Avoiding regret with alar rim lowering surgery: How notching and relapse occur

Notching (stepwise depressions) and relapse following alar rim lowering surgery typically result from removing too much cartilage or skin, causing loss of structural support. Dedicated research into the complication rate of this procedure itself is scarce; instead, we organize the mechanism of how these complications arise by drawing on knowledge from surgery that corrects the opposite deformity (alar rim retraction upward).

Dedicated data for this procedure is limited; we consider the reverse-direction findings

Within the scope of references reviewed, dedicated research investigating the frequency of notching or relapse specific to alar rim lowering surgery was not found. However, multiple reports exist on surgery to correct alar retraction—the upward posterior displacement of the alar rim—and these provide insight into why alar rim lowering surgery tends to lead to notching and relapse.

Removing too much cartilage or skin causes shape to shift in the opposite direction

It has been reported that excessive removal of cartilage in the alar wing or vestibular skin in prior nasal surgery weakens the cartilage, causing it to retract upward, resulting in deformity at the junction between the alar wing and columella.[1]Alar rim lowering surgery operates in the reverse direction—lowering the alar rim. Similarly, if soft tissue is removed excessively or cartilage support is compromised, notching, irregular contours, or relapse (gradual return to the original position over time) may occur.

Excessive shaving of the lateral cartilage can also lead to breathing difficulty

Excessive removal or malposition of the lateral crural cartilage can cause collapse of the external nasal valve, resulting in functional problems such as impaired breathing.[1]This is a point worth confirming, as changes extend beyond appearance to respiratory function.

Excessive removal is not unique to alar rim lowering surgery

Across nasal surgery in general, over-removal is recognized as a cause of many complications.[2]Since alar rim lowering surgery inherently involves removal and repositioning, it shares the same pitfalls.

Several methods exist to correct relapse

To correct alar retraction, one approach involves reinforcing the lateral cartilage by grafting[1]or skin-only external V-Y plasty[3], cartilage graft to the alar rim[4]and others have been reported. If reversal or recurrence occurs, cartilage-based reinforcement may also be an option.

Whether cartilage support is present determines long-term stability

In summaries of alar rim grafting, the presence or absence of cartilage graft support is positioned as a factor that determines correction of retraction or depression, and long-term stability of alar shape[4]. Methods relying on skin excision or repositioning alone are thought to change shape during scar contraction.

Points to confirm during consultation

First, whether to add cartilage support relative to the amount of lowering[1][4]Second, the degree to which lateral cartilage is handled and whether there is any impact on breathing[1]Third, what correction methods are available if recurrence occurs[1][3][4]Since there is no data showing the complication rate for this procedure itself, it is important to confirm these individual points specifically during consultation.[2]