A line is drawn from posterior to anterior nostril apex (PA). A line perpendicular to the PA line is then extended up to the point of maximal retraction along the alar margin. The “target” level of alar rim position was assigned to be 1 mm above the PA line.
Percentage of target alar rim position attained according to each rhinoplasty maneuver.
Percentage of target alar rim position attained with cartilage grafting vs without cartilage grafting when the preoperative width of the lateral crura was less than 4 mm.
Percentage of target alar rim position attained with and without cartilage grafting when a cephalic trim of greater than or equal to 4 mm was concurrently performed.
Effects of preoperative cephalically oriented lower lateral cartilages on alar retraction. negative value indicates increased retraction.
A and B, Preoperative frontal and right lateral views of a patient with severe alar retraction. C and D, Eight-year postoperative views showing markedly improved alar rim position following composite auricular cartilage grafting.
A and B, Preoperative left-sided alar retraction. C and D, Postoperative views showing improvement in alar rim position following placement of a lateral crural strut graft.
Algorithm for management of alar retraction. LLC indicates lower lateral cartilage.
Alexander AJ, Shah AR, Constantinides MS. Alar RetractionEtiology, Treatment, and Prevention. JAMA Facial Plast Surg. 2013;15(4):268-274. doi:10.1001/jamafacial.2013.151
The effect of different rhinoplasty maneuvers on alar retraction remains to be elucidated.
To determine the etiology and treatment of alar retraction based on a series of specific rhinoplasty maneuvers.
Retrospective review of a single surgeon’s rhinoplasty digital photo database, examining preoperative alar retraction from January 1, 2002, to December 31, 2005, in 520 patients. Patients with more than 1 mm of alar retraction on preoperative photographs were identified. Postoperative photographs were examined to determine the effect of specific rhinoplasty maneuvers on the position of the alar margin; these maneuvers included cephalic trim, cephalic positioning of the lower lateral cartilage, composite grafts, alar rim grafts, alar batten grafts, and overlay of the lower lateral cartilage.
Tertiary care academic health center.
Forty-five patients with alar retraction met inclusion criteria, resulting in 63 nasal halves with alar retraction.
Main Outcomes and Measures
Intraoperative findings, postoperative results.
Forty-seven percent of the patients (n = 21) had prior surgery; 47% also had cephalically positioned lower lateral cartilages. Among patients with less than 4 mm of cartilage width at the outset, 46% of those who received supportive grafts achieved target correction vs only 7% for patients who did not undergo supportive cartilage grafting. In patients who underwent more than 4 mm of cephalic trim, those who received supportive grafts achieved 46% of target correction vs 11% among those who did not. Ninety-five percent of composite grafts, 69% of alar strut grafts, 47% of alar rim grafts, 43% of vertical lobule division, and 12% of alar batten grafts achieved their target correction values.
Conclusions and Relevance
Alar retraction is a highly complex problem. It can be seen de novo and is associated with cephalically positioned lower lateral cartilages. Structurally supportive grafting—including composite grafts, alar strut grafts, alar rim grafts, vertical lobule division, and alar batten grafts—can improve alar retraction.
Level of Evidence
Alar retraction is classically thought to be an unsightly stigma of overly aggressive rhinoplasty. However, it has been our experience that alar retraction is also prevalent in the general population and can be seen in patients without a prior history of rhinoplasty. In addition to an unfavorable aesthetic appearance, alar retraction may also have functional consequences, manifesting in the collapse of the external nasal valve.1- 3
In the analysis of alar-columellar disproportion, alar retraction is identified by the presence of alar notching, weak lateral crura, retraction of the alar margin, or excessive curve to the alar rim margin. These various etiologies can be congenital or acquired.4
Iatrogenic alar retraction results when aggressive resection of the cephalic portion of the lower lateral cartilage leads to weakening of the cartilage, causing it to retract superiorly. A central tenet of rhinoplasty surgery espouses the preservation of a critical width of the lateral crura—typically greater than 7 mm—to maintain the structural integrity of the cartilage framework. Some alar cartilages are inherently weak, so a smaller cephalic excision may be needed to prevent alar retraction.
