47-year-old female who presents with aesthetic nasal concerns. Patient desires dorsal hump reduction, tip refinement, straightened nasal pyramid. The patient underwent Primary Joseph Rhinoplasty, Septoplasty, Right SEG, crushed cartilage tip, supratip and alar onlay grafts.

Procedure:
An inverted V columellar incision and marginal incisions were marked out and incised. The soft tissue envelope was lifted off the cartilage and bony framework. The periosteum over the nasal bones was incised and elevated.

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 high-low-high lateral osteotomies. The dorsal roof was reduced with a diamond tip Piezotome and 15 blade. The dorsal roof remained intact. A 4-0 PDS suture was then used to reapproximate the nasal dorsum and upper lateral cartilages. Ballerina maneuver was performed to help release the lateral portions of the lower lateral cartilages for reposistioning.

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.

Inferior septal cartilage was harvested in one piece with care taken to maintain greater than 1.5 cm L strut. The anterior left upper lateral cartilage was released from the septum. Cephalic trims were performed leaving 8mm wide lower lateral cartilages and releasing the scroll. A septal extension graft was fashioned from the harvested septal cartilage and secured to the maxillary crest and left side of the native septum with 4-0 PDS and 5-0 prolene. 5-0 prolene dome spanning and lateral crural tensioning sutures were placed to create new domes and increase 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. Footplate binding suture was performed with 5-0 chromic suture.