24-year-old female presents for initial consultation for rhinoplasty. She is most bothered by her dorsal hump. She has had a lot of trauma to the nose growing up with 5 older brothers. An incision was then made along the pyriform aperture and the skin and soft tissue were elevated off the maxilla and nasal bones to prepare for osteotomies. The piezo saw was then used to make low-low-high osteotomies with mobilization of the left nasal pyramid to correct asymmetry.

The medial crura were separated sharply. The anterior septal angle was identified. A left mucoperichondrial flap was elevated. Dissection proceeded anteriorly around the caudal end of the septum allowing elevation of a mucoperichondrial flap on the right. The septum was found to be severely deviated and a fracture site was present at the caudal septum. Anterior upper lateral cartilages were released from the septum bilaterally. A small portion of cartilaginous septum and a large portion of bony septum was removed to correct deviation. The caudal cartilaginous septum was then removed, trimmed mobilized from a perpendicular angle obstructing the left to midline. The new L strut septum was secured to the maxillary crest and upper lateral cartilages at the keystone with  5-0 prolene with a 2.5 cm septal extension graft which was carved and fashioned from septal cartilage. This provided support and straightened the nose.

 The septal extension graft was secured to the left side of the septum with 5-0 prolene and the spreader graft was secured between the septum and left upper lateral cartilage with 5-0 prolene. A left z flap was secured to the septal cartilage and secured to the SEG. This straightened the nose and provided additional support.

5-0 prolene dome spanning and lateral crural tensioning sutures were placed to create new domes and decrease rotation, securing the lower lateral cartilages to the septal extension graft. The skin was elevated off the medial crura. A tongue-and-groove procedure was performed and the medial crura were sutured to the caudal septum with 5-0 prolene. Medial crural fixation sutures were placed to secure the medial crura together and narrow the columella.