrent inspection and modification of bilateral LLCs diminish asymmetries that necessitate revisions in closed rhinoplasty. Additionally, alleviation of constraining attachments bolsters long-term structural stability and reduces deformity recurrence.
This proficiency in addressing complex tip pathologies through closed access expands clinical applicability, particularly for patients averse to scarring who require extensive alterations.
Preserved Nasal Function and Anatomy
Notwithstanding comprehensive dissection, the technique preserves closed rhinoplasty’s principal advantages: maintenance of the columellar-labial junction and absence of cutaneous scars. Hydrodissection and precise mucosal handling preserve vestibular integrity, thereby safeguarding nasal patency concomitant with aesthetic enhancement.
Clinical Versatility
Improved access broadens the indications for closed rhinoplasty to encompass intricate asymmetries, projection adjustments, and alar contouring sans external incisions. Its methodical detachment and repositioning protocol furnishes a reproducible paradigm for uniform results across varied nasal tip morphologies, mitigating the inconsistency inherent in operator-dependent closed techniques.
Expanded applicability to specific cartilage deformities, such as a dish-shaped cartilage deformity. 20 Cartilage grafts can be sutured in position or placed as free grafts over the dome, secured by external tapes.
Our aim was to propound a technique practised extensively by Professor Dr Arumugam over his career. This article endeavours to explain the methodological nuances of his technique and clinical implications of this distinctive approach, offering a detailed account for wider academic dissemination.
Conclusion
The Arumugam Technique, through its comprehensive lower lateral cartilage liberation, offers a refined approach to nasal tip modification within the confines of closed rhinoplasty, demonstrating improved aesthetic outcomes, greater anatomical visualisation, and manoeuvrability.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.