528464

research-article2014
AESXXX10.1177/1090820X14528464Aesthetic Surgery JournalDaniel et al

AL CON
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Rhinoplasty

Aesthetic Surgery Journal

Rhinoplasty: The Lateral Crura–Alar Ring 2014, Vol. 34(4) 526­–537

© 2014 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
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DOI: 10.1177/1090820X14528464
Rollin K. Daniel, MD; Peter Palhazi, MD; Olivier Gerbault, MD; www.aestheticsurgeryjournal.com
and Aaron M. Kosins, MD

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Abstract
Background: Rhinoplasty surgeons routinely excise or incise the lateral crura despite nostril rim retraction, bossa, and collapse. Given recent emphasis
on preserving the lateral crura, a review of the lateral crura’s anatomy is warranted.
Objectives: The authors quantify specific anatomical aspects of the lateral crura in cadavers and clinical patients.
Methods: This was a 2-part investigation, consisting of a prospective clinical measurement study of 40 consecutive rhinoplasty patients (all women) and 20 fresh
cadaver dissections (13 males, 1 female). In the clinical phase, the alar cartilages were photographed intraoperatively and alar position (ie, orientation), axis, and
width were measured. Cadaver dissections concentrated on parts of the lateral crura (alar cartilages and alar ring) that were inaccessible clinically.
Results: Average clinical patient age was 28 years (range, 14-51 years). Average cadaver age was 74 (range, 57-88 years). Clinically, the distance of the
lateral crura from the mid-nostril point averaged 5.9 mm, and the cephalic orientation averaged 43.6 degrees. The most frequent configuration of the axis
was smooth-straight in the horizontal axis and a cephalic border higher than the caudal border in the vertical axis. Maximal lateral crura width averaged
10.1 mm. In the cadavers, average lateral crural dimensions were 23.4 mm long, 6.4 mm wide at the domal notch, 11.1 mm wide at the so-designated
turning point (TP), and 0.5 mm thickness. The accessory cartilage chain was present in all dissections.
Conclusions: The lateral crura–alar ring was present in all dissections as a circular ring continuing around toward the anterior nasal spine but not
abutting the pyriform. The lateral crura (1) begins at the domal notch and ends at the accessory cartilages, (2) exhibits a distinct TP from the caudal border,
(3) has distinct horizontal and vertical vectors, and (4) should have a caudal border higher than the cephalic border. Alar malposition may be associated
with position, orientation, or configuration.

Keywords
rhinoplasty alar rim, alar malposition, alar graft, cephalic orientation, external valve collapse, nostril rim retraction, bossa, caudal border, lateral crura, caudal
border

Accepted for publication October 10, 2013.

