A woman in her 40s, with a history of congenital cleft lip and palate who had over 20 previous surgeries. She presented with an over-rotated nasal tip with severe alar retraction and inability to breathe through her nose. She is now six months post-op from complex revision rhinoplasty with correction of nasal tip asymmetry, tip derotation, correction of alar retraction, and spreader graft placement using MTF cartilage. In addition to her goal of having a natural looking nose, her breathing has dramatically improved. This case was performed by Dr. Reish and Dr. Ruotolo working as co-surgeons together.