Division and, in some cases, removal of the soft-tissue and ligamentous attachments of the lower lateral cartilage may weaken its support and render it more susceptible to upward retraction. Medially, the medial crura have ligamentous connections to the nasal septum. Laterally, the accessory cartilages and their encasing ligaments serve as an attachment for the lateral crus to the pyriform aperture to form the lateral crural complex.5 Cephalically, the alar cartilage has fibrous attachments to the upper lateral cartilage at the scroll. During rhinoplasty, these attachments are subject to disruption. Moreover, resection of the actual cartilage not only may decrease the structural framework of the nostril but also may remove adjoining supportive attachments, further weakening the alar cartilages.
Preoperative alar rim retraction can be managed with several different techniques. Typically, repair of alar rim retraction requires cartilage grafting to effectively lower the nostril margin and support the lateral crus.4,6,7 Determining which reparative technique is best suited to which alar retraction is one of the great challenges in rhinoplasty.
Surgeons seeking to avoid and correct alar retraction are forced to rely on the experience of other surgeons rather than compelling objective data. We sought to analyze the records of the senior author (M.S.C.) to determine which maneuvers were most effective in improving alar retraction and which cartilage states were most likely to result in retraction of the alar margin.
An institutional review board–approved retrospective analysis of the senior author’s (M.S.C.) rhinoplasty database was performed to identify all patients who underwent primary or revision rhinoplasty from January 1, 2002, to December 31, 2005. In total, 520 patients were found. From this group, all patients with preoperative alar retraction greater than 1 mm on lateral view were identified. All patients had a minimum of 6 months postoperative follow-up.
Preoperative and postoperative photographs were taken with a Canon EOS 5D digital single-lens reflex camera with a 105-mm macro lens in a standardized manner. Distances were measured only on lateral view as previously described. Preoperative measurements were obtained using Adobe Photoshop.
Alar retraction was identified by Gunter’s classification system.8 A line was drawn from the anterior to the posterior apex of the nostril. A line perpendicular to this line was then drawn to the point of maximal retraction. An additional line was drawn that would create the ideal level of alar rim position, which should be 1 to 2 mm above the anterior-to-posterior apex line. For consistency, the ideal line was determined to be 1 mm above the anterior-to-posterior apex line and was defined as the “target” level of alar position (Figure 1). Postoperative photographs were then analyzed to determine the postoperative alar retraction distance. The postoperative measurements were compared with preoperative values. A fixed data point from the midpoint of the tragus to the lateral canthus was used to derive a multiplier to standardize lengths between photographs. This allowed an objective means of comparing preoperative and postoperative photographs.
The senior author (M.S.C.) used detailed rhinoplasty worksheets to document the amount of cartilage removed, the amount that was preserved, and the size and location of any cartilage graft that was employed. Calipers were used for all intraoperative measurements. For patients in whom cartilage-splitting techniques were used, the amount of overlap was measured. In addition, patients with cephalically oriented cartilages were identified on preoperative photography based on the presence of lower lateral cartilages that were aligned with the medial canthus rather than the lateral canthus.9,10
Statistical analysis involved a 1-tailed t test comparing preoperative and postoperative values.
The lateral crural strut graft is placed by elevating the vestibular skin off the undersurface of the lateral crus and positioning the graft deep to the lateral crus in an underlay fashion. The graft is usually directed more caudally than the posterior portion of the lateral crus, essentially acting to support the region of the external valve devoid of cartilage. Therefore, its medial portion supports the lateral crus lateral to the dome, while its lateral portion supports the hinge area, where ligaments course from the lateral crus toward the pyriform aperture. In the setting of malpositioned lateral crura and severe cases of alar collapse and alar retraction, a longer strut is used. When the lower lateral cartilages are cephalically malpositioned, a caudal repositioning of the lateral crura can be performed to bring the cartilage to a more anatomic position; in this case, a lateral crural strut may be placed concomitantly for structural support to the repositioned lateral crus. Last, when faced with significant convexity of the lateral crura, a lateral crural strut graft can be used to provide a brace against which the crura can be straightened. Typically, the lateral end of the strut graft is positioned in a pocket at the level of the pyriform aperture edge (not in the flaccid portion of the alar wall) to avoid medial graft displacement with inspiration. To prevent postoperative visibility, the lateral end of the strut is placed caudal to the alar groove. The graft is typically either secured to the overlying lateral crus with 6-0 permanent or 5-0 absorbable monofilament suture or can be secured full thickness through the underlying vestibular skin with a 4-0 or 5-0 absorbable monofilament suture. Cartilage from the septum or rib is most ideally suited to lateral crural strut grafts; conchal cartilage is usually too weak to provide adequate support.