In contrast to their focus on the nasal tip’s domal segment,
rhinoplasty surgeons have traditionally approached the lat-
eral crura either by routinely excising the cephalic portion to
reduce tip volume or transecting to obtain tip definition or
deprojection. This approach leads to aesthetic deformities
(eg, bossa, prominences, retracted alars) and functional com-
promise (external valve collapse). Sheen’s recognition of alar
malposition emphasized the link between lateral crura anat-
omy and external valve function.1 Plastic surgeons are now
preserving more of the lateral crura and also developing inno-
vative methods of controlling shape (lateral crural convexity
sutures), stability (lateral crural strut grafts), and position
Dr Daniel is a Clinical Professor and Dr Kosins is a Clinical Assistant
Professor in the Department of Plastic Surgery, University of California,
Irvine, Orange, California. Dr Palhazi is a PhD student in the
Department of Medicine, Simmelweis University, Budapest, Hungary.
Dr Gerbault is a plastic surgeon in private practice in Paris, France.
The article was presented in part at the Rhinoplasty Society 18th
Annual Meeting; April 2013; New York, NY.
Scan this code with your smartphone
to see the operative video. Need help?
Visit www.aestheticsurgeryjournal.com.
Daniel et al 527
(reposition, transposition).2,3 As such, reviewing the lateral
crura’s anatomy, aesthetics, and surgical modification is
merited.
A specific focus on anatomy and specific terminology is
essential to any discussion of the lateral crura. Perhaps the
best method of defining the lateral crura is to look first at its
4 borders and then the lateral crura itself. The medial
cephalic border of the lateral crura has an S-shaped fibrous
scroll junction with the upper lateral crura that often
includes interspersed sesamoid cartilages. Based on fixed
cadaver studies, the actual scroll area varies from the most
common S-shape to appositional to separation.4 As the
cephalic border extends laterally, it becomes isolated in jux-
taposition to the Hoksteder mucosal space.5,6 The caudal
border often parallels the nostril rim before turning cephali-
cally. In certain cases, the caudal border is distinctly visible
as the alar groove. The medial border occurs at the domal
junction with the domal segment of the middle crura.7 The
lateral border occurs at the junction of the lateral crura with
the first accessory cartilage. As noted by Cottle,8 this junc-
tion frequently can be seen intranasally and acts as a baffle
to redirect airflow into the middle meatus.
The lateral crura’s shape within the overall population
traditionally has been classified into 6 types based on the
transverse axis: (1) smooth-convex (10%), (2) convex-
concave (30%), (3) concave-convex (25%), (4) concave-
convex-concave (25%), (5) concave (5%), and (6) totally
irregular (5%).9 Even greater refinement can be achieved
by applying Johnson and Toriumi’s concept10 of both the
horizontal—or transverse—axis (medial to lateral) and the
vertical axis (cephalic to caudal). Recent emphasis on the
height relationship between the cephalic and caudal bor-
der has led to a better understanding of nasal aesthetics
and nostril rim support.11 The importance of the lateral
crura’s position relative to the nostril rim became clear
with Sheen’s identification1 of alar malposition. He stated
that “if the lateral crus does not parallel the alar rim half-
way, but sharply angles cephalad, then the caudal edge of
the crus forms a parenthesis bordering the tip.” If we
examine the nostril rim’s cephalic border, there is an apex
that often corresponds to the most caudal portion of the
lateral crura before it turns cephalad. The lateral crura’s
most caudal point is always more medial than the mid-
nostril point, and we have designated it as the “turning
point” (TP).
The alar ring, also called the narial ring, is defined as the
entire alar cartilage and its continuation with the accessory
cartilage chain.12,13 The ring begins at the footplates of the
medial crura, passes through the entire length of the alar car-
tilage, and continues in the accessory cartilage chain toward
the anterior nasal spine. The alar ring is quite flexible and
Corresponding Author:
Dr Rollin K. Daniel, Clinical Professor in the Division of Plastic Surgery, University of California, 1441 Avocado Ave, Ste 308, Newport Beach,
CA 92660, USA.
E-mail: rkdanielmd2@gmail.com
undergoes dilatation or compression depending on the nasal
musculature.14 As previously mentioned, the junction of the
lateral crura with the first accessory cartilage is denoted intra-
nasally by the baffle of the vestibule. Aesthetically, the alar
depression correlates with a convex-concave transverse axis
of the lateral crura, while the alar dimple is created by a con-
cave accessory cartilage. One important point is that neither
the lateral crura nor the accessory cartilages abut the pyri-
form aperture. Rather, the alar ring is a mucosally adherent
structure that turns around toward the nasal spine. The alar
crease, also termed the alar base facial crease, signifies the
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junction of the alar base and the cheek.14 As the alar crease
turns onto the nose, it becomes the alar groove. The alar
groove marks the caudal border of the lateral crura with vari-
able expression at the skin surface. The groove is most evi-
dent when the lateral crura is convex and the skin is thin and
is obscured when the lateral crura is concave and the soft
tissue envelope is thick.
Methods
We conducted a 2-part anatomical measurement study,
including a clinical series of 40 primary aesthetic open rhi-
noplasty patients, plus 20 fresh cadaver dissections. The
cadaver dissections focused on those parts of the lateral
crura that were inaccessible clinically.
Clinical Series
Initially, 41 consecutive primary patients, all white and
Indo-European women who were undergoing open rhino-
plasty between December 2012 and January 2013, were
studied prospectively. Asian and African American patients
were excluded because their tip anatomy is markedly dif-
ferent from that of whites and Indo-Europeans.15 One
patient was dropped from the study when she was found
intraoperatively to have a significant bilateral segmental
gap in her middle crura,16 leaving 40 patients for study.
Standardized photographs were taken preoperatively, fol-
lowing application of tip surface markings.7 Immediately
prior to surgery, with the patient seated, surface landmarks of
the tip were made. Once the patient was under general anes-
thesia, photographs were taken from multiple views. Prior to
injection of local anesthesia, surface landmarks were trans-
ferred from the skin surface to the underlying alar cartilage
via a 25-gauge needle dipped in methylene blue. At the opera-
tion’s commencement, the mid-nostril point along the alar
rim was marked, and the distance from this point to the cau-
dal border of the alar cartilage was recorded.17 Once the skin
envelope was elevated, the alar cartilages were photographed
and multiple measurements were made to determine alar
528 Aesthetic Surgery Journal 34(4)

