384

The Articulated Alar Rim Graft: Reengineering the

Conventional Alar Rim Graft for Improved Contour
and Support
Annelyse C. Ballin, MD1 Haena Kim, MD1 Elizabeth Chance, MD1 Richard E. Davis, MD, FACS1,2

1 Division of Facial, Plastic, and Reconstructive Surgery, Department of Address for correspondence Richard E. Davis, MD, FACS, The Center
Otolaryngology, University of Miami Miller School of Medicine, for Facial Restoration, 1951 SW 172nd Ave., Suite 205, Miramar, FL
Miami, Florida 33029 (e-mail: drd@davisrhinoplasty.com).
2 The Center for Facial Restoration, Miramar, Florida

Facial Plast Surg 2016;32:384–397.

Abstract Surgical refinement of the wide nasal tip is challenging. Achieving an attractive, slender,
and functional tip complex without destabilizing the lower nasal sidewall or deforming
the contracture-prone alar rim is a formidable task. Excisional refinement techniques
that rely upon incremental weakening of wide lower lateral cartilages (LLC) often
destabilize the tip complex and distort tip contour. Initial destabilization of the LLC is

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usually further exacerbated by “shrink-wrap” contracture, which often leads to progres-
sive cephalic retraction of the alar margin. The result is a misshapen tip complex
accentuated by a conspicuous and highly objectionable nostril deformity that is often
very difficult to treat. The “articulated” alar rim graft (AARG) is a modification of the
conventional rim graft that improves treatment of secondary alar rim deformities,
including postsurgical alar retraction (PSAR). Unlike the conventional alar rim graft, the
AARG is sutured to the underlying tip complex to provide direct stationary support to
the alar margin, thereby enhancing graft efficacy. When used in conjunction with a well-
designed septal extension graft (SEG) to stabilize the central tip complex, lateral crural
tensioning (LCT) to tighten the lower nasal sidewalls and minimize soft-tissue laxity, and
lysis of scar adhesions to unfurl the retracted and scarred nasal lining, the AARG can
eliminate PSAR in a majority of patients. The AARG is also highly effective for prophylaxis
against alar retraction and in the treatment of most other contour abnormalities
Keywords involving the alar margin. Moreover, the AARG requires comparatively little graft
► alar retraction material, and complications are rare. We present a retrospective series of 47 consecu-
► alar rim graft tive patients treated with the triad of AARG, SEG, and LCT for prophylaxis and/or
► cephalic treatment of alar rim deformities. Outcomes were favorable in nearly all patients, and no
overresection complications were observed. We conclude the AARG is a simple and effective method
► rhinoplasty for avoiding and correcting most alar rim deformities.

Overview apparatus greatly augments LLC rigidity by consolidating

In the healthy and attractive human nose, structural tip
support is derived from the inherent rigidity of the paired
lower lateral cartilages (LLC).1,2 However, secondary tip
support derived from the surrounding soft-tissue suspensory
structural cohesion between the paired medial crura and
by uniting the LLC with the adjacent septum/upper lateral
cartilage (ULC) complex for added stability. In noses where
septal height and projection are naturally strong, the under-
girding and buttressing provided by the nasal septum can be

Issue Theme Challenging Problems in Copyright © 2016 by Thieme Medical DOI http://dx.doi.org/
Rhinoplasty; Guest Editor, Hossam M.T. Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0036-1585573.
Foda, MD New York, NY 10001, USA. ISSN 0736-6825.
Tel: +1(212) 584-4662.

