The subalar graft

What repeats

Four findings that hold across the literature.

A nose that points to one side often sits on a face that is flatter on that side

Photographic analysis of 35 consecutive patients found nasal axis deviation correlated with the alar-facial angle on the base view (P < .001), whether the cause was trauma or was present from birth. There was no correlation with the alar-facial angle on the frontal view. The conclusion drawn is that the tip is being pulled by the soft tissue attachment of the nostril to a maxilla that is lower or set back on one side.

Rests on: Yao et al., midfacial asymmetry and nasal axis · the anatomy of the nose.

Building up the base moves the tip, by measurable amounts

Sixty-eight patients were followed a mean 11.0 months, range 3 to 72. Nasal axis deviation improved by 4.32 degrees toward the midline and the alar-facial angle on the base view by 1.01 degrees toward the horizontal, both statistically significant.

Rests on: Lee et al., subalar graft and nostril symmetry.

Nostril symmetry improves with it, and not only because the nose is straighter

The mean change in the nostril show ratio was 0.19 toward a one to one ratio in the 68-patient series. In 37 earlier patients the improvement in nostril symmetry correlated with correction on the base view and was not explained by the general improvement in nasal deviation.

Rests on: Lee et al. · Aynehchi et al., tip medialization and nostril symmetry.

The same name is used for a different graft at the nasal valve

A sub-alar batten graft is placed along the undersurface of the lateral crus to hold the sidewall open. In 27 patients grafted on 39 sides, results were rated optimal on 10 sides (26%), improved on 15 (39%), unchanged on 13 (33%) and worse on 1 (2%), with 25 sides (65%) better than before surgery. The authors call that result slightly disappointing on function alone, and keep the technique for cases where surface irregularity must be avoided.

Rests on: Andre et al., sub-alar batten grafts · alar rim grafts.

By what is being corrected

The graft sits in one place and answers several separate problems.

One cheek sits back further than the other

The core indication. A graft placed on the bone under the nostril base lifts that side forward and brings the tip across, without an osteotomy of the jaw.

Rests on: Yao et al. · Aynehchi et al..

One nostril shows more than the other

Horizontal displacement of the nostril and unequal nostril show are named as a second indication, separate from the deviation itself.

Rests on: Aynehchi et al. · Lee et al..

The pyriform rim is short on the cleft side

In a cleft nose the bone around the nostril is deficient, which sets the alar base back, out to the side and lower than the other. Costal cartilage grafted to the pyriform rim through the gum was used in 12 patients, average follow-up 15.3 +/- 14.4 months, with no graft-related complications and one minor breach of the chest lining during harvest. A related technique fixes a graft to the piriform crest after releasing the alar base and joins it to a long alar strut.

Rests on: Moore et al., pyriform costal cartilage graft · Gassner et al., the foundation graft · Toriumi, structural approach to cleft repair.

The whole cleft nasal base needs rebuilding

Maxillary augmentation is one part of a combined repair. In 20 secondary cleft patients treated with costal cartilage for maxillary augmentation, a columellar strut and lateral crural strut grafts, nostril width, height and gap area ratios between the two sides improved significantly (P < 0.05), columellar axis deviation improved toward the midline (P = 0.004) and alar base inclination toward the horizontal (P = 0.0045). Two further series add nostril base augmentation to lateral crural and rim work, with nostril symmetry improving at one year.

Rests on: Talaat et al., anthropometric analysis · Han et al., lateral crural reinforcement · Moltaji et al., circumferential alar rim graft · rib cartilage grafts.

The middle of the face is flat on both sides

In Binder syndrome the paranasal area is flat and grafts confined to the nostril sill do not change it. Cartilage placed around the pyriform aperture as well as at the sill and the dorsum augmented the paranasal and infraorbital areas in two patients without a jaw osteotomy.

Rests on: Watanabe and Matsuo, Binder's syndrome.

The nostril sidewall collapses on breathing in

This is the batten version of the graft, and the comparison is with grafts placed further out on the sidewall or under the lateral crus. In 46 patients given alar batten grafts, all but one reported improvement, with a mean gain of 2.5 points on a five-point obstruction scale. In a cohort of 203 primary and 108 revision rhinoplasties comparing lateral crural tensioning with rim grafts against lateral crural strut grafts, the rim graft technique improved obstruction in 81% of primary cases against 64% (P < 0.01).

