The nasal septum is a structure poorly understood and appreciated by the lay public and the nonotolaryngologist—head and neck surgeon alike. Deviation of the caudal portion of the nasal septum may result in nasal obstruction, a crooked nose, and columellar irregularities. The correction of a severely deviated caudal septum is one of the most difficult challenges of the otolaryngologist and facial plastic surgeon. A variety of options are available for correction of mild, to the most severe, deflections. This condition, as with all challenges in medicine, should not be a one size fits all or one surgery fits all situation. The skilled surgeon should understand the multiple options available for surgical correction and tailor fit the procedure to the deformity.