considerable and may be almost as important to structural tip
support as the tip cartilages themselves.1–4 The collective
result of these interdependent support mechanisms is a
structural steady state with long-term architectural stability.
In contrast to the attractive nasal tip, the unsightly nasal tip
is characterized by a misshapen skeletal framework. Intrinsic
derangements in LLC size, shape, or symmetry are often the
cause of cosmetic tip malformations,5 but inadequate struc-
tural support is also a common cause of cosmetic tip defor-
mity.6 Tip ptosis, lobular pinching, inadequate tip projection,
and splaying of the tip complex are all unsightly manifesta-
tions of inadequate structural support, and these deformities
may derive from deficiencies in both primary and/or second-
ary support mechanisms. Such deformities are also frequent-
ly compounded by overly thick nasal tip skin that exacerbates
LLC distortion and dulls tip definition.7 Not surprisingly,
misguided attempts to enhance tip contour that sacrifice
structural support are prone to failure. The typical outcome
is an unsightly and dysfunctional tip complex that will
deteriorate with time, underscoring the fundamental impor-
tance of strong and durable tip support.
Cephalic Trim Technique
Classically, tip refinement has been accomplished using
partial (cephalic) resection of the lateral crura—the so-called
cephalic trim technique—as the primary means of lobular
width reduction. Intended to flatten a wide and overly convex
lateral crus by resecting the cephalic margin and thereby
partially reducing crural rigidity, the cephalic trim technique
remains a popular, albeit unpredictable, rhinoplasty work-
horse. Although an immediate reduction in tip width is
virtually guaranteed and satisfactory tip refinement can be
achieved in a subset of cases, the cephalic trim technique is
also notoriously imprecise. Correctly identifying the exact
configuration of cartilage resection that will achieve tip
refinement without triggering secondary crural deformities
is challenging. Because the extent of crural resection is largely
guesswork, inadvertent crural overresection and skeletal
destabilization are common, and distortion and collapse of
the tip framework with a wide array of stigmatic and slowly
progressive tip deformities frequently ensue.1,2,4,5,8 Because
cephalic resection also typically destroys the nasal scroll—the
articulation of the ULC and LLC that stabilizes the internal
nasal valve—functional morbidity is often considerable. And
since the adverse effects of cephalic overresection may re-
quire decades to fully manifest, the true morbidity of cephalic
resection is often underappreciated. Due to its continued
widespread use, the cephalic trim technique remains a fre-
quent cause of surgical tip deformity, and overaggressive
cephalic resections are a near-universal finding in patients
undergoing revision tip surgery (►Fig. 1). Indeed, most
iatrogenic nasal deformities occur in the lower one-third of
the nose,9 and tip irregularities are a common problem
prompting revision rhinoplasty.10 Based on its associated
morbidity, the cephalic trim is also widely regarded among
rhinoplasty experts as an imprecise and unpredictable tech-
nique that should be performed judiciously, if at all.
Articulated Alar Rim Graft Ballin et al. 385
Perhaps the most common scenario in which cephalic
resection leads to treatment failure is the overtly bulbous
nasal tip with its large and obtrusive tip morphology. To treat
the cosmetically objectionable cupping of bulbous tip carti-
lages, many surgeons resort to unusually aggressive crural
resections that far exceed the (ill defined) threshold for
structural instability. Such overresections trigger immediate
instability and collapse of the tip complex, followed by gradual
distortion of the severely weakened crural remnants.1,2,4,5,8
Ironically, because cupping adds stiffness to naturally weak
crural cartilage, the loss of crural rigidity from overresection is
compounded by the simultaneous loss of shape-derived sup-
port from crural cupping, making the morbidity of overresec-
tion in the bulbous tip disproportionately severe (►Fig. 1).
However, the hazards of cephalic resection are not just limited
to the overtly bulbous nasal tip. Even when treating modest
lobular fullness, a seemingly “conservative” excision that
preserves 6 or 7 mm of the lateral crus can still compromise
structural equilibrium and lead to severe adverse functional
and cosmetic outcomes. Indeed, destabilization produced by
cephalic overresection can cause distortion and/or collapse of
the tip framework in virtually any nose unless structural
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support is properly maintained or restored.
Shrink-Wrap Contracture
While cephalic overresection alone is sufficient to deform the
tip complex, further deformation of the surgically weakened
framework usually results from postoperative “shrink-wrap”
contracture of the inner or outer nasal lining. Even when
cephalic resection seems to provide satisfactory tip refine-
ment in the operating room, the loss of crural rigidity, coupled
with the potent and unremitting forces of shrink-wrap con-
tracture, can lead to progressive and sometimes profound
skeletal deformation (►Fig. 1). Severe tip deformities are
most likely following crural overresection in noses with
naturally weak tip cartilage, particularly those with unfavor-
able tip architecture such as the bulbous tip or the wide and
overprojected tip. In both cases, excessive lateral crural length
combined with overaggressive resection results in dispropor-
tionately long, narrow, and flimsy crural remnants that can
only achieve structural stability through concave col-
lapse.1,2,4 Moreover, when these overly long flail segments
are then subjected to the potent forces of contracture, a
combination of foreshortening, buckling, twisting, and/or
retraction gradually compounds the initial concave deformi-
ty. In susceptible noses, gradual distortion of the tip frame-
work may also continue unabated for decades.
While shrink-wrap contracture is triggered by skeletal over-
resection and subsequent instability, numerous independent
factors determine the susceptibility and potency of epithelial
contraction. The risk of clinically significant shrink-wrap con-
tracture is much higher in noses with thin skin and/or in
individuals with genetic predispositions to scar contracture.
Scar contracture is also exacerbated by excessive and prolonged
inflammation. Inadvertent losses of tip support produced by
overresection of the septal L-strut can also predispose to
shrink-wrap contracture through further volumetric reduction
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386 Articulated Alar Rim Graft Ballin et al.

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Fig. 1 Nasal deformity following overaggressive cephalic resection of bulbous tip cartilages. (A–D) Postsurgical nasal contour with pinched tip,
alar retraction, and deformed lateral crural remnants. (E) Intraoperative view (from above) of severe lateral crural distortion from overresection.
Note severe serpentine deformity of the 2.0-mm-wide left lateral crus. (F–I) Postoperative contour (1-year post–revision rhinoplasty) following
septal extension graft placement to increase tip projection, tensioning of the crural/cutaneous complex to stabilize the lower nasal sidewalls, and
articulated alar rim graft placement using rib cartilage.

of the tip framework and a corresponding loss of sidewall
tension.1–5,8 This, in turn, produces an increase in both soft-
tissue laxity and subcutaneous dead space, thereby increasing
susceptibility to both shrink-wrap contracture and subcutane-
ous fibrosis. The morbidity of compromised septal support is
most severe when the tip cartilages are naturally weak and thus
predisposed to shape distortion, when cephalic resection is
extreme, and/or when contractile forces are particularly force-
ful. In severe cases of skeletal overresection, the combined
effects of structural instability, severe contracture, and subcu-
taneous fibrosis can produce a decidedly undersized and
amorphous nasal tip that profoundly degrades facial aesthetics.
The cumulative effects of this process can also be difficult or
even impossible to reverse.1,2,4,5
Cosmetic Morbidity of Cephalic
Overresection
The cosmetic consequences of cephalic overresection are unde-
sirable and highly stigmatic. The most common manifestation of
cephalic overresection is an unsightly “pinching” of the tip
complex. In an attractive nose, the tip defining points (TDPs)
are connected to the adjacent alar lobules by a flat and narrow
ridgeline located immediately cephalad to the alar margin
(►Fig. 1F, G).11 We have named this important topographic
feature the “alar ridge” to highlight its critical role in tip
aesthetics. Without flat, narrow, and well-defined alar ridges
to increase domal width at the TDPs, thereby producing a
(horizontal) fusiform-shaped dome complex that blends softly
with the adjacent alar lobules, an elegant and natural tip contour
is lacking. Concave distortion of the normally flat alar ridge
produced by collapse of the adjacent lateral crus creates discrete
concavities that flank the dome region and disrupt the normally
soft and gradual transition between the tip and alar lo-
bules.1,2,4,5,11,12 Harsh and well-demarcated shadows generated
by these concavities extend vertically from the alar margin
traversing the alar ridge to merge with the supra-alar crease
and visually isolate the dome region. The unnatural and unsight-
ly circular delineation of both the tip lobule and the alar lobules,
as seen from the frontal view, is the hallmark of the severely
pinched tip (►Figs. 1A and 2A). Alar rim concavities are also
easily appreciated on basal view, producing a “three-leaf clover”