position (ie, orientation), axis, and width. The distance

between the mid-nostril point and the caudal border of the
lateral crura was measured to determine the position of the
lateral crura as defined by Sheen.1 A clear protractor mea-
sured orientation of the lateral crura’s caudal border relative
to the midline. The protractor’s fixed limb was placed along
the nose midline; the measuring limb was rotated to a line
tangential to the lateral crura’s caudal border and the domal
notch’s lateral genu.

Cadaver Dissections

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To fully understand the anatomy of this region—especially
the anatomy not normally visible during open rhinoplasty—
dissection studies were done on 20 white fresh cadavers
(13 male, 7 female) at the time of autopsy. An initial 10
dissections identified specific structures and areas of inter-
est; a definitive series of 10 dissections, with emphasis on
the alar cartilages and alar ring, was subsequently com-
pleted. Videos of each of the 2 procedures are available at
www.aestheticsurgeryjournal.com. You may also scan the
code on the first page of this article with any smartphone
to be taken directly to the video at www.YouTube.com.
The first video demonstrates a cadaver case; the second
video demonstrates a clinical case.

Results
Clinical Study
The average age of the 40 clinical patients was 28 years
(range, 14-51 years). The following measurement results
were recorded.

Lateral Crura Position (Orientation)
Nostril length ranged from 13 to 18 mm, with a mean of
16.1 mm. The perpendicular distance from the mid-nostril
point to the caudal border of the lateral crura ranged from
3 to 9 mm, with a mean of 5.9 mm (Figure 1A).
Lateral Crura Axis.  The lateral crura axis, as defined by
Johnson and Toriumi,10 was classified via the convex-smooth-
concave terminology of Zelnik and Gingrass.9 The horizon-
tal axis (transverse) was as follows: (1) smooth-straight,
n = 13 (32.5%); (2) convex, n = 9 (22.5%); (3) concave,
n = 7 (17.5%); (4) smooth-convex, n = 6 (15.0%); and
(5) convex-concave-convex, n = 5 (12.5%). The vertical
axis was as follows: (1) smooth-straight, n = 11 (27.5%);
(2) convex, n = 10 (25.0%); (3) smooth-convex, n = 8
(20.0%); (4) concave, n = 6 (15.0%); and (5) convex-
concave-convex, n = 5 (12.5%). Importantly, the cephalic-
caudal border relationship was as follows: (1) cephalic
higher than caudal, n = 24 (60.0%); (2) cephalic equal
to caudal, n = 14 (35.0%); and (3) caudal higher than
cephalic, n = 2 (5.0%). The lateral crura axis at its caudal
Figure 1.  The lateral crura. (A) The lateral crura has a
distinct starting point at the dome and an ending point
at the junction with the A-1 accessory cartilage, with an
intervening turning point (TP). In alar malposition, the
reference points are the same, but the position of the caudal
border at the mid-nostril rim point is greater than 7 mm from
the nostril rim. This differs from cephalic orientation, where
the lateral crura runs more parallel to the mid-vault and is
directed toward the medial canthal region (as opposed to
the lateral canthal region). (B) The lateral crura has both
horizontal and vertical axes. The most aesthetic vertical axis
occurs when the caudal border is higher than the cephalic
border. CA, caudal; CE, cephalic.
border was measured intraoperatively with a clear protrac-
tor. The caudal border axis ranged from 30 to 60 degrees
with a mean of 43.6 degrees (Figure 1B).
Lateral Crura Width.  The lateral crura width was mea-
sured at a range of 7 to 14 mm and a mean of 10.1 mm. The
scroll configuration was considered S-shaped in all cases
