Research

Original Investigation

Alar Retraction
Etiology, Treatment, and Prevention
Ashlin J. Alexander, MD; Anil R. Shah, MD; Minas S. Constantinides, MD

IMPORTANCE The effect of different rhinoplasty maneuvers on alar retraction remains to be

elucidated.

OBJECTIVE To determine the etiology and treatment of alar retraction based on a series of
specific rhinoplasty maneuvers.

DESIGN Retrospective review of a single surgeon’s rhinoplasty digital photo database,

examining preoperative alar retraction from January 1, 2002, to December 31, 2005, in 520
patients. Patients with more than 1 mm of alar retraction on preoperative photographs were
identified. Postoperative photographs were examined to determine the effect of specific
rhinoplasty maneuvers on the position of the alar margin; these maneuvers included cephalic
trim, cephalic positioning of the lower lateral cartilage, composite grafts, alar rim grafts, alar
batten grafts, and overlay of the lower lateral cartilage.

SETTING Tertiary care academic health center.

PARTICIPANTS Forty-five patients with alar retraction met inclusion criteria, resulting in 63
nasal halves with alar retraction.

MAIN OUTCOMES AND MEASURES Intraoperative findings, postoperative results.

RESULTS Forty-seven percent of the patients (n = 21) had prior surgery; 47% also had
cephalically positioned lower lateral cartilages. Among patients with less than 4 mm of
cartilage width at the outset, 46% of those who received supportive grafts achieved target
correction vs only 7% for patients who did not undergo supportive cartilage grafting. In
patients who underwent more than 4 mm of cephalic trim, those who received supportive
grafts achieved 46% of target correction vs 11% among those who did not. Ninety-five
percent of composite grafts, 69% of alar strut grafts, 47% of alar rim grafts, 43% of vertical
lobule division, and 12% of alar batten grafts achieved their target correction values.

CONCLUSIONS AND RELEVANCE Alar retraction is a highly complex problem. It can be seen de
novo and is associated with cephalically positioned lower lateral cartilages. Structurally
supportive grafting—including composite grafts, alar strut grafts, alar rim grafts, vertical
lobule division, and alar batten grafts—can improve alar retraction.

LEVEL OF EVIDENCE 4.

Author Affiliations: Division of Facial

Plastic & Reconstructive Surgery,
Department of Otolaryngology, New
York University, New York, New York
(Alexander, Constantinides); Private
practice in Chicago, Illinois (Shah).
Corresponding Author: Ashlin J.
Alexander, MD, Division of Facial
Plastic & Reconstructive Surgery,
Department of Otolaryngology, New
York University, 530 First Ave, Ste 7U,
JAMA Facial Plast Surg. 2013;15(4):268-274. doi:10.1001/jamafacial.2013.151 New York, NY 10016 (ashlin
Published online April 25, 2013. _alexander@yahoo.com).

