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Randall et al. Plast Aesthet Res 2024;11:18 https://dx.doi.org/10.20517/2347-9264.2023.115 Page 7 of 13

Figure 1. Historical guidance was to leave a minimum of 6 mm of width (orange lines) to the lateral crus after performing a cephalic
trim. This type of trim can leave a structural void between the upper and lower lateral cartilages, leading to alar retraction. It can also
sufficiently weaken the cartilage longitudinally, predisposing to buckling of the cartilage and bossa formation. The senior author prefers
a more medially placed cephalic trim, which preserves most of the structural integrity of the lateral crura (blue lines). This type of trim
will permit reorienting the short axis of the lateral crus, flattening its shape and decreasing the volume in the supratip, moving the
supratip break closer to the tip defining point.

shape, or position of the lower lateral cartilages.

Already mentioned in the setting of prevention, a common “workhorse” for correction of mild alar
retraction is the alar contour graft. Alar contour grafts consist of a thin, 2-3 mm strip of cartilage that is
used to reinforce and reshape the caudal edge of the lower lateral cartilage where the retraction has
occurred. However, this graft may not be as effective in treating more severe notching or in a case with
significant scarring, leading Boahene et al. and Rohrich et al. to suggest against its use in these scenarios [46,47] .

For mild retraction in the setting of weak lower lateral cartilages, an alar batten graft can be used to help
strengthen shape. This can be used in both treatment of mild retraction and prevention of postoperative
retraction during primary rhinoplasty in patients who have notably weak alar cartilage .
[48]
Lateral crural strut grafts are used most frequently in approaching revision of the lower lateral crura. These
grafts are secured to the underside of the remaining lower lateral crura and can help to reestablish stability
of the lateral nasal wall while correcting asymmetry. Some authors, when faced with severe alar retraction
and sagitally malpositioned lower lateral crura, employ lateral crural strut grafting and caudal repositioning
[49]
for correction [Figure 2]. This method can be helpful in reorienting the nasal base but should not be
considered for mild or focal alar retraction that can be approached with a more focused correction.
Cartilage grafts measuring approximately 25 mm × 5 mm × 1.5 mm are attached to the underside of the
lower lateral cartilage remnants with 5-0 polydioxanone (PDS) sutures. Costal or septal cartilage is preferred
over conchal cartilage for lateral crural strut grafts because the strength of cartilage from these donor sites
allows for thinner grafts without sacrificing integrity. This graft is then placed in a pocket dissected in a
caudal position compared to the original position of the lower lateral crura between the soft tissue envelope
[50]
and vestibular mucosa .
In instances of severe alar retraction, it can become necessary to replace all or some of the lower lateral
crura with septal or costal cartilage. In this scenario, it is essential to retain as much of the dome as possible,
as reshaping this curved structure can be difficult and result in nasal tip asymmetry [36,51] . The articulated alar