Background <p>Rhinoplasty is among the most frequently performed procedures in facial surgery, creating a growing need for evidence-based approaches. Recent innovations have expanded the range of available primary rhinoseptoplasty (RSP) techniques, increasing the complexity of surgical decision-making. Selecting the appropriate technique for each region of the nose, particularly the tip, midvault, and septum, demands an understanding of well-established principles.We aimed to evaluate outcomes and complication rates of commonly used techniques in RSP including those for tip positioning, midvault reconstruction, and extracorporeal septal reconstruction (ESR)—to support evidence-based surgical decision-making. Also, to develop a comprehensive database and establish a baseline against which emerging techniques in primary RSP can be systematically compared.</p> Methods <p>A retrospective analysis of 3,364 nasal and septal surgeries (2,067 primary RSP cases) performed between January 1, 2010, and August 31, 2020, assessed columellar strut grafts (CSG), tongue-in-groove (TIG), suspension sutures, spreader flaps, spreader grafts, conchal cartilage grafts, and ESR. Major complications requiring hospitalization or revision surgery included bleeding, infection, septal perforation, tip ptosis, midvault collapse, and bony edges. Associations between techniques and complications were analysed using chi-squared tests and logistic regression.</p> Results <p>Complication rates in primary RSP were low, with bleeding, infection, septal perforation, and midvault collapse occurring in fewer than 1% of cases. No significant association between ESR or autologous cartilage grafting and these complications was found. Spreader grafts and flaps were equally effective for midvault reconstruction, with no significant difference in complication rates (0.39% vs. 0.55%, <i>p</i> = 0.56). CSG and TIG reliably maintained tip position without increasing tip ptosis risk. Suspension sutures showed a weak association with tip ptosis (<i>p</i> &lt; 0.001, Phi = 0.08), but not in the primary RSP subgroup.</p> Conclusions <p>The complexity of RSP techniques reviewed in this study do not impact revision rates. Findings support the safety and efficacy of CSG, TIG, spreader grafts, and spreader flaps for nasal framework stabilization. Comprehensive databases remain crucial for advancing evidence-based surgical decision-making and optimizing patient outcomes as rhinoplasty evolves.</p> Level of evidence <p>Level III, therapeutic study.</p>