25 Ancillary Maneuvers in Rhinoplasty: Alar Rim Grafts

Jason Roostaeian and Sean Saadat

Abstract

Cartilage grafts have long been used in all aspects of both aesthetic and functional rhinoplasty to help correct deformities and provide a sound structural support to the nasal complex. The alar rim is naturally composed of fibrofatty tissue with no cartilaginous support, thus leading to a high incidence of deformities especially after trauma or prior rhinoplasty. Alar notching is a significant deformity that can occur for multiple reasons and cannot be corrected without some form of support to smooth out any irregularities in the nasal skin envelope. Multiple techniques including dermal grafts, fat grafting, and skin redraping techniques have been described to try and correct notches in the alar rim, but none of these options have proven as successful as the alar contour graft. As described in this chapter, alar contour grafts, which are composed of a strip of autologous or cadaveric cartilage, are a key component when correcting alar deformities such as notching or collapse. The cartilage is placed into a bluntly dissected subcutaneous pocket at the alar margin as a last step in the procedure. Alar contour grafts are a key component of rhinoplasty and their routine use has been shown to consistently improve overall nasal function and aesthetic outcomes.

Nasal ala – rhinoplasty – alar contour graft – alar rim – cartilage grafting – nasal aesthetics – nasal reconstruction – alar reconstruction

25 Ancillary Maneuvers in Rhinoplasty: Alar Rim Grafts

Key Points

Without the proper structural support, the nasal ala can retract, notch, or collapse, leading to both aesthetic and functional deficits in the nasal complex.
Alar rim grafts are an effective way of correcting alar notching or asymmetries of the alar rims in both primary and revision rhinoplasty as well as nasal reconstruction.
The alar rim is ideally located <2 mm from the long axis of the nostril.
It is important to remember that the basal view of the nasal complex should be an equilateral triangle with an alar to lobular ratio of 2:1 (Fig. 25.1c).
The aesthetic goal should be to achieve a gentle gull-in-flight appearance on anteroposterior view (Fig. 25.1b).

**Fig. 25.1** **(a–c)** Overview of alar aesthetic and functional position. **(a)** The alar position of profile view is key to ensuring the nose does not appear notched or have excessive columellar show. **(b)** A gentle gull-in-flight appearance on anteroposterior view. **(c)** Basal view of the nasal complex should be an equilateral triangle with an alar to lobular ratio of 2:1. (Reproduced with permission from Dallas Rhinoplasty Meeting Alar Contour Grafting Presentation by Dr Jason Roostaeian, originally from Dallas Rhinoplasty.)

25.1 Preoperative Steps

25.1.1 Initial Assessment of Need for Alar Rim Grafts

Indications for alar rim graft placement include weak and asymmetric alar rims; a ptotic, boxy, or bulbous nasal tip; secondary rhinoplasty requiring a correction of alar notching; and nasal reconstruction after the compromise of the nasal–alar complex (Fig. 25.2).
Alar contour grafts are also an important adjunct to other alar grafts such as the alar batten graft or lateral crural strut graft.
Be sure to determine the strength and position of the lower lateral cartilages, as this may reveal a need for further support in addition to alar contour grafts to correct significant alar deformities.
On functional examination, have the patient take a deep nasal inhalation, and repeat while manually blocking the left or right nostril sequentially to reveal if there is marked collapse of either nostril indicating a lack of structural support in the ala.