when assessed at the widest point of the lateral crura.
Daniel et al 529
Figure 2.  The lateral crura and alar ring, featuring lateral, oblique, and basilar aspects.
Cadaver Study
Average cadaver age was 74 years (range, 57-88 years). The
average lateral crura dimensions were as follows: (1) 23.4
mm long, (2) 6.4 mm wide at the dome (lateral genu of the
domal notch), (3) 11.1 mm wide at the TP, (4) 13.3 mm in
distance from the dome to the TP, and (5) 0.5 mm thick. The
accessory cartilage chain, with an average length of 18 mm,
was present in all dissections (Figures 2 and 3). However, the
number of individual cartilages varied as follows: A-1 (n =
40), 100% (average 8.5 × 4.5 mm); A-2 (n = 38), 94% (6.5
× 3.4 mm); A-3 (n = 16), 38% (6.3 × 3.6 mm); and A-4 (n
= 8), 19% (4.7 × 3.0 mm) (Figure 4). Despite such variance,
the total length of the accessory chain was relatively constant.
Note that the accessory cartilages did not abut the bony pyri-
form aperture but rather turned medially toward the anterior
nasal spine to end at a variable distance in the nostril floor
(Video 1). In addition, the accessory cartilages were closely
adherent to the mucosa but separated from the skin by the
intervening superficial musculoaponeurotic system (SMAS).
Discussion
To achieve the ideal tip during rhinoplasty, surgeons must
clearly understand the anatomy and surgical techniques
applicable to the lateral crura. In this Discussion section,
we will discuss 5 anatomical components of the lateral
crura–alar ring, as well as certain surgical techniques
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applicable to lateral crura modification. One point must be
emphasized: the anatomy of the lateral crura observed at
the beginning of any patient case changes dramatically
during surgery. For example, excising a variable amount of
cephalic lateral crura creates a “new” cephalic border,
changes the cephalic-caudal border relationship, and alters
the vectors of its shape. Additional surgical steps can fur-
ther modify or even disrupt the initial anatomy. Thus, sur-
geons must be able to recognize anatomical variations and
adapt their surgical plan to the actual anatomy encoun-
tered. This plan must be flexible, as each maneuver can
further change the anatomy of the lateral crura.
Alar Groove
The importance of the lateral crura’s caudal border cannot
be overemphasized. Zelnik and Gingrass9 noted that the
average caudal border of the alar cartilages was 6 mm from
the rim at the domal segment, 5 mm at its mid-portion,
and 13 mm at its posterior portion. We have observed that
a distinct TP occurs along the caudal border of the lateral
crura, the point closest to the nostril rim. In virtually all
cases, it is anterior to the mid-nostril point.
In white patients, the combination of rigid cartilage and
thin skin often allows expression of a visible alar groove at
the skin surface that effectively separates the tip lobule
from the alar lobule. Histological studies by Wu18 indicated
that the alar groove is created by fibrous attachments
530 Aesthetic Surgery Journal 34(4)

Figure 3.  Cadaver dissections focusing on the alar cartilage and alar ring. (A, B) Lateral and anterior views of the external Downloaded from https://academic.oup.com/asj/article-abstract/34/4/526/2801377 by guest on 12 October 2019
nose (predissection). (C-F) Lateral and anterior positions with the skin removed and the lateral crura and accessory cartilages
outlined. Following skin removal, it becomes obvious the accessory cartilage ring is a definite structure that continues inward
toward the anterior nasal spine, rather than outward toward the pyriform bony aperture.