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 Alar Retraction
A
lar retraction is classically thought to be an unsightly
stigma of overly aggressive rhinoplasty. However, it has
been our experience that alar retraction is also preva-
lent in the general population and can be seen in patients with-
out a prior history of rhinoplasty. In addition to an unfavorable
aesthetic appearance, alar retraction may also have functional
consequences, manifesting in the collapse of the external na-
sal valve.1-3
In the analysis of alar-columellar disproportion, alar re-
traction is identified by the presence of alar notching, weak lat-
eral crura, retraction of the alar margin, or excessive curve to
the alar rim margin. These various etiologies can be congen-
ital or acquired.4
Iatrogenic alar retraction results when aggressive resec-
tion of the cephalic portion of the lower lateral cartilage leads
to weakening of the cartilage, causing it to retract superiorly.
A central tenet of rhinoplasty surgery espouses the preserva-
tion of a critical width of the lateral crura—typically greater than
7 mm—to maintain the structural integrity of the cartilage
framework. Some alar cartilages are inherently weak, so
a smaller cephalic excision may be needed to prevent alar
retraction.
Division and, in some cases, removal of the soft-tissue and
ligamentous attachments of the lower lateral cartilage may
weaken its support and render it more susceptible to upward
retraction. Medially, the medial crura have ligamentous con-
nections to the nasal septum. Laterally, the accessory carti-
lages and their encasing ligaments serve as an attachment for
the lateral crus to the pyriform aperture to form the lateral cru-
ral complex.5 Cephalically, the alar cartilage has fibrous at-
tachments to the upper lateral cartilage at the scroll. During
rhinoplasty, these attachments are subject to disruption. More-
over, resection of the actual cartilage not only may decrease
the structural framework of the nostril but also may remove
adjoining supportive attachments, further weakening the alar
cartilages.
Preoperative alar rim retraction can be managed with sev-
eral different techniques. Typically, repair of alar rim retrac-
tion requires cartilage grafting to effectively lower the nostril
margin and support the lateral crus.4,6,7 Determining which re-
parative technique is best suited to which alar retraction is one
of the great challenges in rhinoplasty.
Surgeons seeking to avoid and correct alar retraction are
forced to rely on the experience of other surgeons rather than
compelling objective data. We sought to analyze the records
of the senior author (M.S.C.) to determine which maneuvers
were most effective in improving alar retraction and which car-
tilage states were most likely to result in retraction of the alar
margin.
Methods
An institutional review board–approved retrospective analy-
sis of the senior author’s (M.S.C.) rhinoplasty database was per-
formed to identify all patients who underwent primary or re-
vision rhinoplasty from January 1, 2002, to December 31, 2005.
In total, 520 patients were found. From this group, all pa-
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Original Investigation Research
tients with preoperative alar retraction greater than 1 mm on
lateral view were identified. All patients had a minimum of 6
months postoperative follow-up.
Preoperative and postoperative photographs were taken
with a Canon EOS 5D digital single-lens reflex camera with a
105-mm macro lens in a standardized manner. Distances
were measured only on lateral view as previously described.
Preoperative measurements were obtained using Adobe
Photoshop.
Alar retraction was identified by Gunter’s classification
system.8 A line was drawn from the anterior to the posterior
apex of the nostril. A line perpendicular to this line was
then drawn to the point of maximal retraction. An addi-
tional line was drawn that would create the ideal level of
alar rim position, which should be 1 to 2 mm above the
anterior-to-posterior apex line. For consistency, the ideal
line was determined to be 1 mm above the anterior-to-
posterior apex line and was defined as the “target” level of
alar position (Figure 1). Postoperative photographs were
then analyzed to determine the postoperative alar retrac-
tion distance. The postoperative measurements were com-
pared with preoperative values. A fixed data point from the
midpoint of the tragus to the lateral canthus was used to
derive a multiplier to standardize lengths between photo-
graphs. This allowed an objective means of comparing pre-
operative and postoperative photographs.
The senior author (M.S.C.) used detailed rhinoplasty
worksheets to document the amount of cartilage removed,
the amount that was preserved, and the size and location of
any cartilage graft that was employed. Calipers were used
for all intraoperative measurements. For patients in whom
cartilage-splitting techniques were used, the amount of
overlap was measured. In addition, patients with cephali-
cally oriented cartilages were identified on preoperative
photography based on the presence of lower lateral carti-
lages that were aligned with the medial canthus rather than
the lateral canthus.9,10
Statistical analysis involved a 1-tailed t test comparing pre-
operative and postoperative values.
Lateral Crural Strut Graft
The lateral crural strut graft is placed by elevating the ves-
tibular skin off the undersurface of the lateral crus and posi-
tioning the graft deep to the lateral crus in an underlay fash-
