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Page 6 of 13 Randall et al. Plast Aesthet Res 2024;11:18 https://dx.doi.org/10.20517/2347-9264.2023.115

[35]
the appearance .

Prevention
Surgical etiologies of alar retraction include excessive resection of the lower lateral cartilage, improperly
placed sutures to manipulate the shape of the lower lateral cartilage, and contracture due to scarring. When
performing trimming of the lower lateral cartilage, it has historically been suggested that leaving at least
6-10 mm in width to an intact strip of lateral crus would help to prevent alar retraction and preserve shape.
In current practice, surgeons are preserving more of the lateral crus and are using structural techniques or
[37]
[38]
lateral crural tensioning to reshape convex lateral crura instead of resecting a large cephalic trim
[Figure 1]. The degree of cephalic resection and subsequent rotation has been shown to relate to the severity
[39]
of alar retraction following surgery .

When considering the necessity of cephalic resection, simple repositioning of the lower lateral cartilages
may be an effective alternative and has been shown to result in a significant lowering of the alar rim even
[40]
without additional grafting . To ensure that the function of the external nasal valve remains intact with
repositioning of the lower lateral cartilage, it can be helpful to draw a line that represents the long axis of the
lateral crus. For optimized external nasal valve function, this long axis should point at the lateral canthus
when secured in the corrected position .
[41]

Appropriate handling and manipulation of the soft tissue and vestibular skin overlying the lower lateral
cartilages is also essential in preventing alar retraction. Because the soft tissue envelope is comprised of skin,
subcutaneous fat, and the superficial musculoaponeurotic system (SMAS), its thickness can vary between
[42]
patients . While a healthy soft tissue envelope may be freely mobile in many cases, patient age, gender,
ethnicity, and prior trauma or surgery may impact its general laxity [42,43] . These variables may impact the soft
tissue envelope in which the alar cartilage is contained and may not always be amenable to stretching. This
restriction can even result in minimal scar contracture from surgical intervention, leading to appreciable
alar retraction. The pyriform ligament, attaching the pyriform rim to the lower lateral cartilage, must also be
considered, and usually released, when approaching malpositioned crura in need of repositioning or
[44]
grafting .
Alar contour grafts are often thought of as a first line in correcting alar deformities but can also be an
effective method of preventing this complication in patients who are at high risk for alar retraction. In a
controlled retrospective study comparing patients who received alar contour grafts and those who did not in
primary rhinoplasty, Unger et al. not only found significantly reduced rates of alar retraction in the alar
contour graft group, but also found improved alar aesthetics in general . Additionally, there was no
[45]
complication in this series associated with graft placement, suggesting that alar contour grafting may be a
low-risk option during primary rhinoplasty to not only prevent alar retraction, but also to improve the
aesthetic appearance of the nasal ala.

Correction
Every rhinoplasty surgeon should have a repertoire of lower lateral cartilage grafts that can be employed to
address alar retraction. The shape of the lower lateral cartilages, the severity of the retraction, and the
availability of donor cartilage may all influence which type of grafting is used to correct alar retraction.
When placing lower lateral cartilage grafts, it is helpful to create a dissection pocket to hold the graft that is
closer to the vestibular skin than the external skin, which may help to prevent the graft from becoming
visible externally or displacement of soft tissue into the vestibule . Regardless of the type of graft used, both
[37]
the form and function of the nose need to be considered with any manipulation or adjustment of the size,