running from the SMAS layer upward to the dermis. This
groove runs laterally from the TP as an extension from the
lower lateral cartilages and accessory cartilages to the alar-
cheek junction. This groove can be made more prominent
by asking the patient to flare his or her nostrils. Using the
nasalis muscle, with contraction of the nasal SMAS, the
alar groove becomes more apparent due to its “triflanged”
fibrous attachment at the caudal border of the lateral crura.
The fibers attach to the caudal border of the lower lateral
cartilage, the underlying mucosa, and the dermis. It is this
triflanged arrangement that is responsible for the alar
groove. Ali-Salaam et al19 further noted the presence of a
rigid fatty layer on the tip side versus the paucity of fat tis-
sue within the alar lobule. It must also be stressed that
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Figure 4.  Cadaver dissections demonstrating the varying number of cartilages composing the accessory cartilage chain.
Despite individual cartilage variation, the chain itself averages 18 mm in length. (A) Dissection revealing a single accessory
cartilage; (B) a 2-cartilage chain; (C) a 3-cartilage chain; (D) a 4-cartilage chain.

when the alar groove extends all the way to the nostril rim,
this preoperatively indicates alar rim weakness.
Vertical Axis
Johnson and Toriumi10 emphasized the vertical and hori-
zontal axes of the lateral crura. Recently, Toriumi11 has
examined the height of the caudal and cephalic borders of
the lateral crura relative to each other and suggested that
the 2 margins should be near the same horizontal level.
Diagrammatically, the shape of the intervening lateral
crura in the vertical axis is depicted as straight. Again, in
our 40 patients, the vertical axis was as follows: (1)
smooth-straight, n = 11 (27.5%); (2) convex, n = 10
532 Aesthetic Surgery Journal 34(4)
(25.0%); (3) smooth-convex, n = 8 (20.0%); (4) concave,
n = 6 (15.0%); and (5) convex-concave-convex, n = 5
(12.5%). At the time of exposure, the cephalic-caudal bor-
der relationship was as follows: (1) cephalic higher than
caudal, n = 24 (60.0%); (2) cephalic equal to caudal, n =
14 (35.0%); and (3) caudal higher than cephalic, n = 2
(5.0%). In the majority of rhinoplasties, a variable amount
of the cephalic portion of the lateral crura is excised.
Classically, this excision was made to improve tip appear-
ance by reducing volume, narrowing width, and increasing
definition. With the rise of open-tip suture techniques, it
has become apparent that incision/excision of the lateral
crura also increases the malleability of the remaining alar
cartilage.
In our clinical study, we observed that incision followed
by excision of the lateral crura resulted in a more horizon-
tal flat rim strip with dramatic changes in the relative lev-
els of the cephalic and caudal borders. The importance of
the caudal border being above the cephalic border of the
lateral crural rim strip cannot be overemphasized. Excising
a portion of the cephalic lateral crura yielded positive
effects in the majority of cases, but on occasion the simple
act of excision accentuated a lateral crural convexity.
Gruber’s lateral crura mattress suture proved extremely
effective both in neutralizing convexities and in bringing a
prominent cephalic border back to a horizontal level.2
When the lateral crura’s shape was concave, the selected
technique depended on the severity of associated aesthetic
and functional factors. If the primary problem was aes-
thetic, then a “turn-over” flap of lateral crura was done.20
If collapse of the external valve was the primary concern,
then a “turn-under” flap of lateral crura was performed.21
For truly severe cases, a “flip plus swap” of the lateral crura,
as pioneered by Eitner in the 1930s, can be performed.22 It
should be noted that in our series, tip suturing—the trans-
