28-year-old female for rhinoplasty. She is concerned about a nasal hump and widening of her nasal tip. She has a deviated septum and some obstruction from her nose. She would like to have this repaired. She has done extensive research into rhinoplasty and wants improvement in dorsum and elevation of her nasal tip. Bilateral spreader grafts were placed between the upper lateral cartilages and septum. A thicker spreader graft was placed on the left side to compensate for the depressed midvault. This with the upper lateral cartilages were resecured to the septum with multiple 5-0 prolene and 4-0 PDS mattress sutures. An incision was made along the pyriform aperture and the skin and soft tissue was elevated off the maxilla and nasal bones. Lateral incomplete osteotomies were then performed to narrow the upper vault. The domes of the lower lateral cartilages were divided and the caudal septum exposed. A caudal extension graft was placed to rotate up the tip and provide support. This was secured to the nasal spine and caudal septum with 4-0 PDS. We then moved to tip refinements. Cephalic trims of the lower lateral cartilages were done leaving 8 mm lateral crural struts. Dome spanning sutures were placed to create tip defining points, and lateral crural steal techniques used to create more rotation. Lateral crural tension was then placed to approximate and secure the domes and flatten the lateral crura. Columellar strut was placed to provide even more rotation.