Rhinoplasty is a complex operation that requires precise preoperative diagnosis to select the appropriate surgical technique. In reduction rhinoplasty, I generally use the external rhinoplasty approach. Most dorsal humps are comprised primarily of cartilage, and overreduction of the bony dorsum must be avoided. The decision concerning the extent of hump removal should be determined preoperatively. Following hump removal and to close the open roof, osteotomies are considered for repositioning and reshaping the nose. A medial osteotomy is defined as the separation of the nasal bones and the bony septum. This can be further subclassified as medial oblique and paramedian osteotomies. I prefer to use a fading medial osteotomy(medial oblique). The fading medial osteotomy avoids those deformities created by extending osteotomies into the thick frontal bone. A lateral osteotomy may be used to narrow a wide nasal base, or to close open roof deformity. "Low-high", "low-low" and double osteotomies have been described. After dorsal hump removal and osteotomies, I frequently use spreader grafts to reconstruct middle nasal vault.