Alar rim grafts

What repeats

Five findings that hold across the literature.

The rim of the nostril has no skeleton, and surgery on the tip takes away what support it has

The lower lateral cartilage sits above the nostril margin, not in it. Trimming the top edge of that cartilage, the cephalic trim, is named in the literature as the cause of postsurgical alar retraction. Scar contracture then pulls the margin further up. The rim graft puts a skeleton where there was none.

Rests on: Kao and Davis, postsurgical alar retraction · Ballin et al., the articulated alar rim graft · alar retraction.

Breathing scores improve after it is placed

Ninety patients who had septorhinoplasty with an articulated alar rim graft moved from a mean NOSE score of 70.4 before surgery to 25.1 after (P < .001). The improvement held regardless of graft size, of whether a caudal septal extension graft was used, and of whether the lateral crus was tensioned. In a separate 25-patient series treating lateral wall insufficiency with rim grafts, batten grafts and a turned-in flap, mean NOSE scores went from 72.5 to 22.1 at a median follow-up of 14 months.

Rests on: Calloway et al., functional and aesthetic outcomes · Nicodemi et al., lateral wall insufficiency algorithm · nasal airway obstruction.

Sewing the graft to the tip changes what it can do

The conventional graft floats in a soft tissue pocket. The articulated version is stitched to the tip cartilages, which gives the alar margin fixed support rather than a loose splint. A series of 47 consecutive patients treated with that graft alongside a septal extension graft and lateral crural tensioning reported favourable outcomes in nearly all patients and no complications. A modified position, fixed further forward on the facet and infratip, was used in 317 patients with favourable results at one year.

Rests on: Ballin et al. · Lyrio et al., modified positioning.

Against the lateral crural strut graft it wins on measured resistance and ties on symptoms

Ninety-four patients were compared, 26.6% having lateral crural tensioning with an articulated rim graft and 73.4% a lateral crural strut graft. The change in nasal airway resistance was significantly better in the rim graft group (p < 0.001). Peak inspiratory flow, visual analogue score, NOSE score and the proportion reporting improvement showed no significant difference between the two.

Rests on: Kondo et al., rim graft against strut graft.

It is used to prevent a deformity as often as to correct one

Across 150 consecutive septorhinoplasties, 31 patients received alar rim grafts. The three commonest reasons were cephalic malposition of the lower lateral cartilage with weak alar support in 9 patients (29%), correction of alar flare in 9 (29%) and dynamic collapse of the alar margin in 8 (26%). At a mean six months there were no graft displacements or extrusions.

Rests on: Boahene and Hilger, indications and outcomes · Cingi et al., nasal tip grafts.

By what the graft is asked to do

One strip of cartilage answers several separate complaints.

The nostril rim has pulled up

For slight retraction, a rim cartilage graft is named as the first choice, and for significant retraction the lining itself has to be advanced. A 25-patient revision series combining an articulated rim graft with a V-to-Y advancement of the lining measured the distance from the alar rim to the nostril axis at 3.4 mm before surgery and 1.5 mm after, a mean reduction of 1.9 mm at a mean follow-up of 8 months.

Rests on: Guyuron, alar rim deformities · Zhan and Wang, rim graft with V-Y advancement · alar retraction.

The rim is pinched or hollow

A mono-unit graft carved from the outer layer of rib cartilage was used in 29 patients. Of 10 patients with a parenthesis deformity, 8 (80.0%) had near-complete correction. Of 16 with alar concavity on the basal view, 15 (93.8%) had partial or near-complete correction. Of 11 with soft triangle notching, 9 (81.8%) improved. No complications were attributed to the technique.

Rests on: Kim and Jang, mono-unit alar rim graft · the pinched tip.

The sidewall falls in on breathing in

External valve collapse is the functional indication. The comparison technique is the alar batten graft, placed further back on the sidewall. In 46 respondents from 63 patients given batten grafts, all but one reported improvement, with a mean gain of 2.5 points on a five-point obstruction scale. The published algorithm places rim grafts, batten grafts and a turned-in flap at different points on the lateral wall depending on where the collapse is.

Rests on: Toriumi et al., alar batten grafts · Nicodemi et al. · the butterfly graft.

The tip is being narrowed and the rim needs protecting first

Narrowing a wide tip weakens the sidewall it is built on. The rim graft is placed at the same operation to hold the margin while the tip is tightened, described as prophylaxis rather than repair.

Rests on: Ballin et al. · Lyrio et al..

The nostrils are asymmetric after a cleft repair

A circumferential rim graft anchored to the septum at one end and the intermediate crus at the other was used in adults with unilateral cleft lip and palate. Nostril height symmetry improved by 10% (P < 0.001), width symmetry by 22% (P = 0.012), area symmetry by 21% (P = 0.008) and tip projection by 10% (P = 0.029). Five graft-related complications occurred, including two detachments and one fracture.

