Reshaping of the bony vault in primary and revision rhinoplasty is a simple, yet precise, maneuver that requires both skill and experience in creating predictable outcomes. Different methods for remodeling the nasal pyramid using various types of osteotomies have been devised to achieve narrowing, straightening, and reduction in nasal height. However, the current options of techniques including medial, transverse oblique, low to low lateral, low to high lateral, and intermediate osteotomies do not address all types of deformities encountered. These include the wide pyramid, the prominent frontal process of the maxilla, the convex nasal bone, and the deviated nose. Accordingly, the senior author has devised a new procedure, named the "perforating double lateral osteotomy," that has been used on hundreds of patients, with excellent results.