Alar batten grafts serve a similar function to lateral crural strut grafts: they provide structural support to the alar sidewall. They can also help push down a retracted alar rim. The alar batten graft is placed lateral to the lateral crura as an overlay, as opposed to the lateral crural strut graft, which is an underlay graft.
Alar batten grafts are typically fashioned from septal or auricular cartilage (cymba cavum or cymba concha), although rib is also used. They are cut into a rectangle measuring 10 to 15 mm in length and 4 to 8 mm in width.11 Alar batten grafts are curvilinear in shape, with the convexity of the graft oriented laterally to provide maximum support to the lateral wall. Grafts are placed into a dissected precise pocket: for internal nasal valve collapse, this pocket is situated at the point of maximal lateral wall collapse, which is usually at the lateral margin of the upper lateral cartilage (ie, at the supra-alar crease). For external valve collapse, the pocket is dissected caudal to the lateral crus; this usually occurs in the setting of cephalically oriented lateral crura. Alar batten grafts are suture fixated either to the overlying skin or to the underlying lateral crus with absorbable 4-0 or 5-0 monofilament sutures.
Preoperatively, the area of sidewall collapse can be marked while the patient inspires during a modified Cottle maneuver.11 This maps out the area of the precise pocket to be dissected.
Alar rim grafts are nonanatomic cartilage grafts used to provide structural support to the alar margin. They can be used to straighten alar notching, treat mild alar retraction by pushing the alar margin down 1 to 2 mm, or prophylax against alar retraction in at-risk primary or revision cases. Alar rim grafts are typically cut in a rectangular shape measuring 10 to 15 mm in length and 2 to 3 mm in width. After infiltration with 1% lidocaine with 1:100 000 epinephrine, the skin caudal to the marginal incision is dissected with a tip scissor. The graft is then inserted into this pocket and trimmed to the appropriate length to prevent visibility. The medial leading edge of the graft is crushed with Brown-Adson tissue forceps to prevent a sharp edge distorting the soft triangle. A 5-0 absorbable suture is used to secure the leading edge to the skin edge.
Significant alar retraction (>3 mm) requires composite grafting to the nasal vestibule to lower the alar margin. Composite grafts are harvested from the lateral concha and contain cartilage and overlying skin on one side only. There are equal amounts of cartilage and skin in the graft. The donor site is closed primarily; if the defect is too large, a postauricular full-thickness skin graft or a postauricular island flap is used.
An incision is made in the nasal vestibule, 2 mm behind the alar rim, paralleling the alar margin. Sharp-tip scissors are used to spread perpendicular to the incision to create space for the graft to be inset. With the skin side facing into the nasal airway, the graft is inset with interrupted 5-0 absorbable sutures under minimal tension to avoid vascular compromise.
Vertical lobule division has a variety of applications, including decreasing nasal tip projection, increasing or decreasing rotation, narrowing a wide domal arch, addressing a hanging infratip lobule, equalizing tip asymmetries, or correcting an elongated nostril.12 In the present study, vertical lobule division was used for this last indication.
Vertical lobule division involves dividing the crura anywhere between the medial crural and lateral crural angles12; the decision of where to make the division is dependent on the desired outcome. Anderson’s tripod theory predicts the resultant changes in rotation and deprojection.13 For example, division in the middle of the intermediate crus causes deprojection without rotation. Conversely, division lateral to the dome will affect deprojection and cephalic rotation. By overlapping and suturing together the cut segments, additional stability is conferred to the resultant construct.
The vestibular skin is dissected off the undersurface of the tip cartilages in the area of intended division, typically lateral to the dome for correction of the elongated nostril. Calipers are used to measure precisely how much cartilage is to be overlapped. The lateral crus is then divided, the medial segment is positioned over the lateral segment, and the overlapped edges are sutured together using 6-0 permanent monofilament sutures. This produces deprojection and mild cephalic rotation while shortening the elongated nostril.
Forty-five patients were identified with alar retraction, resulting in a total of 63 retracted alar rims. Twenty-one of the 45 patients (47%) had undergone previous rhinoplasty, while the remaining 24 patients had not. Twenty-one of the 45 patients (47%) with alar retraction had cephalically oriented cartilages.
Figure 2 shows the percentage of target correction of alar retraction that was achieved with various techniques in isolation (ie, without the use of another graft). Figure 3 shows the effects of grafting when less than a 4-mm width of lower lateral cartilage was present at the outset of the case. When grafting occurred, the alar retraction was improved to 46% of the target goal on average, while the alar retraction only improved 7% without grafting. In patients with 4 mm or more of cephalic trim excised, those who received cartilage grafts reached 46% of their target goal, while patients without cartilage grafts achieved only 11% of their target goal (Figure 4).