Rests on: Moltaji et al., circumferential alar rim graft.

The rim needs to be lowered rather than supported

A high-arched or asymmetric nostril can be treated by unfurling the lining downward and placing a cartilage graft between the layers at the new rim height. The graft sets the height rather than resisting collapse.

Rests on: Ellenbogen, alar rim lowering.

What to ask about alar rim grafts

Questions the evidence supports asking.

Free in a pocket, or stitched to the tip

Both are in use. The stitched version was designed because the free graft can drift and gives no fixed support. Ask which the surgeon places and what they do when the rim is already scarred.

Rests on: Ballin et al. · Boahene and Hilger.

How does the graft get in

Through the marginal incision at the nostril rim in an open operation, through a tunnel from inside the nostril in a closed one, through a 2 mm stab in the ala after an alar base resection in 84 patients, or through an incision in the crease at the base of the ala. The route determines where the scar is.

Rests on: Fallahi et al., transcutaneous placement · Orlando and Marquez, external approach · open versus closed rhinoplasty.

Will the graft show

Rim grafts sit under thin skin at the nostril edge. Published series report no extrusion at six months and no technique-related complications in 29 cases, and a graft shaped as a continuation of the lateral crus was proposed to make the transition smoother. Ask to see basal-view photographs at a year.

Rests on: Boahene and Hilger · Kim and Jang · Gruber et al., anatomical graft.

Is a graft enough for my retraction

If the lining is short or scarred, cartilage alone will not bring the rim down. The published answers add lining: a V-to-Y advancement, or a graft of turbinate mucosa used in 22 patients with scar contracture alongside articulated rim grafts.

Rests on: Guyuron · Zhan and Wang · Rose and Jumeau, turbinate graft · revision rhinoplasty.

What is being measured

Ask for the NOSE score before and after, and for the basal view. One series also measured the distance from the rim to the nostril axis in millimetres, which is the direct measure of retraction.

Rests on: Calloway et al. · Zhan and Wang · what recovery looks like.

The terms, defined

The words used about this graft.

• Alar rim graft: a strip of cartilage placed in a pocket along the free edge of the nostril. [19797088]
• Articulated alar rim graft: the same graft sutured to the tip cartilages instead of left free. [27494582]
• Alar retraction: the nostril rim sitting higher than it should, showing more of the nostril. [31587768]
• Cephalic trim: removal of the upper edge of the lower lateral cartilage, named as the cause of postsurgical retraction. [31587768]
• Lower lateral cartilage: the paired cartilage of the tip and nostril sidewall. [31899163]
• Lateral crus: the outer arm of the lower lateral cartilage, running toward the cheek. [25415110]
• External nasal valve: the nostril opening and the sidewall around it, which can collapse on breathing in. [9260543]
• Alar batten graft: a curved graft set further back on the sidewall, at the point of maximum collapse. [9260543]
• Lateral crural strut graft: a graft placed underneath the lateral crus, the main alternative for supporting the sidewall. [32326747]
• Parenthesis deformity: the curved shadows either side of the tip from cartilage that runs the wrong way. [32502275]
• Soft triangle notching: a nick at the apex of the nostril where skin meets skin. [32502275]

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 the surgeon should assess before operating and what should be recorded afterwards, whichever graft is chosen.

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 a chapter on this graft and chapters on the sidewall support it belongs to. They are written for surgeons and go further into technique than a patient page should.

• Alar rim grafts
• Integrated Alar-Lateral Crural Strut Graft
• Tip Rhinoplasty: Alar Structural Support Techniques

The operation on video

The same archive hosts recorded operations placing the articulated graft.

• Articulated Alar Rim Graft Placement
• Lateral Crural Tensioning and Articulated Alar Rim Grafts

The reference summary

StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy, the indications and the complication list in full text at no charge.

• Rhinoplasty Tip-Shaping Surgery
• Rhinoplasty

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.

What is not settled

• One cohort study compares the rim graft with the lateral crural strut graft. It found a resistance difference and no symptom difference, in 94 patients at one practice. [32326747]
• Series are single-surgeon and retrospective. The largest, 317 patients, reports outcomes as favourable without a score. [38510328]
• Follow-up is short. Published intervals run 6 months, 8 months, 11 to 19 months and one year, so late migration and late visibility are not measured. [19797088] [41400907] [25415110]
• How much retraction a cartilage graft alone can correct is not defined. The threshold between graft alone and graft plus lining advancement is stated as slight against significant. [11304615]
• Grafts placed to prevent a deformity cannot be evaluated against the deformity that did not happen. The prophylactic claim has no control group. [27494582]