ion. The graft is usually directed more caudally than the
posterior portion of the lateral crus, essentially acting to
support the region of the external valve devoid of cartilage.
Therefore, its medial portion supports the lateral crus lat-
eral to the dome, while its lateral portion supports the hinge
area, where ligaments course from the lateral crus toward
the pyriform aperture. In the setting of malpositioned lat-
eral crura and severe cases of alar collapse and alar retrac-
tion, a longer strut is used. When the lower lateral cartilages
are cephalically malpositioned, a caudal repositioning of the
lateral crura can be performed to bring the cartilage to a
more anatomic position; in this case, a lateral crural strut
may be placed concomitantly for structural support to the
repositioned lateral crus. Last, when faced with significant
JAMA Facial Plastic Surgery July/August 2013 Volume 15, Number 4 269
 Research Original Investigation
Figure 1. Preoperative Lateral View of a Patient With Significant
Alar Retraction
PA
A line is drawn from posterior to anterior nostril apex (PA). A line perpendicular
to the PA line is then extended up to the point of maximal retraction along the
alar margin. The “target” level of alar rim position was assigned to be 1 mm
above the PA line.
convexity of the lateral crura, a lateral crural strut graft can
be used to provide a brace against which the crura can be
straightened. Typically, the lateral end of the strut graft is
positioned in a pocket at the level of the pyriform aperture
edge (not in the flaccid portion of the alar wall) to avoid
medial graft displacement with inspiration. To prevent post-
operative visibility, the lateral end of the strut is placed cau-
dal to the alar groove. The graft is typically either secured to
the overlying lateral crus with 6-0 permanent or 5-0 absorb-
able monofilament suture or can be secured full thickness
through the underlying vestibular skin with a 4-0 or 5-0
absorbable monofilament suture. Cartilage from the septum or
rib is most ideally suited to lateral crural strut grafts;conchal
cartilage is usually too weak to provide adequate support.
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Alar Retraction
Alar Batten Graft
Alar batten grafts serve a similar function to lateral crural
strut grafts: they provide structural support to the alar side-
wall. They can also help push down a retracted alar rim. The
alar batten graft is placed lateral to the lateral crura as an
overlay, as opposed to the lateral crural strut graft, which is
an underlay graft.
Alar batten grafts are typically fashioned from septal or au-
ricular cartilage (cymba cavum or cymba concha), although rib
is also used. They are cut into a rectangle measuring 10 to 15
mm in length and 4 to 8 mm in width.11 Alar batten grafts are
curvilinear in shape, with the convexity of the graft oriented
laterally to provide maximum support to the lateral wall. Grafts
are placed into a dissected precise pocket: for internal nasal
valve collapse, this pocket is situated at the point of maximal
lateral wall collapse, which is usually at the lateral margin of
the upper lateral cartilage (ie, at the supra-alar crease). For ex-
ternal valve collapse, the pocket is dissected caudal to the lat-
eral crus; this usually occurs in the setting of cephalically ori-
ented lateral crura. Alar batten grafts are suture fixated either
to the overlying skin or to the underlying lateral crus with ab-
sorbable 4-0 or 5-0 monofilament sutures.
Preoperatively, the area of sidewall collapse can be marked
while the patient inspires during a modified Cottle maneuver.11
This maps out the area of the precise pocket to be dissected.
Alar Margin (Rim) Graft
Alar rim grafts are nonanatomic cartilage grafts used to pro-
vide structural support to the alar margin. They can be used
to straighten alar notching, treat mild alar retraction by
pushing the alar margin down 1 to 2 mm, or prophylax
against alar retraction in at-risk primary or revision cases.
Alar rim grafts are typically cut in a rectangular shape mea-
suring 10 to 15 mm in length and 2 to 3 mm in width. After
infiltration with 1% lidocaine with 1:100 000 epinephrine,
the skin caudal to the marginal incision is dissected with a
tip scissor. The graft is then inserted into this pocket and
trimmed to the appropriate length to prevent visibility. The
medial leading edge of the graft is crushed with Brown-
Adson tissue forceps to prevent a sharp edge distorting the
soft triangle. A 5-0 absorbable suture is used to secure the
leading edge to the skin edge.
Composite Graft
Significant alar retraction (>3 mm) requires composite grafting
to the nasal vestibule to lower the alar margin. Composite grafts
are harvested from the lateral concha and contain cartilage and
overlying skin on one side only. There are equal amounts of car-
tilage and skin in the graft. The donor site is closed primarily; if
the defect is too large, a postauricular full-thickness skin graft
or a postauricular island flap is used.
An incision is made in the nasal vestibule, 2 mm behind the
alar rim, paralleling the alar margin. Sharp-tip scissors are used
to spread perpendicular to the incision to create space for the
graft to be inset. With the skin side facing into the nasal air-
way, the graft is inset with interrupted 5-0 absorbable sutures
under minimal tension to avoid vascular compromise.
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 Alar Retraction Original Investigation Research

