How do we choose between cartilage grafting and composite tissue grafting for lowering the alar rim?

Surgery to lower the alar rim is not a single fixed technique, but rather a combination of three types: cartilage grafting to the alar rim, grafting to the lateral crus, and composite tissue grafting harvested from the ear[1]. Which type to use is not a matter of preference, but is determined by whether what is lacking is structural support or tissue volume.[2][3].

Three types of grafting approaches

The three types differ in where they add tissue. Cartilage grafting to the alar rim places thin cartilage just inside the rim edge to maintain the rim contour, grafting to the lateral crus acts on the cartilage that supports the rim itself, and composite tissue grafting fills in the missing inner lining by adding a single unit of skin and cartilage.[1][2]. Even with the same description of 'lowering the alar rim,' the actual approach can differ significantly.[3].

How far does cartilage grafting reach in mild cases?

For mild retraction, the method of grafting cartilage to the alar rim can restore proper contour.[2]. However, this method is less effective when the outer aspect of the rim is elevated, and sometimes the rim does not descend even with repeated grafting.[2]. When the range we can reach is exceeded, we move to the next approach.

Choice when the outer aspect is strongly elevated

When outer retraction is significant, we either expand the grafting area or choose to move the lateral crus that supports the rim itself caudally.[2]. In textbooks, lateral crus extension grafting is considered more stable than alar rim grafting and allows more precise targeting of the area to be corrected.[3]. In nasal surgery for cleft lip and palate, extended lateral crus strut grafting and extended alar rim grafting are also mentioned as methods to increase support for the nasal tip and rim.[4].

What do we add when inner lining is insufficient?

When the mucosa of the inner lining is deficient, the rim will not descend even if we add only structural support.[3]. In severe retraction, the basic approach combines lateral crus strut grafting to re-establish support with composite skin-cartilage grafting to replace the inner lining.[3]. There are reports of restoring both form and function by harvesting skin and cartilage from the ear and suturing them to match the contour of the nasal interior, but this is reconstruction for full-thickness defects of the alar wing, and caution is warranted before applying it directly to routine cases of retraction.[5].

Is there a way to lower the rim without adding grafts?

A method called lateral V-Y advancement has been reported, in which a triangular flap is raised full-thickness from the position of the alar crease and advanced caudally.[6]. It is said that a single operative technique alone can restore a natural rim contour, and it has the advantage of being less conspicuous because the scar can be placed in the recessed area.[6]. However, this is a report from a single institution with limited Before-after cases, and it is not a comparative trial against other techniques, so the range in which it can be substituted remains unclear.[6].

How is the decision made in my case?

The decision process follows this sequence: assess the severity of retraction, determine whether structural support or inner lining is deficient, and then confirm what graft material is available.[1][3]. Because the usable tissue varies depending on whether it is a primary or revision case, sharing information about prior surgery early in the discussion will help move things forward.[1]. Which approach is most suitable is determined individually by the surgeon after examining the interior of the nose.