In secondary septorhinoplasty, the septal L-strut extension graft (SLEG) is the preferred method for reconstructing the nasal framework, especially in cases with perforations or infections. Cantilever grafts are more prone to complications due to poor integration, while SLEG offers superior stability against late-onset inflammation. Securing the anterior nasal spine (ANS) and rhinion is key for graft stability; if the ANS is compromised, alternative fixation becomes necessary. Donated rib cartilage provides additional options when calcification or patient-specific factors arise, though with limitations. Repairing high septal perforations is essential to maintain nasal integrity, using techniques such as surgical closure, local flaps, or perichondrial grafts. The perichondrium’s critical role in healing underscores the need for meticulous planning and method selection to achieve optimal surgical outcomes.