Figure 2. Target Correction of Alar Retraction Figure 4. Target Correction of Alar Retraction

100 50

90 45
Target Correction of Alar Retraction, %

Target Correction of Alar Retraction, %

80 40

70 35

60 30

50 25

40 20

30 15

20 10

10 5

0 0
Composite Alar Strut Alar Rim Vertical Lobule Alar Batten All 4 mm 4 mm Without 4 mm With
Division Grafts Grafts
Type of Rhinoplasty Maneuver Cephalic Trim

Percentage of target alar rim position attained according to each rhinoplasty Percentage of target alar rim position attained with and without cartilage
maneuver. grafting when a cephalic trim of greater than or equal to 4 mm was concurrently
performed.

Figure 3. Target Correction of Alar Retraction

The vestibular skin is dissected off the undersurface of
50
the tip cartilages in the area of intended division, typically
45
Target Correction of Alar Retraction, %

lateral to the dome for correction of the elongated nostril.

40
Calipers are used to measure precisely how much cartilage
35
is to be overlapped. The lateral crus is then divided, the
30
medial segment is positioned over the lateral segment,
25 and the overlapped edges are sutured together using 6-0
20 permanent monofilament sutures. This produces deprojec-
15 tion and mild cephalic rotation while shortening the elon-
10 gated nostril.
5

0
All 4 mm 4 mm Without
Grafts
Width of the Lateral Crura
Percentage of target alar rim position attained with cartilage grafting vs without
cartilage grafting when the preoperative width of the lateral crura was less than
4 mm.
Vertical Lobule Division
Vertical lobule division has a variety of applications, includ-
ing decreasing nasal tip projection, increasing or decreasing
rotation, narrowing a wide domal arch, addressing a hanging
infratip lobule, equalizing tip asymmetries, or correcting an
elongated nostril.12 In the present study, vertical lobule divi-
sion was used for this last indication.
Vertical lobule division involves dividing the crura any-
where between the medial crural and lateral crural angles12;
the decision of where to make the division is dependent on
the desired outcome. Anderson’s tripod theory predicts the
resultant changes in rotation and deprojection. 1 3 For
example, division in the middle of the intermediate crus
causes deprojection without rotation. Conversely, division
lateral to the dome will affect deprojection and cephalic
rotation. By overlapping and suturing together the cut
segments, additional stability is conferred to the resultant
construct.
4 mm With
Grafts
Results
Forty-five patients were identified with alar retraction,
resulting in a total of 63 retracted alar rims. Twenty-one of
the 45 patients (47%) had undergone previous rhinoplasty,
while the remaining 24 patients had not. Twenty-one of the
45 patients (47%) with alar retraction had cephalically ori-
ented cartilages.
Figure 2 shows the percentage of target correction of
alar retraction that was achieved with various techniques in
isolation (ie, without the use of another graft). Figure 3
shows the effects of grafting when less than a 4-mm width
of lower lateral cartilage was present at the outset of the
case. When grafting occurred, the alar retraction was
improved to 46% of the target goal on average, while the
alar retraction only improved 7% without grafting. In
patients with 4 mm or more of cephalic trim excised, those
who received cartilage grafts reached 46% of their target
goal, while patients without cartilage grafts achieved only
11% of their target goal (Figure 4).
The effects of cephalically oriented lower lateral carti-
lages were also examined (Figure 5). In all patients with ce-
phalically oriented lower lateral cartilages, 32% of target cor-
rection was achieved. In patients with cephalically oriented
cartilages in which less than 4 mm of cartilage remained at the

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 Research Original Investigation Alar Retraction

conclusion of the case and no grafting was performed, alar re-
traction increased by 11% on average. In patients with cephali-
cally oriented cartilages with more than 4 mm of cartilage ex-
cised, patients demonstrated an increase in alar retraction of
9%. Those patients who had cephalically oriented cartilages
and underwent cartilage grafting demonstrated a 54% de-
crease in alar retraction on average.
Discussion
Rhinoplasty is arguably the most complex surgical procedure
in facial plastic surgery. There are a multitude of techniques
Figure 5. Change in Alar Cartilages
60
50
Change in Alar Cartilages, %
and nuances; due to the complexity of the operation, it can be
difficult to ascertain the impact of various maneuvers on a pa-
tient’s final result. To our knowledge, no study has at-
tempted to quantify the effects of various rhinoplasty maneu-
vers on alar margin position.
Gunter et al8 introduced a system that classified alar-
columellar relationships on lateral view into 6 types. In their
classification, they used the distance between the long axis of
the nostril and columella or alar rim to classify the alar-
columellar relationship. Distances greater than 1 to 2 mm were
considered indicative of alar retraction.8 Guyuron,14 claiming
that this classification was only 2-dimensional, included the
basal view to add 3 additional classes of alar rim deformities.
Several of our findings were surprising. First, alar retrac-
tion is conventionally thought to be a result of aggressive rhi-
noplasty. However, in the present study, 53% of patients had
not had rhinoplasty before. Second, composite grafts were
found to be the most efficacious overall maneuver in improv-
ing alar retraction (Figure 6).

