Background: Proper nasal tip projection and rotation have a strong impact on nasal aesthetics. Septal extension graft (SEG) is one of the tools employed to improve tip projection and rotation when performing rhinoplasty. This graft typically overlaps the existing caudal septum in the midline position, lengthening it and facilitating the repositioning of the tip. Objectives: The authors sought to describe the technical evolution of the SEG in endonasal rhinoplasty and evaluate the reliability and long-term efficacy of the current technique. Methods: The authors evaluated presurgical and postsurgical photographs of the nasolabial angle and nasal proportions in 60 patients who underwent endonasal rhinoplasty with SEG. Results: The study demonstrated a clear improvement in tip projection and rotation at the 1-year follow-up. The mean preoperative nasolabial angle was 93.75° ± 9.45° compared with 101.1° ± 5.3° following surgery. Although both were normally distributed, the range of the postoperative nasolabial angle was narrower than 1-year preoperatively (standard deviation = 5.3° vs 9.45°, respectively). The Crumley ratio, utilized to describe nasal proportions, presented significant changes in nasal proportions: 3.84 preoperatively and 4.04 postoperatively (95% confidence interval = -0.24 to -0.149; P < 0.001). Conclusions: The utilization of SEG in endonasal rhinoplasty has significantly changed since first described in 2006. The adaptations made to this technique render it more reliable, and our study demonstrates its efficacy in improving tip projection and rotation over the long-term.