Columellar strut grafts and septal extension grafts are commonly used support structures; however, their relative effectiveness remains debated. The purpose of this study was to compare the long-term stability of septal extension grafts to that of columellar strut grafts. A retrospective review of all primary rhinoplasties performed by the senior author (R.J.R.) from 2016 to 2019 was performed. All adult patients undergoing primary open rhinoplasty with at least 1 year of follow-up were included. Revision cases and those in whom rib grafts were used were excluded. Standardized postoperative imaging was assessed at 2 months (early) and at 12 months (long-term) to measure projection/rotation change over time. Univariate and multivariable statistical comparisons were performed. The chart query yielded 133 patients. Of these, 40 patients were treated with a columellar strut and 37 patients were treated with a septal extension graft. Projection loss at 1 year was 4.7% for the columellar strut group compared with 0.2% for the septal extension graft group ( P < 0.0001). On multivariable logistic regression, there was a 5.1-fold increased risk of greater than 4% projection loss when using a columellar strut ( P < 0.005). Mean rotation loss for the columellar strut group was 4.9 degrees compared with 1.3 degrees for the septal extension graft group ( P < 0.0001). The independent effect of columellar strut use resulted in a 2.8-fold increased risk of rotation loss greater than or equal to 5 degrees ( P < 0.05). Septal extension grafts result in effectively no loss of projection and minimal loss in rotation. A small degree of projection and rotation loss can be expected with the use of a columellar strut alone. These long-term graft tendencies should be anticipated and accounted for appropriately. Therapeutic, III.