40 For cases in which the final width of the lower lateral car-
30
tilage was less than 4 mm, even subsequent cartilage grafting
improved alar retraction to only less than 50% of the target po-
20
sition. The same outcome was true for patients who under-
10 went 4 or more millimeters of cephalic trim of the lateral crura.
0
Cephalically oriented lower lateral cartilages had a propen-
sity for increased alar retraction when the lateral crura were
–10
narrow or underwent a large cephalic trim.
–20 In all 3 instances described above, the proposed etiology
All Cephalically + Remain 4 mm + Excise 4 mm + Graft
Oriented Cephalically Oriented for alar retraction is related to physical dynamics: with exces-
With Cartilage Graft sively narrowed lateral crura or cephalically oriented lower
lateral cartilages that have been narrowed, an increased
Effects of preoperative cephalically oriented lower lateral cartilages on alar
potential space between the upper and lower lateral carti-
retraction. Negative value indicates increased retraction.
lages is created. This potential space then allows the lateral

Figure 6. Preoperative and Postoperative Views

A B C D

A and B, Preoperative frontal and right lateral views of a patient with severe alar retraction. C and D, Eight-year postoperative views showing markedly improved alar
rim position following composite auricular cartilage grafting.

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 Alar Retraction Original Investigation Research

Figure 7. Preoperative and Postoperative Views

A B C D

A and B, Preoperative left-sided alar retraction. C and D, Postoperative views showing improvement in alar rim position following placement of a lateral crural strut graft.

Figure 8. Algorithm

Factors to consider in
alar retraction

Alar retraction Alar retraction Long nostril

without cephalically with cephalically
positioned LLC positioned LLC

<1.5 mm 1.5 mm-3.0 mm >3.0 mm <1.5 mm >1.5 mm

Alar rim graft Lateral crural Weak lateral crural Conchal skin cartilage Alar rim graft Caudal repositioning Vertical lobule
recurvature into integrity? composite graft of lateral crus with or division
the nasal airway? without prophylactic
lateral crural
strut graft

Lateral crural strut Alar batten graft

graft

Algorithm for management of alar retraction. LLC indicates lower lateral cartilage.

crura to retract superiorly, thereby drawing up the alar mar-
gin and producing alar retraction. The objective in managing
this situation is to maintain the refinement of the cephalic
edge of the lateral crura, while bolstering the caudal region to
counteract retraction of the alar margin.
In all cases, the target position of the alar margin was
more readily achieved when c artilage grafting was
employed. In individuals with cephalically oriented lower
lateral cartilages who undergo cephalic trim, it may be pru-
dent to prophylactically employ cartilage grafting—alar strut
and alar rim grafts—to prevent the future development of
alar retraction (Figure 7). On the basis of the results of this
study, we present an algorithm for management consider-
ations in alar retraction (Figure 8).
This study is limited by a short mean follow-up duration
of 6 months. While follow-up of more than 1 year would be de-
sirable, in a diverse international practice (M.S.C.), it is often
difficult to obtain reliable patient photographs and follow-up
after 1 year.
Conclusions
The results of this study objectively confirm that which is in-
tuitively suspected: that overresection of the lateral crura can
lead to alar retraction, and cartilage grafting has a measure-
able effect on improving this retraction. Interestingly, it also
identifies the existence of alar retraction in unoperated noses.

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 Research Original Investigation Alar Retraction

The present study has identified an algorithmic approach to
the management of alar retraction, which is based on the de-
gree of measured retraction. Furthermore, in the setting of ce-
phalically oriented lower lateral cartilages, when cephalic trim
of the lateral crura is performed, one should consider prophy-
lactic cartilage grafting in the form of either alar strut or alar
rim grafts. Future research would be beneficial to further de-
lineate the optimal techniques for various etiologies of alar re-
traction and the long-term success of the interventions em-
ployed herein.

ARTICLE INFORMATION
Accepted for Publication: January 30, 2013.
Published Online: April 25, 2013.
doi:10.1001/jamafacial.2013.151.
Author Contributions: All authors had full access
to all the data in the study and take responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: All authors.
Acquisition of data: Alexander, Shah.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Alexander, Shah.
Administrative, technical, and material support: All
authors.
Study supervision: All authors.
Conflict of Interest Disclosures: None reported.
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