Background <p>Reconstructive rhinoplasty for severely deformed noses requires meticulous technique. While reusing mid-columellar incisions is a common practice, a V-shaped columella-labial incision with V-Y closure may provide superior results. We conducted a prospective study to compare the outcomes of these two approaches.</p> Methods <p>This study included 52 patients (<i>n </i>= 26 per group) who underwent reconstructive rhinoplasty. Group A received a V-shaped columella-labial incision, while Group B received a mid-columellar incision. All surgeries were performed by the same surgeon. Standardized pre- and one-year postoperative photographs were analyzed for changes in nasal projection, columellar height, and scar quality (Stony Brook Scar Evaluation Scale) by independent evaluators.</p> Results <p>The V-shaped incision group demonstrated significantly greater improvement in nasal projection after adjustment for baseline differences (adjusted <i>p </i>= 0.002) and greater columellar height gain (<i>p </i>&lt; 0.001) compared with the mid-columellar group. Linear regression analysis confirmed that columellar incision type remained an independent predictor of projection change after controlling for preoperative projection. Scar assessments showed no significant difference between groups (<i>p </i>= 0.557).</p> Conclusion <p>The V-shaped columella-labial incision provides significantly greater improvement in nasal projection and columellar height without increasing scar-related concerns. This technique demonstrates reliability as an initial approach for managing severely compromised nasal structures, though further studies are warranted.</p> Level of Evidence II <p>This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors <a href="http://www.springer.com/00266">www.springer.com/00266</a>.</p>