domal suture in particular—did not cause lateral crura
eversion.
Horizontal Axis
The primary factor in the horizontal axis is shape. From
our clinical data, the horizontal axis in the 40 patients was
as follows: (1) smooth-straight, n = 13 (32.5%); (2) con-
vex, n = 9 (22.5%); (3) concave, n = 7 (17.5%); (4)
smooth-convex, n = 6 (15.0%); and (5) convex-concave-
convex, n = 5 (12.5%). While Zelnik and Gingrass9 classi-
fied the lateral crura inclusive of the domal segment, our
description pertains just to the lateral crura. The domal
segment, which we consider part of the middle crura, is
excluded. One of the 3 most common complaints of cos-
metic rhinoplasty patients is a wide bulbous tip without
definition. When the preoperative tip width is transferred
to the underlying alar cartilages, the domal segment is
clearly smooth and continues uninterrupted into a smooth
convex lateral crura on the horizontal axis. In contrast,
when the lateral crura is markedly concave, it is often
expressed clinically as an alar depression (Figure 5).
Surgical correction is achieved by placing a lateral crural
strut graft underneath the rim strip (Video 2).
Position
Sheen1 introduced the concept of malposition of the lateral
crura. Sheen’s definition of the normal position was that
“most often the caudal edge of the lateral crus is parallel to
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the alar rim for half the length of the nostril,” whereas
malposition is “any displacement of the lateral crura from
the usual parallel alignment with the nostril rims.” This
definition led the senior author (R.K.D.) to measure the
distance from the mid-nostril point on the alar rim back to
the caudal border of the lateral crura at the beginning of
each case. The distance ranged from 3 to 9 mm, while the
nostril length varied from 13 to 18 mm. Previous reports in
the literature indicated that any distance greater than 7
mm would be considered alar malposition.17 In our current
study, 7 of 40 patients (17.5%) had a mid-nostril distance
of 8 to 9 mm. If a distance greater than 7 mm is measured,
the surgeon can diagnose probable alar malposition.
Instead of the usual infracartilaginous incision, surgeons
can consider making a rim incision 2 mm back from the
nostril rim to insert an alar structure rim graft at the time
of closure. Alternatively, placement of a standard alar rim
graft becomes a virtual certainty. (Alar rim grafts were
placed in all 7 patients with a mid-nostril distance greater
than 7 mm.)
Following Sheen’s original description,1 numerous
authors began to adopt the term cephalic orientation as a
more accurate description of the problem.23,24 With an
open approach, it is possible to measure the lateral crura’s
actual position, but along which axis? One can mark the
midline, then measure the axis of the lateral crura either at
its cephalic border, a midline point through the dome, or
its caudal border. We favor the caudal border for multiple
reasons: (1) it reflects the pathology of the problem, (2) it
is unaltered by excision of the cephalic lateral crura, and
(3) its location is modified surgically to correct the prob-
lem in cases of severe malposition. Once the nose is
opened, a clear protractor can measure the orientation of
the caudal border relative to the midline. The fixed limb is
placed along the midline of the nose, and the measuring
limb is placed tangentially to a line connecting the caudal
border of the lateral crura and the lateral genu of the domal
notch. In our study, the caudal border was also chosen
over the central axis because the central axis is difficult to
define—that is, where does the central axis end laterally?
Lateral crura width varies, and the central axis may be
surgically altered during a rhinoplasty. The biggest advan-
tage of the caudal border is that it is unaltered during
Daniel et al 533