Facial Plastic Surgery Vol. 32 No. 4/2016


Fig. 2 Typical cosmetic and functional stigmata of the overresected
nose. (A) Lobular pinching and alar retraction on frontal view,
(B) severe alar retraction and poor tip projection on profile view, and
(C) lobular pinching and nasal valve collapse on basal view. (From
Davis, 4 Fig. 184.2. Reprinted by permission from Wolters Kluwer/
Lippincott Williams & Wilkins.)
configuration (►Fig. 1D), rather than the preferred “equilateral
triangle” configuration with flat alar sidewalls that characterize
an attractive nasal base (►Fig. 1I). Another common and highly
undesirable consequence of cephalic overresection is cephalic
retraction of the alar rims.1,2,4,5,11–14 On frontal view, alar
retraction is characterized by notched and overly prominent
nostrils (►Fig. 2A), and on profile view, alar retraction
appears as an exaggerated nostril arch with unsightly upward
curvature of the alar ridge and excessive columellar show
(►Fig. 2B).2,4,5,11–14 The magnitude and symmetry of both
lobular pinching and alar retraction will vary considerably
according to the starting anatomy, the extent of lateral crural
collapse, and the intrinsic susceptibility to progressive skeletal
deformation, and these two deformities are commonly observed
in tandem. However, additional deformities of the tip complex
may also develop when asymmetric cephalic resections result in
dissimilar LLC and imbalanced forces of epithelial contracture.
These include tip or nostril asymmetry, deviation or twisting of
the tip complex or columella, bossae, and various other unsightly
irregularities. And while there is a growing trend among accom-
plished rhinoplasty surgeons to limit cephalic resections, or to
avoid cephalic resections altogether,2,4,6,11,15–20 the majority of
surgeons who currently perform rhinoplasty still seem to favor
this unpredictable technique.
Postsurgical Alar Retraction
Because the alar margin lacks direct support along much of its
length, it derives most of its stability from the adjacent lateral
Articulated Alar Rim Graft Ballin et al. 387
crus. Consequently, overresection and collapse of the lateral
crus will adversely impact nostril contour in virtually any
nose. In the healthy nose, the lateral crus functions as a
structural batten to stiffen the lower nasal sidewall span
against concave collapse and also as a vertical buttress to
stabilize the alar margin against upward displacement. Sig-
nificant losses in crural rigidity following cephalic overresec-
tion render the crus vulnerable to both medial collapse and to
cephalic displacement from vertical contracture. Owing to an
average human crural width of approximately 12 mm and an
average crural thickness of only 0.7 mm,21,22 even a cephalic
trim that preserves 6 or 7 mm of residual crural width will
eliminate approximately half of the vertical crural buttress
and potentially predispose to severe alar retraction. Unless
the residual crural strength is sufficient to offset or exceed the
forces of scar contracture, alar retraction is virtually inevita-
ble. Indeed, deformities of the alar rim are among the most
common problems affecting patients undergoing revision
rhinoplasty for tip deformities, and severe postsurgical alar
retraction (PSAR) following cephalic overresection is often
exceedingly difficult to treat.2,4,5,12–14
The pathogenesis of PSAR is complex and stems from the
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synergistic consequences of crural overresection: a critical
loss of lateral crural rigidity and a simultaneous increase in
the extrinsic forces of skeletal deformation. Because the
cartilaginous void generated from crural overresection cre-
ates large sections of denuded and unsupported epithelium,
and because “nature abhors a vacuum,” cicatricial contracture
of the vestibular skin eventually serves to shrink the skeletal
gap. And since shrinkage of the cartilaginous void also results
in progressive distortion and upward displacement of the
weakened crural remnant, retraction of the adjacent alar
margin is an all too common consequence of crural over-
resection. Moreover, as the volume of crural resection in-
creases, both the skeletal susceptibility to deformation and
the epithelial predisposition to contracture increase simulta-
neously, creating an unfavorable synergism that dramatically
increases the risk of alar retraction. Finally, the potential for
severe PSAR is further increased when septal support and
buttressing are simultaneously reduced, thereby producing
additional skin laxity, additional skeletal destabilization, and
an even greater propensity for alar rim deformation. Attempts
to correct PSAR using anatomically positioned augmentation
grafts such as lateral crural batten grafts or lateral crural strut
grafts (LCSGs) are often unsuccessful since they lack direct
rim support, making it difficult to stabilize rim position.
Moreover, such grafts may also add unwanted bulk to the
valve region and excessive stiffness in the lower nasal side-
wall, creating both functional and cosmetic morbidity, espe-
cially in naturally narrow noses.1,2,4,23
Stabilization of the Alar Rim
The alar rim plays a central role in both the aesthetics and
function of the nasal base, and alar rim deformities produced
by cephalic overresection have received growing attention in
recent years. In fact, conspicuous alar rim deformities follow-
ing lateral crural overresection are now recognized as a
Facial Plastic Surgery Vol. 32 No. 4/2016
388 Articulated Alar Rim Graft Ballin et al.
leading source of rhinoplasty treatment failure.1,4,12 In 2002,
