Introduction: Complex reconstructive septorhinoplasty requires harvesting a large amount of tissue for grafting. Autogenous costochondral and auricular cartilage has generally considered the gold standard grafting material, if insufficient septal cartilage remains. The aim of this paper was to describe our technique and report our experience with the use of costal cartilage grafts in cases with significant nasal deformities with insufficient septal cartilage. Design: Retrospective review of patients who underwent septorhinoplasty with costochondral grafts between 1995 and 2015. Results: Over a 20-year period from 1995 to 2015, a total of 711 rhinoplasties were carried out at Aintree University Hospital, Liverpool. Of these, 46 (5.7%) utilized costal cartilage as the material to provide skeletal support. Male to female ratio was 2:1, and mean age was 34 years (15–56); 22 presented with congenital deformity and 24 with acquired deformity. All had severe nasal collapse (grades III and IV). Conclusion: Costal cartilage is the ideal material for reconstruction of severe saddle noses. There are no crossinfection risks, the donor site is low morbidity, it is easy to harvest, has a plentiful supply, and is easy to carve and sculpt. The tendency to warping is a disadvantage, but this can be prevented in most cases by careful attention to technique, and is usually easy to correct by minor revision where necessary. It is usually dimensionally stable and is able to resist infection, and where exposure occurs due to wound breakdown, it will heal without total graft loss.