Very complicated revision rhinoplasty. Patient presented for nasal deformity, aesthetic nasal concerns and nasal obstruction. She had undergone a previous rhinoplasty 20 years ago. On examination she was noted to have a severe crooked nasal deformity and a total septal perforation. Several factors make this a particularly challenging case: previous rhinoplasty, severe crooked appearance, thin skin, and total septal perforation. Given the complexity of her case and the absence of septal cartilage, a rib cartilage revision rhinoplasty was performed. Her goals were for the straightening of her nose while maintaining a refined, narrow appearance. A revision rhinoplasty was performed using rib cartilage graft with the placement of spreader grafts, caudal septal extension graft, and lateral crural strut grafts. Seen here are post-operative results at one and three months. Note the significant changes in swelling in the elapsed time period.