Rohrich et al12 described the “alar contour graft”—a long
narrow strip of autologous cartilage implanted within a
nonanatomic skin pocket created immediately above the
nostril rim—to prevent or correct alar rim deformities. They
preferred septal cartilage for graft construction, but other
sources of cartilage were used when needed. Grafts sizes
varied according to defect size and severity, but standard
dimensions were 4 to 6 mm wide and up to 25 mm long. A
precise skin pocket was recommended to create a “snug” graft
fit, and wider and longer grafts were used for more severe
secondary alar rim deformities. In their retrospective review
of 123 patients treated with adjunctive alar contour grafting
using the open rhinoplasty approach (50 primary and 73
secondary rhinoplasty patients), they concluded that the alar
contour graft is “very effective” for correcting mild to moder-
ate alar retraction or collapse and in preventing alar rim
deformities after rhinoplasty.12 Malposition of the LLC was
also cited as an indication for the alar contour graft in both
primary and secondary rhinoplasty patients. Complications
were restricted to three patients who reported a palpable
graft edge, but the problem resolved within 6 months in all
three cases. In primary rhinoplasty patients, 91% experienced
correction or prevention of alar notching or collapse, while
only 73% of revision cases demonstrated satisfactory correc-
tion. However, the majority of revision rhinoplasty patients
who failed treatment were noted to have alar retraction
caused by “scarring or lining loss” prompting the authors to
advise against the use of the alar contour graft for alar
retraction in revision cases with significant loss of vestibular
lining and/or severe scarring. Nevertheless, favorable clinical
outcomes, coupled with low morbidity and ease of graft
insertion, resulted in immediate widespread popularity of
the “alar rim graft” as it has since become more commonly
known.11,13
In 2009, Boahene and Hilger13 published a similar retro-
spective analysis of alar rim grafts used in cosmetic and
functional rhinoplasty. Like their predecessors, they also
preferred grafts fashioned from septal cartilage, measuring
2 to 3 mm wide and 15 to 25 mm long, with beveled edges to
prevent graft prominence. Grafts were placed in a “tight and
precise” skin tunnel created “directly along the alar margin.”
Over a 20-month period, 150 consecutive rhinoplasties were
performed by the senior author. Of these, 31 cases with
adjunctive alar rim grafting were identified. All but five cases
were primary rhinoplasties. Indications for alar rim graft
placement included cephalic malposition of the LLC (nine
cases [29%]), alar flare (nine cases [29%]), dynamic external
valve collapse (eight cases [26%]), alar retraction or notching
(three cases [10%]), and alar asymmetry (two cases [6%]). No
complications were reported or observed, and the authors
reported satisfactory improvement in all cases, but cautioned
that even in mild cases of notching or retraction, sufficient
lining and skin elasticity must be present to facilitate suc-
cessful repositioning of the alar rim. For moderate to severe
cases of alar notching or retraction, the authors concluded
that alternative techniques such as “composite grafts, alar
batten grafts, and LCSGs may be needed.”
Facial Plastic Surgery Vol. 32 No. 4/2016
Augmenting Alar Rim Support
A major drawback of the conventional alar rim graft is the lack
of rigid integration with the tip framework, and this short-
coming is most evident when attempting to correct PSAR.
Even when a precise pocket along the alar rim is used to
restrict graft mobility, the conventional alar rim graft is a
structurally autonomous “floating” batten that lacks direct
support from the tip framework, making it more susceptible
to upward migration from moderate to severe scar contrac-
ture. Although the conventional (floating) rim graft has
proven highly effective at correcting various rim deformities
such as dynamic rim collapse, concave rim collapse, alar
flaring, rim asymmetry, or rim deformities resulting from
cephalic malposition of the LLC, the floating rim graft has
little demonstrated efficacy in the correction of severe
PSAR.12,13 This shortcoming likely derives from its lack of
structural integration with the tip complex that leaves the
grafted alar rim complex susceptible to cephalic displace-
ment by the forces of shrink-wrap contracture.
In an effort to improve treatment outcomes for postsurgical
alar rim deformities, the senior author (R.E.D.) has modified
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the conventional floating alar rim graft (FARG) to produce a
fixed appendage of the tip complex, which we have named the
articulated alar rim graft (AARG) to emphasize direct articula-
tion with the tip framework.1,4,6 Although the AARG shares
many features with the conventional FARG, including a batten-
type stiffening of the alar margin, the biomechanical character-
istics are otherwise profoundly different. Unlike the FARG,
which is structurally autonomous from the tip complex, the
AARG is an integrated structural extension of the tip complex
that is secured to the tip framework with multipoint suture
fixation to provide strong cantilevered support to the alar
Fig. 3 Diagrammatic illustration of articulated alar rim graft place-
ment (solid blue line) relative to the native lateral crus (dashed blue line).
Mattress suture fixation at three separate points is shown in red. TDP,
tip defining point; SEG, septal extension graft.
 Articulated Alar Rim Graft Ballin et al. 389

