The challenge for the modern rhinoplasty surgeon is to create a nose that appears natural and balances with the individual's face and ethnicity. The use of spreader grafts in endonasal rhinoplasty as described by Sheen has been expanded by the external approach to (1) straighten and buttress weakened L-struts in a high dorsally deviated septum, (2) recreate dorsal aesthetic lines, (3) reconstruct a narrow middle vault, and (4) restore the internal nasal valve. The advantages of the external approach in the use of septal spreader grafts includes ease of harvest, accurate contouring, and precise placement and suture stabilization to minimize postoperative graft displacement. The versatility of this technique allows the surgeon to attain consistent functional and aesthetic results in the management of dorsal mid-vault problems in primary and secondary rhinoplasty.