Alar retraction

Alar retraction is a nostril rim that has pulled up, so too much of the nostril shows from the front and the profile reads notched between the rim and the columella. It follows loss or malposition of the lateral crus, most often after cephalic trimming took too much, and it is corrected by putting support back along the rim rather than by lowering the rim itself.

What repeats

Four findings that hold across the literature.

It belongs to the over-resection family

The review of reductive rhinoplasty gone wrong names alar retraction alongside the pinched tip, bossae, deep alar grooves and external valve collapse: all consequences of removing lateral crural cartilage, all answered by grafting.

Rests on: Moritz et al., when reductive rhinoplasty goes wrong.

The lateral crural strut graft was built for this list

The graft is described for bulbous tip, lateral crus malposition, alar retraction, collapsed external valve, lateral crus concavity and alar deformity after domal suture, one construction for a family of related failures. A cadaveric study set out to measure the anatomical change it makes rather than rest on the clinical impression.

Rests on: Silva Filho et al., cadaveric study.

The extended alar contour graft evolved from the strut graft to carry support further along the rim, toward the soft triangle, where retraction actually shows. In a secondary series in Asian patients the same family of grafts corrected notching, pinching and retraction produced by implants and capsular contracture.

Rests on: Cochran, extended alar contour grafts · Kook et al., secondary rhinoplasty in Asians.

In the cleft nose the graft is shaped by its own curvature

For secondary unilateral cleft rhinoplasty, the natural curve of rib cartilage has been used as the alar rim graft, with three-dimensional stereophotogrammetry used to measure symmetry over the long term across 47 consecutive patients. It is the one place in this literature where the correction is assessed with objective three-dimensional measurement rather than photographs.

Rests on: Liu et al., rib curvature as an alar rim graft · and cleft and reconstructive rhinoplasty.

By what caused it

The mechanism decides the graft.

Cephalic trim that took too much

The classic route. The lateral crus is left too narrow to hold the rim down, and the rim rides up as scar contracts. Support is added under and along it.

Rests on: Moritz et al. · Silva Filho et al..

A malpositioned lateral crus

The crus points the wrong way, cephalically oriented rather than running toward the cheek, so it never supported the rim in the first place. This is repositioning, not just grafting.

Rests on: Silva Filho et al. · Kook et al..

Scar and capsular contracture around an implant

In the Asian secondary series the deformities were traced to implants, tip plasty and capsular contracture. The capsule is released as part of the correction.

Rests on: Kook et al. · and ethnic rhinoplasty.

Congenital, in the cleft nose

Here retraction is part of the original deformity rather than a complication, and the correction is built into a staged reconstruction.

Rests on: Liu et al..

What to ask about a retracted rim

Questions the evidence supports asking.

How much of this is retraction and how much is a hanging columella?

Too much nostril showing can be a rim that has risen or a columella that has dropped. They look similar and the operations differ.

Is my lateral crus weak, or in the wrong place?

A weak crus is supported; a malpositioned one is moved. Ask which is being done.

Rests on: Silva Filho et al..

Where does the graft go, and how far out?

Retraction shows near the soft triangle, which is why the extended graft exists. Ask how far along the rim the support is being carried.

Rests on: Cochran.

Will this change my breathing?

A retracted, unsupported rim is an incompetent external valve. If the nostril collapses on inspiration, the same graft is doing functional work.

Rests on: Kook et al. · and the septum and the airway.

The terms, defined

The words used about this deformity.

Alar retraction: a nostril rim pulled cephalically, showing excess nostril and notching the profile. [40199493]
Alar-columellar relationship: how the rim and the columella sit against each other; the measurement retraction is judged on.
Lateral crus: the outer arm of the lower lateral cartilage; its loss or malposition is the usual cause. [27277274]
Lateral crural strut graft: cartilage set under the crus to support and reposition it. [27277274]
Alar rim graft: a strip placed along the rim itself, in a pocket, to push the margin down. [32097325]
Extended alar contour graft: rim support carried further out toward the soft triangle. [28953723]
Soft triangle: the small area of skin between the rim and the dome; where retraction is most visible.
Composite graft: skin and cartilage together, for a rim that has lost lining as well as support.

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should record about the nostril rim and the external valve before operating, and what counts as an outcome afterwards.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries three chapters on rim support and the grafts used to restore it. They are written for surgeons and go further into technique than a patient page should.

The reference summary

Rhinoplasty Tip-Shaping Surgery in StatPearls, on the National Library of Medicine's Bookshelf, sets out the anatomy of the lower lateral cartilage, the graft options and the complication list in full text at no charge. The general Rhinoplasty chapter sits beside it.

The societies

American Society of Plastic Surgeons, patient information.
American Academy of Facial Plastic and Reconstructive Surgery, patient information.
The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

One registered trial covers lateral crural handling in primary rhinoplasty. No registered trial tests the correction of a retracted rim.

Lateral Crural Steal With Columellar Strut Graft in Primary Open Rhinoplasty, recruiting, 22 participants.

What is not settled

No series compares alar rim graft against lateral crural strut against extended alar contour graft at matched severity. [27277274, 28953723]
Incidence after cephalic trim is unreported.
Objective measurement is rare: the cleft series uses three-dimensional stereophotogrammetry, the aesthetic series use photographs and surgeon rating. [32097325]
Composite grafting for a rim short of lining is described in textbooks rather than in the core journal archive; there is little on file about when lining, rather than support, is the limit.

Written by rhinoplasty.cc from the sources linked above, 2026-09-09.

Who publishes on revision and secondary rhinoplasty

Ranked surgeons with papers under this topic in the archive, most first.

Rod J. Rohrich (8) · Dean M. Toriumi (7) · Samuel Lin (5) · Richard E. Davis (4) · Sam P. Most (4) · Michael Lee (3) · Paul Nassif (2) · Angela Sturm (1) · Anil Shah (1) · Anita Patel (1)

The literature: Revision and secondary rhinoplasty, 181 papers. Video: Nostrils and the alar base, 54 videos. Every technique.