The effects of cephalically oriented lower lateral cartilages were also examined (Figure 5). In all patients with cephalically oriented lower lateral cartilages, 32% of target correction was achieved. In patients with cephalically oriented cartilages in which less than 4 mm of cartilage remained at the conclusion of the case and no grafting was performed, alar retraction increased by 11% on average. In patients with cephalically oriented cartilages with more than 4 mm of cartilage excised, patients demonstrated an increase in alar retraction of 9%. Those patients who had cephalically oriented cartilages and underwent cartilage grafting demonstrated a 54% decrease in alar retraction on average.
Rhinoplasty is arguably the most complex surgical procedure in facial plastic surgery. There are a multitude of techniques and nuances; due to the complexity of the operation, it can be difficult to ascertain the impact of various maneuvers on a patient’s final result. To our knowledge, no study has attempted to quantify the effects of various rhinoplasty maneuvers on alar margin position.
Gunter et al8 introduced a system that classified alar-columellar relationships on lateral view into 6 types. In their classification, they used the distance between the long axis of the nostril and columella or alar rim to classify the alar-columellar relationship. Distances greater than 1 to 2 mm were considered indicative of alar retraction.8 Guyuron,14 claiming that this classification was only 2-dimensional, included the basal view to add 3 additional classes of alar rim deformities.
Several of our findings were surprising. First, alar retraction is conventionally thought to be a result of aggressive rhinoplasty. However, in the present study, 53% of patients had not had rhinoplasty before. Second, composite grafts were found to be the most efficacious overall maneuver in improving alar retraction (Figure 6).
For cases in which the final width of the lower lateral cartilage was less than 4 mm, even subsequent cartilage grafting improved alar retraction to only less than 50% of the target position. The same outcome was true for patients who underwent 4 or more millimeters of cephalic trim of the lateral crura. Cephalically oriented lower lateral cartilages had a propensity for increased alar retraction when the lateral crura were narrow or underwent a large cephalic trim.
In all 3 instances described above, the proposed etiology for alar retraction is related to physical dynamics: with excessively narrowed lateral crura or cephalically oriented lower lateral cartilages that have been narrowed, an increased potential space between the upper and lower lateral cartilages is created. This potential space then allows the lateral crura to retract superiorly, thereby drawing up the alar margin and producing alar retraction. The objective in managing this situation is to maintain the refinement of the cephalic edge of the lateral crura, while bolstering the caudal region to counteract retraction of the alar margin.
In all cases, the target position of the alar margin was more readily achieved when cartilage grafting was employed. In individuals with cephalically oriented lower lateral cartilages who undergo cephalic trim, it may be prudent to prophylactically employ cartilage grafting—alar strut and alar rim grafts—to prevent the future development of alar retraction (Figure 7). On the basis of the results of this study, we present an algorithm for management considerations in alar retraction (Figure 8).
This study is limited by a short mean follow-up duration of 6 months. While follow-up of more than 1 year would be desirable, in a diverse international practice (M.S.C.), it is often difficult to obtain reliable patient photographs and follow-up after 1 year.
The results of this study objectively confirm that which is intuitively suspected: that overresection of the lateral crura can lead to alar retraction, and cartilage grafting has a measureable effect on improving this retraction. Interestingly, it also identifies the existence of alar retraction in unoperated noses. The present study has identified an algorithmic approach to the management of alar retraction, which is based on the degree of measured retraction. Furthermore, in the setting of cephalically oriented lower lateral cartilages, when cephalic trim of the lateral crura is performed, one should consider prophylactic cartilage grafting in the form of either alar strut or alar rim grafts. Future research would be beneficial to further delineate the optimal techniques for various etiologies of alar retraction and the long-term success of the interventions employed herein.
Corresponding Author: Ashlin J. Alexander, MD, Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology, New York University, 530 First Ave, Ste 7U, New York, NY 10016 (email@example.com).
Accepted for Publication: January 30, 2013.
Published Online: April 25, 2013. doi:10.1001/jamafacial.2013.151
Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition of data: Alexander, Shah.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Alexander, Shah.
Administrative, technical, and material support: All authors.
Study supervision: All authors.
Conflict of Interest Disclosures: None reported.