Fig. 4 Primary rhinoplasty with high-riding alar rim and excessive columellar show. (A–D) Preoperative photos demonstrating congenital high- Downloaded by: Cornell. Copyrighted material.
riding alar rim and a bulbous nasal tip. (E) Intraoperative view showing reciprocal articulated alar rim graft (AARG) sewn to the septal extension
graft at the tip defining point (TDP). (F) Intraoperative profile view showing AARG placement aligned with the TDP and angled slightly downward
for modest overcorrection. (G) Symmetric AARG contributing to a modest increase in tip width. (H–K) Postoperative nasal contour demonstrating
improved alar/columellar aesthetics and a well-defined, flat alar crest.

margin (►Fig. 3). In many respects, the physical characteristics
of the AARG are similar to those of a healthy and attractive
lateral crus—thin, firm, lightweight, and flat, and structurally
supported by the nasal L-strut. However, in contradistinction
to the orthotopic lateral crus that diverges from the nasal
midline at a roughly 45-degree angle, the wing-like AARG is
positioned nonanatomically at 90 degrees to the sagittal
midline and then sutured to the tip complex (►Fig. 4E) for
direct, stationary rim support, thereby safeguarding against
vertical and medial rim displacement. By horizontally aligning
the AARG with the TDP (►Fig. 4F, E), the AARG can also
support the alar rim in a cosmetically pleasing orientation
while simultaneously ensuring a well-defined and flat alar
ridge to enhance alar rim topography (►Fig. 4H–K).
Whenever employing the AARG, we prefer the concomi-
tant use of a strong and stationary septal extension graft

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390 Articulated Alar Rim Graft Ballin et al.

(SEG) to achieve rigid immobilization of the AARG. In primary

Fig. 5 Primary rhinoplasty with slit-like nostril openings and dynamic
external valve collapse. (A) Preoperative base view. (B) Postoperative
base view with improved alar rim contour and elimination of external
valve collapse after septal extension graft placement, lateral crural
tensioning, and articulated alar rim graft placement.
rhinoplasty, the combined use of the AARG and the SEG has
proven highly effective in the prevention of iatrogenic alar
rim deformities in patients with weak LLC, while simulta-
neously ensuring a flat and well-defined alar ridge. However,
preserving the cephalic border of the nasal scroll, and thus
avoiding contracture-mediated destabilization of the alar
rim, is the most important factor in preventing PSAR. The
AARG can also be used to eliminate a naturally high-riding
alar margin (►Fig. 4), but secure immobilization of the AARG
with an SEG is paramount since caudal repositioning of the
alar rim requires maximum cantilevered support. Finally, in
primary rhinoplasty patients with a naturally concave alar
ridge and/or external valve collapse, the AARG has also

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Fig. 6 Revision of the overresected nasal tip with sidewall tensioning. (A) Overly short nose after overzealous excisional rhinoplasty. (B)
Counterrotation of lateral crural (remnants) prevented by fibrous adhesion of cephalic margin (C) sharp lysis of fibrous adhesions to unfurl
contractured vestibular skin and release retracted lateral crura. (D) Improved tip cartilage mobility after lysis of fibrous adhesions. (E) Placement
of SEG to reproject, counterrotate, and tension the lateral crural remnants (F) counterrotated and reprojected tip cartilages after fixation to SEG.
(From Davis, 4 Fig. 184.12. Reprinted by permission from Wolters Kluwer/Lippincott Williams & Wilkins.)

Facial Plastic Surgery Vol. 32 No. 4/2016

 Articulated Alar Rim Graft Ballin et al. 391

proven highly effective in generating a smooth and flat alar

ridgeline and/or in stabilizing the alar rim against concave
collapse (►Fig. 5), both of which help to create an elegant tip
contour.
In addition to beneficial applications in primary rhinoplas-
ty, perhaps the most useful aspect of the AARG is in the
treatment of PSAR. However, an AARG alone is unlikely to
successfully eliminate severe PSAR. Forcefully displacing the
retracted alar rim with a cantilevered cartilage graft will
achieve only temporary or partial correction at best. There-
fore, to optimize treatment of severe PSAR with the AARG,
three adjunctive measures are also required: (1) release of the
contractured and scarred nasal lining to facilitate a tension-
free repositioning of the alar rim (►Fig. 6), (2) placement of
an SEG to create robust and nondeforming central tip support
for effective AARG immobilization and crural resuspension
without destabilizing the tip complex, and (3) reduction of
excessive lateral crural length to effectively stretch, flatten,
and tension the lower nasal sidewalls for improved tip
dynamics.

Materials and Methods

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A retrospective chart review was conducted on 220 consecu-
tive patients undergoing rhinoplasty by the senior author (R.
E.D.) between January 2010 and December 2011. Of the 220
patients, 111 underwent primary rhinoplasty and the re-
maining 109 underwent revision rhinoplasty ranging any-
where from one to eight prior surgeries. Of the 220 patients
reviewed, 114 underwent AARG placement, but only 47
patients underwent AARG placement with concomitant
SEG placement and tensioning of the cutaneous/crural com-
plex (CCC). This last subgroup was chosen for this study. The
study population consisted of 36 females (77%) and 11 males
(23%) with an average age of 31 years. Seventeen patients
underwent primary rhinoplasty and 30 patients were revi-
sion cases with an average of 1.2 previous procedures. The
study population had a mean follow-up interval of 7 months
with a range of 3 to 23 months.