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Figure 5.  This 17-year-old woman presented with a lateral crura–alar ring deformity. (A) Preoperatively, the topmost “X”
denotes transition from convex medial to concave lateral crura. The middle “X” denotes depth of alar depression. The bottom
“X” denotes the alar dimple overlying A-1 accessory cartilage. (B) Postoperative surgical correction of the patient’s lateral
crura–alar ring deformity. (C) Intraoperative exposure reveals the concave lateral crura; the blue mark has been transferred
from the alar depression. (D) Insertion of a lateral crural strut graft.

surgery. The range of values was 30 to 65 degrees, with a
mean of 43.6 degrees.
One of our most important observations was the reduc-
tion in measurable cephalic orientation, which occurred
from compression of the middle crura without any trans-
position of the lateral crura. The patient in Figure 6 had an
approximately 72-degree cephalic orientation of the caudal
border of the lateral crura on photographic analysis after
exposure and 42 degrees following tip suturing. Nothing
was done to the lateral crura except excision of cephalic
lateral crura, which reduced its width from 8 to 6 mm, and
tip suturing.
Lateral Crura–Accessory Cartilage
Junction
As described previously, the alar ring comprises 1 to 4
accessory cartilages plus distinct ligaments. It extends
from the junction with the lateral crura around to the ante-
rior nasal spine.12,25-27 Anatomical dissections revealed that
the alar ring was present in all cadavers. A distinct
ligament, stretching from the second accessory cartilage to
the pyriform aperture, was found. However, lateral crura
does not conform to the aesthetic and surgical planning
concept of a tripod, even though this concept is a valuable
teaching tool. Anderson28 and Anderson and Ries29 devised
the “tripod” analogy as a teaching concept for tip surgery.
Anderson suggested that the lower lateral cartilage com-
plex forms a tripod, anchored centrally by the conjoined
medial crura and laterally by the lateral crura that “extend
to or near the pyriform aperture.”
Instead, it must be emphasized that the lateral crura acces-
sory cartilage complex does not rest on the bone, as the tripod
concept would indicate.28 Rather, it functions as a dynamic
baffle to help regulate airflow through the nose (Figure 7).
The lateral crura/accessory cartilage junction (LC/ACJ) is a
distinct entity, often indicated on the skin surface by the alar
dimple and intranasally by the recruvatum. Understand that
surgically, the shape of these structures is influenced more by
their direct attachment to the mucosa rather than the overly-
ing skin with its intervening muscles. The most common sur-
gical treatment is to insert a lateral crura strut graft under the
534 Aesthetic Surgery Journal 34(4)

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Figure 6.  This 27-year-old woman experienced dramatic change in the angle of cephalic orientation without alteration of
the lateral crura’s position. (A,C) The angle of cephalic orientation is approximately 72 degrees at rest. (B,D) Following
compression of the middle crura onto a columellar strut, the angle of cephalic orientation is now 42 degrees.

junction, with direct excision of the junctional cartilages per-
formed only as necessary.30,31
Our current study is perhaps the first definitive anatom-
ical study of the accessory cartilages and emphasizes their
functional importance. Most previous reports either largely
ignore the accessory cartilages or state that the accessory
cartilages are either minor sesamoid cartilages or highly
variable. Virtually none discuss their role in nasal func-
tion. To be clear, the lateral portion of the lateral crura
extends as accessory cartilages, whereas in the space
between the upper lateral and lower lateral cartilages,
there may be a varied number of small sesamoid carti-
lages.32,33 As Gunter27 pointed out in his classic article on
the lower lateral cartilages, in both anatomical and rhino-
plasty texts, depiction of the lower lateral cartilages, espe-
cially the accessory cartilages, varies widely. This study
helps clarify the anatomic and functional importance of
the lower lateral cartilages and alar ring.
Surgical Relevance
On the basis of our anatomical dissections, we have 3
observations with clinical importance. First, the lateral
crura begins at the domal junction of the middle crura and
ends at the LC/ACJ, even in cases with significant alar
malposition and cephalic orientation. Anatomically, the
lateral crura passes between these defined points with a
variable configuration and position. Second, the lateral
crura–alar ring is a mucosally-adherent structure rather
than a skin-adherent structure. The alar cartilages are
enveloped on their external surface by the nasal SMAS,
with the lateral crura covered by the compressor narim
major, anterior nasal dilator, and multiple muscles com-
posing the alar lobule.34 On their internal surface, the car-
tilages are covered by a thin adherent mucosa, which
readily reveals their structure. In cases of severe ball tips,
one can often see little change in the fundamental shape of
the tip cartilages following skin elevation, despite excision
of a large amount of cephalic lateral crura and extensive
suturing. It is only when the mucosal adherence to the alar
cartilages is released that one sees the desired change in
shape. Third, the lateral crura do not conform to the aes-
thetic and surgical planning concept of a tripod. The ana-
tomical reality is that the lateral crura are usually convex
and directed outward in their horizontal axis but turn
inward at their junction with the first accessory cartilage;
the rest of the alar ring runs medially toward the anterior
nasal spine. Clinically, most lateral crura strut grafts that
Daniel et al 535

