Caudal extension grafts have been described for use in correcting a retracted columella, over-rotated tip, short nose, or to increase tip support and projection (3) (Appendix F). This graft is sutured to the caudal margin of the nasal septum and is secured between the medial crura in the midline with 5-0 buried polydioxanone suture (PDS) (Fig. 2). When suturing the caudal extension graft to the caudal septum, the caudal margin of the graft must be in the precise midline. Deviation off the midline will result in a deviation of the nasal base or tip. It is critical to assess nasal projection, length, tip rotation, and alar/columellar relation when positioning a caudal extension graft. Patients should be told preoperatively that their nasal tip will be stiffer, with loss of the normal tip recoil.