Operative Technique
AARG placement was performed using the external rhino-
plasty approach in all patients. All patients evaluated in this
series also underwent concomitant SEG placement and LCT6
as part of the treatment protocol. Degloving of the entire
lateral crus was performed from the dome to the sesamoid
cartilages, followed by complete degloving of the middle vault
including release of the vertical scroll ligament. Wide expo- Fig. 7 Articulated alar rim graft (AARG) fixation. (A) Schematic overlay
sure was essential for adequate release of the contractured showing skin pocket position relative to the alar rim and marginal incision.
(B) Precise pocket formation with scissor dissection. (C) Intraoperative
vestibular skin and for optimal tensioning of the lateral crura.
photo showing AARG (mattress) fixation suture placement. Note fixation to
In primary rhinoplasty cases, septal cartilage was used for both the lateral crus and septal extension graft with the medial-most suture.
AARG fabrication, but conchal and rib cartilage was used in a The third (lateral-most) suture is placed on the cephalic border of the AARG
small number of revision cases in whom quadrangular carti- and is not shown.
lage was previously depleted or rendered unsuitable. Conchal
cartilage proved to be the least desirable graft material since a LCSGs, lateral crural batten grafts, auricular composite grafts,
rigid and flat construct was difficult to achieve on a consistent and/or lateral crural transposition procedures were not used
basis, and double-layered conchal grafts were often required. in this patient series.

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392 Articulated Alar Rim Graft Ballin et al.

AARGs typically measured 20 to 25 mm in length (de-
pending upon nasal size) to fully bridge the tip and alar
lobules. A maximum graft width of 4 to 5 mm was typically
located 8 to 10 mm from the TDP. That portion of the cephalic
border extending beyond the septal profile was angled cau-
dally to preserve the supratip break and to produce a medial
edge width of approximately 3 mm. The remaining graft was
tapered laterally to a final width of 3 mm. The medial and
cephalic graft edges were beveled for seamless camouflage,
and the medial border was usually positioned flush with the
TDP to prevent unwanted increases in tip projection
(►Fig. 4F, G). Thickness of the lobular (medial) segment of
the AARG varied according to the desired tip width. When
additional tip width was deemed undesirable, the medial end
of the AARG was thinned to a narrow taper to minimize width
increases and/or the graft was recessed 1 to 3 mm below the

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Fig. 8 Revision rhinoplasty with lateral crural tensioning (LCT), septal extension graft (SEG), and articulated alar rim grafts (AARGs). (A–D) Preoperative nasal
contour. (E–G) Damaged, malpositioned, and overprojected lower lateral cartilage remnants after flap degloving. (H–J) Tip complex after SEG placement and
LCT. (K–M) Final tip complex after AARG placement. (N–Q) Postoperative nasal contour with improved alar-columellar aesthetics and alar rim contour.

Facial Plastic Surgery Vol. 32 No. 4/2016


Fig. 8 (Continued)
TDP. Conversely, when additional tip width was deemed
beneficial, the lobular segment was kept 1.5 to 2.0 mm thick
with only a modest taper of the medial-most edge for
camouflage, thereby increasing overall tip width by 3 to
4 mm. In most cases, the central segment of the AARG
(bridging the tip and alar lobules) was also 1.5 to 2.0 mm
thick so as to ensure a flat and well-delineated alar ridge.
When the alar ridge was concave, a modest graft convexity
was also used to create a flat alar ridgeline. In patients with a
naturally favorable rim shape requiring only prophylaxis
against distortion, the AARGs were placed at 90 degrees to
the sagittal midline with the long axis of the graft aligned
vertically with the TDP (►Fig. 3). However, in patients with a
naturally high-riding alar rim or with alar rim notching, the
lateral aspect of the graft was angulated inferiorly by an
additional 5 to 10 degrees for slight overcorrection
(►Fig. 4F). At the conclusion of tip-work (including LCT),
fixation of the AARG to the underlying lateral crus was
performed in at least two or more locations using mattress
sutures of 5–0 polydioxanone for secure multipoint fixation
(►Fig. 3). Care was taken to incorporate the SEG into at least
one of the mattress sutures for added strength (►Fig. 7C).
After graft fixation, a precise intracutaneous pocket was
dissected along the lateral aspect of the alar rim, beginning
where the graft diverges from the lateral crus and extending
into the central alar lobule (►Fig. 7A, B). Pocket length was
also kept slightly longer than graft length. Following AARG