Rests on: Toriumi et al., alar batten grafts · Liang et al., tensioning against strut grafts · nasal airway obstruction.

What to ask about a subalar graft

Questions the evidence supports asking.

Which subalar graft is being described

Two different grafts carry the name. One sits on the bone under the nostril base and changes where the nose points. One sits under the lateral crus and holds the airway open. Ask which one, and what it is meant to change.

Rests on: Lee et al. · Andre et al. · Cingi et al., nasal tip grafts.

Will straightening the septum be enough

The published position is that the subalar graft works alongside septoplasty rather than instead of it, because it treats the foundation the nose sits on rather than the septum. Ask what proportion of the deviation the surgeon expects each step to correct.

Rests on: Aynehchi et al. · Yao et al..

How will the result be measured

The published measures are all photographic: nasal axis deviation, alar-facial angle on the base view, alar-facial angle on the frontal view and the nostril show ratio. Ask for standardised base view photographs before and at a year.

Rests on: Lee et al. · Aynehchi et al. · what recovery looks like.

Where does the cartilage come from

Septum where it is available. In cleft and Binder cases the published grafts are costal cartilage, because the volume needed at the pyriform rim is larger than the septum can supply.

Rests on: Moore et al. · Watanabe and Matsuo · costal cartilage harvest.

Will the nostril base need narrowing as well

Alar base reduction is a separate step and it is common. Across 621 primary open septorhinoplasties, alar base reduction was performed in 53.0%, and it was needed significantly more often in patients with thick skin who had lateral crural repositioning with a strut graft (odds ratio 1.995, P = .005).

Rests on: Ilhan et al., skin thickness and alar base reduction.

The terms, defined

The words used about this graft.

• Subalar graft: cartilage placed under the base of the nostril, on the maxilla, to build up that side of the face. [33835105]
• Sub-alar batten graft: a different graft, placed along the undersurface of the lateral crus for valve support. [16792170]
• Alar base: where the nostril meets the cheek and the lip. [28750132]
• Alar-facial angle: the angle between the ala and the face, measured on the base view or the frontal view. [19451449]
• Nasal axis: the line the nose follows from root to tip, measured against the midline of the face. [19451449]
• Nostril show: how much of each nostril is visible from the front, compared side to side. [33835105]
• Maxillary hypoplasia: an underdeveloped upper jaw, which sets the nostril base back. [8919390]
• Pyriform aperture: the pear-shaped bony opening of the nose in the skull. [31749373]
• Foundation graft: a graft fixed to the piriform crest to project the cleft-side nasal base. [27097143]

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 assess and document before operating, including the photographs the published measures depend on.

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 two on the neighbouring problems, the flat paranasal area and the collapsing sidewall. They are written for surgeons and go further into technique than a patient page should.

• The Subalar Graft
• Bilaminar augmentation for paranasal and premaxillary deficits
• Lateral Crural Tensioning and Articulated Alar Rim Grafts

The reference summary

Cartilage Graft in StatPearls covers the graft sources and the complication list in full text at no charge. Rhinoplasty in StatPearls gives the anatomy of the nasal base and the operation around 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

Both registered studies sit on the cleft side of this graft, where the nasal base is the problem.

• Correction of the Unilateral Cleft Lip Nasal Deformity With Sliding Chondrocutaneous Flap and Autologous Cartilage Graft, status unknown, 35 participants.
• Outcome of Alar Base Support in Unilateral Secondary Cleft Lip and Nasal Deformity Repair With Dermal Roll Flap, completed, 45 participants.

What is not settled

• Every series is retrospective and from one surgeon or one unit, the largest with 68 patients. [33835105] [24065208]
• The graft is rarely placed alone. The authors state that measuring its independent effect is limited by the other procedures done at the same time. [24065208]
• Follow-up in the largest series has a range of 3 to 72 months around a mean of 11.0, so late behaviour of the graft is not separated from early. [33835105]
• Nothing measures whether the graft resorbs on the maxilla, or how much of the 4.32 degree correction is still there at five years. [33835105] [31749373]
• The batten version is reported as improving roughly two-thirds of treated sides, which its own authors call disappointing, and no trial compares it with the alternatives. [16792170] [9260543]