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Figure 7.  This 21-year-old woman presented with a blocked vestibule due to the lateral crura/accessory cartilage junction.
(A) Preoperative endoscopic view prior to injection of local anesthetic. (B) Postoperative view of open vestibule with excised
junctional cartilage. (C) Submucosal release of the junction. (D) Mobilization of the lateral crura and A-1 cartilage.

extend to the pyriform aperture are inserted for support
and thus are placed into a nonanatomical location.31
Rhinoplasty surgery can create dramatic changes in the
lateral crura anatomy. The most obvious changes follow inci-
sion and excision of cephalic lateral crura. Incision of the lat-
eral crura 6 mm parallel to the caudal border profoundly
changes the vertical axis and, often, rigidity of the cartilage.
This maneuver also destroys the scroll junction with the
upper lateral cartilage, which may well impact the function of
the internal valve. In addition, removing a portion of the
cephalic lateral crura creates a “dead space” that can poten-
tially contract and negatively influence alar rim position.3
Sheen’s favored treatment of alar malposition often
involved excising the entire lateral crura as well as the
domal segment of the middle crura, followed by replace-
ment with a multilayer tip graft centrally and reinsertion of
modified lateral crura laterally to support the alar rim.35
Hamra36 emphasized reorienting the lateral crura and bring-
ing it down toward the alar rim. In fact, the angle of cephalic
orientation can help define the following: (1) alar malposi-
tion due to cephalic orientation is greater than 55 degrees,
(2) surgical repositioning is orienting the lateral crura at 45
degrees, and (3) surgical transposition is orienting the lat-
eral crura along the nostril rims at approximately 30 degrees.
The 3 most common etiologies of alar malposition in pri-
mary cases are positional malposition, cephalic orientation,
and contour.37 The senior author completes most of these
cases through an open approach. Deciding which surgical
technique is most appropriate is based on the following 3
observations: (1) distance from mid-nostril rim to caudal
border of lateral crura, (2) cephalic orientation of the lateral
crura, and (3) configuration of the middle crura. The most
important clinical finding from our study is that in patients
with long dependent tips, malposition and cephalic orienta-
tion of the lateral crura often corresponds with the middle
crura and, specifically, the columellar breakpoint. Surgeons
can vertically align and compress the middle crura, which
dramatically shortens the distance from the dome to the
columellar breakpoint. This reduces the malposition and the
apparent cephalic orientation from unfavorable to favor-
able—all without any change in the lateral crura’s position
(Figure 8).
536 Aesthetic Surgery Journal 34(4)

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Figure 8.  This 32-year-old woman represents a typical case in which the alar cartilages are sutured to achieve a narrower,
more refined tip. (A, C, E) Presuturing. (B, D, F) Postsuturing.

One limitation of this study is that even though we con-
ducted our dissections with fresh cadavers, separating the
skin from the lateral crura may have possibly affected
some of our measurements secondary to contraction of the
cartilage still attached to the vestibular mucosa.
Conclusions
An in-depth knowledge of the lateral crura–alar ring’s anat-
omy and terminology represents an essential component for
understanding the aesthetics and surgical planning of rhino-
plasty surgery. A prospective study of 40 primary female rhi-
noplasty patients indicated that the caudal border of the
lateral crura was on average 5.9 mm from the mid-nostril
point and had an axis of 43.6 degrees. The most common
shape was smooth-straight in both the horizontal and vertical
axes. Contrasting with the aesthetic ideal at the end of the
procedure, which arguably consists of the 2 margins at or
near the same horizontal level, the cephalic border is higher
or equal to the level of the caudal border in 95% of cases on
Daniel et al 537
initial exposure. Further, cadaver dissections revealed that the
accessory cartilage chain was present in all cadavers; the A-1
accessory cartilage forms the vestibular baffle, while the rest
of the chain completes the alar ring. The correlation between
the lateral crura and surgical techniques is provided as it
relates to the following areas: alar groove, vertical axis, hori-
zontal axis, alar malposition, and alar ring.
Disclosures
The authors declared the following potential conflicts of inter-
est with respect to the research, authorship, and/or publica-
tion of this article: Dr Daniel receives book royalties from
Springer Publishing (New York, New York). The other authors
have nothing to disclose.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
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