placement, the marginal incision was closed meticulously to
prevent graft exposure.
In secondary rhinoplasty cases, wide-field degloving of the
entire lower nasal sidewall was performed using the external
rhinoplasty approach. In nearly all cases of PSAR, a sizeable
Articulated Alar Rim Graft Ballin et al. 393
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(cephalic) resection of the lateral crus was evident within the
scroll area, along with contracture and foreshortening of the
internal nasal lining. To release the vestibular skin and to
enable tension-free caudal repositioning of the retracted alar
margin, the contractured soft tissue at the LLC/ULC interface
was surgically “unfurled” with a series of partial-thickness
relaxing incisions oriented parallel to the alar margin
(►Fig. 6). These incisions were performed with a double
skin hook providing downward traction on the nostril rim,
with a finger on the underside of inner lining to prevent
inadvertent perforation (►Fig. 6C). Parallel serial incisions
were repeated until the alar margin assumed a satisfactory
resting position, but maximum release was performed in all
cases. When treating PSAR and/or lobular pinching in sec-
ondary rhinoplasty, AARG fabrication and graft placement
were modified to further enhance rim support. When possi-
ble, graft dimensions were slightly thicker ( 2.0–2.5 mm) to
enhance graft rigidity and to flatten the alar ridge, and length
was typically increased to 30 mm to provide more secure
lateral stabilization within the inferolateral skin pocket.
Laterally, the marginal incision was also placed 3 to 4 mm
distal to the caudal margin of the lateral crus. This “premar-
ginal” incision placement served to optimize lateral position-
ing and stabilization of the AARG by restricting pocket
dissection to only the caudal-most aspect of the alar lobule.
Results
Medical records, including office follow-up notes, and before
and after photographic comparisons, were analyzed to assess
the surgical outcome. The mean follow-up interval was
7 months, with a range of 3 to 23 months. Of the 47 patients
Facial Plastic Surgery Vol. 32 No. 4/2016
394 Articulated Alar Rim Graft Ballin et al.
Fig. 9 Revision rhinoplasty for severe postsurgical alar retraction. (A–D) Preoperative nasal contour. (E–H) Postoperative contour after lateral
crural tensioning, septal extension graft, and articulated alar rim grafts.
included in the study group, 17 were primary rhinoplasty
patients, and the remaining 30 rhinoplasty patients pre-
sented after previous unsuccessful rhinoplasty procedures.
The 30 revision rhinoplasty patients presented with a wide
variety of tip deformities including lobular pinching, supra-
alar pinching, PSAR, internal valve collapse, external valve
collapse, and various other tip deformities. All of the revision
rhinoplasty patients had intraoperative evidence of previous
cephalic trim with varying degrees of rim distortion.
Seventeen primary rhinoplasty patients underwent pro-
phylactic AARG placement to prevent alar rim defects or for
treatment of mild congenital rim disturbances such as a high-
riding alar arch or alar notching (►Fig. 4). Satisfactory alar rim
contour was observed in all 17 primary rhinoplasty patients
at the time of follow-up. Seventeen additional (revision)
rhinoplasty patients underwent AARG placement for the
treatment of moderate to severe PSAR with or without lobular
pinching. Eleven (65%) patients showed total correction of
PSAR at the time of follow-up (►Figs. 1, 8, and 9), and the
remaining six patients had partial but significant improve-
ment. The remaining 13 revision rhinoplasty patients pre-
Facial Plastic Surgery Vol. 32 No. 4/2016
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sented with a variety of other rim deformities. Eight patients
who presented with lobular pinching or supra-alar pinching
demonstrated total correction at follow-up (►Fig. 1). In five
patients with moderate to severe external valve collapse, all
but one patient experienced improvement, with two patients
demonstrating total correction and two patients demonstrat-
ing partial correction. At a mean 7-month follow-up, there
were no overly visible grafts, graft displacements, graft
infections, or graft extrusions observed, and no patients
voiced complaints relating to AARG placement.
Discussion
The challenge of permanently refining nasal tip contour without
compromising structural integrity or airway function is formi-
dable. Owing to the alar rim’s relative lack of direct support, alar
rim contour is a frequent casualty of cosmetic nasal surgery
especially when lateral crural rigidity is severely compromised.
We present a structural rhinoplasty technique that not only
preserves existing lateral crural rim support but also enhances
tip dynamics to increase indirect rim support while also

