BACKGROUND: Septal extension grafts in rhinoplasty can successfully support tip projection/position, tension the lower lateral cartilages, and thereby open the nasal airway. Since long cartilage grafts under tension may warp or collapse over time, long-term outcomes must be evaluated in these patients. We aimed to assess long-term functional outcomes in a large series of patients who underwent septal extension grafting. METHODS: Retrospective chart review was performed on all patients who underwent an open rhinoplasty approach that included use of a septal extension graft performed by a single surgeon from February 2013 through December 2018. Patients with a minimum 12-month postoperative follow-up were included. Pre- and postoperative functional outcomes including history of nasal obstruction, snoring, sleep apnea, sinus congestion, and sinus headaches were recorded. Patient demographics, types of grafts used, patient complaints, readmission, and reoperation rates were recorded. Statistical analysis was performed using McNemar’s test. RESULTS: Of the 385 patients who underwent open rhinoplasty with septal extension grafting during the study period, 127 with adequate follow-up were included; 72% females, 28% males, mean age 28 (range: 5–72) years. 83.5% primary rhinoplasty, 16.5% secondary rhinoplasty. Mean follow-up was 24.2 (range: 11.2–74.0) months. 10.2% had history of cleft lip, 49.6% had history of nasal trauma. Other graft types used included tip/infratip (92.9%), dorsal onlay (90.6%), spreader graft/flap (92.1%), and columellar strut/onlay (7.9%). 85.0% underwent a turbinate outfracture/coblation. Patients reported an improvement in (pre- versus postoperative) nasal airway obstruction (89.8% versus 11.8%; P < 0.001), snoring (55.1% versus 1.6%; P < 0.001), sleep apnea (5.5% versus 0.0%; P = 0.016), sinus congestion (45.7% versus 15.7%; P < 0.001), and sinus headaches (6.3% versus 0.0%; P = 0.008). All patients reported an improvement in aesthetic appearance, with 7.9% undergoing touch-up procedures such as filler or fat injection to smooth a minor contour deformity. 6.5% of patients in this cohort required reoperation; the most common reasons for reoperation were for nasal deformity/deviation (72.0%), persistent airway obstruction (20.0%), and scar revision/dermabrasion (8.0%). Only 3.1% of noncleft, nontrauma patients required revision. No patients reported worsening of nasal airway patency. CONCLUSIONS: Septal extension grafts, when applied in open rhinoplasty patients, can reliably and significantly improve functional outcomes in addition to the aesthetic benefits to tip projection and rotation. Quantitative analysis of nasal airway changes following septal extension grafting will be presented.