Fig. 10 Extended articulated alar rim graft (AARG) fabricated from rib
cartilage for treatment of postsurgical alar retraction. (A) Frontal view
demonstrating AARG support along the entire nasal base. (B) Profile view
showing extreme caudal positioning of AARG within the alar lobule.
employing a nonanatomic structural graft (rigidly integrated to
the tip framework with multipoint suture fixation) for more
effective direct rim support.1,4,6 In primary rhinoplasty cases,
this multifaceted approach has proven extremely reliable in
preventing unwanted distortion of alar rim contour and in
correcting most natural alar rim deformities. In secondary
rhinoplasty cases, this approach has also proven effective at
correcting moderate to severe PSAR in a majority of patients,
primarily those in whom surgical release of the contractured
internal lining permits tension-free repositioning of the alar
margin. However, successful correction also requires (1) an
AARG of sufficient rigidity, (2) secure graft immobilization,
and (3) a sturdy and nondeforming SEG to stabilize the entire
tip complex. Satisfactory cosmetic outcomes were achieved in
both primary and secondary rhinoplasty patients while simul-
taneously safeguarding airway function and preserving long-
term structural support; and all corrections were achieved
without the use of LCSGs, lateral crural batten grafts, transposi-
tion procedures, or auricular composite grafts.
Admittedly, the retrospective chart review presented here
lacks an optimal follow-up interval. This limitation reflects
the senior author’s (R.E.D.) practice, which contains a large
number of overseas patients who were unavailable for follow-
up. However, the largely favorable results observed at a mean
follow-up interval of 7 months indicates a tendency toward
long-term efficacy.
Without question, the most difficult challenge in this patient
series was the treatment of PSAR. In most noses, the limiting
factor in PSAR treatment was the contractured and inelastic
inner nasal lining. Unless the bunched and foreshortened inner
lining is successfully lengthened (►Fig. 6), the likelihood of
Articulated Alar Rim Graft Ballin et al. 395
effectively repositioning the retracted alar margin is poor.
However, the methodical lysis of vestibular skin adhesions
substantially lengthened the contractured lining, even in those
patients with heavily scarred and inelastic tissue. Using parallel
(partial thickness) relaxing incisions along the LLC/ULC interface
to recreate the initial skeletal void produced by cephalic over-
resection (►Fig. 6), favorable (initial) repositioning of the alar
margin was achieved in nearly all cases. However, in the grossly
overresected and severely foreshortened nose, PSAR correction
proved far more challenging since the restoration of appropriate
nasal length also serves to enlarge the gap between the retracted
alar margin and the desired rim position.24,25 Consequently, all
tethers, adhesions, and contractures must be thoroughly dis-
rupted for maximum rim mobilization in these cases. Not
surprisingly, PSAR treatment proved most prone to failure in
this patient subgroup.
Another key component of PSAR treatment is LCT. Follow-
ing successful release of the incarcerated vestibular lining, tip
dynamics are reconfigured to tension the lower nasal sidewall
and eliminate excess horizontal laxity of the vestibular skin,
thereby providing additional intrinsic protection against re-
current PSAR. Excessive crural length as well as horizontal
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laxity of the inner lining are two frequently overlooked factors
that potentiate PSAR. Both problems can be negated by
longitudinally stretching the crural remnant and the underly-
ing vestibular skin—what we have termed the “crural/cutane-
ous complex”—between their piriform attachments laterally,
and the newly created SEG medially, to restore lost sidewall
tone. By first adjusting lateral crural length to compliment the
final dimensions of the lower sidewall span and then suturing
the size-matched CCC to the distal-most point on the SEG (i.e.,
the newly designated TDP), horizontal tension is generated
along the entire sidewall that mechanically resists both up-
ward displacement of the crural remnant and inward collapse
of the nasal sidewall. In the wide and underprojected nose,
reductions in lateral crural length are easily accomplished
using a lateral crural steal procedure,2,4,6,26 whereas vertical
transection of the LLC is used for crural length reduction in the
overprojected nose.6 Regardless of how the crural span is
tensioned, the result is a flat and taut lower nasal sidewall
that resists shape deformation and greatly potentiates AARG
efficacy. Moreover, increases in sidewall rigidity are achieved
without increases in sidewall mass or bulk. Conceptually, LCT
mimics natural tip dynamics by enhancing sidewall rigidity
using skeletal suspensory forces, rather than by relying upon
the bulk and mass of sidewall augmentation grafts such as the
LCSG, and this advantage is particularly useful in narrow,
overresected noses in which sidewall grafts may be poorly
tolerated.2,4,23 In addition to sidewall stabilization, LCT also
enhances tip contour since force vectors serve to flatten the
crural remnants, minimizing both concavity and convexity for
a more attractive lobular contour. And when judicious bilateral
tensioning is applied symmetrically, laterally directed force
vectors of equal and opposite magnitude also create a durable
steady state that ensures long-term stability of the tip tripod.4,6
The practical benefits of this approach include a stiffened, but
thinner and lighter sidewall span that typically increases cross-
sectional airway size while simultaneously resisting
Facial Plastic Surgery Vol. 32 No. 4/2016
396 Articulated Alar Rim Graft Ballin et al.
inspiratory collapse and alar retraction, all while concomitant-
ly enhancing nasal contour with minimal graft tissue.4,6
Although LCT adds both strength and stability to the tip
complex, a stable and strong SEG is essential for safe and effective
sidewall tensioning. In fact, our entire strategy of tip refinement
is predicated upon strong and reliable tip support provided by
the SEG, and its importance to PSAR treatment cannot be
overstated. Without a rigid and stationary column of central
tip support to stabilize the AARG and tip complex, the benefits of
this protocol are largely negated. The SEG is preferred for its
unique biomechanical properties that are well suited to precise
tip positioning, reliable stabilization of the tip complex, and
negligible increases in skeletal bulk.1,2,4,6,11,24,25,27,28 By uniting
the SEG with a strong septal L-strut using rigid suture fixation
(with or without splinting grafts), support to the AARG is
optimized and the tip complex becomes far less susceptible to
unwanted displacement or distortion caused by LCT, by recur-
rent shrink-wrap contracture, by an overly tight skin closure,
and/or by postoperative edema.
After release of the scarred vestibular lining, fortification
of central tip support with a robust SEG, and optimization of
tip dynamics with LCT, the stage is set for placement of the
AARG. Although PSAR is eliminated intraoperatively before
AARG placement, direct skeletal support is needed to stabilize
the rim against recurrent alar retraction. The addition of
direct cantilevered support to actively resist upward rim
displacement from recurrent contracture is the final element
in this multifaceted approach to PSAR treatment. By securely
fastening the AARG to the fortified tip complex, a nonana-
tomic skeletal buttress is created to stabilize the rim against
virtually all forms of distortion including PSAR. In addition to
direct skeletal support, the AARG also serves to correct alar
rim concavity and to delineate and flatten the alar ridge, a
subtle but important topographic feature that embellishes tip
contour in virtually any nose.
The observed failure of AARGs to fully correct PSAR in every
case is disappointing. We postulate that this reflects a subset of
patients with particularly aggressive shrink-wrap tendencies,
inadequate graft rigidity, and/or inadequate graft stabilization.
Incomplete correction of PSAR was most commonly observed in
patients undergoing concomitant nasal lengthening procedures
in which L-strut elongation created an even greater gap between
the alar rim and the columellar margin. Interestingly, since
performing this retrospective chart review, we have modified
our PSAR treatment protocol to create AARGs fabricated from
prehydrated strips of rib cartilage that are extended laterally to
abut the lateral alar crease at the caudal-most aspect of the alar
lobule (►Fig. 10B). Initial clinical results suggest that longer,
thicker, and stiffer AARGs fashioned from rib cartilage are
significantly more effective in correcting PSAR than softer grafts
fabricated from septal or conchal cartilage, and extreme caudal
positioning within the alar lobule also appears to improve
efficacy. The use of rib cartilage seems to be particularly impor-
tant in patients with naturally weak septal cartilage that lacks
sufficient rigidity for dependable alar rim stabilization, and we
have begun to use rib cartilage for AARGs in primary rhinoplasty
when treating naturally high-riding alar rims. Early clinical
observations suggest that laterally extended AARGs fashioned
Facial Plastic Surgery Vol. 32 No. 4/2016
from rib cartilage appear to be a superior means of stabilizing
alar rim deformities, particularly in severe PSAR. Further evalu-
ation of the AARG is warranted and we anticipate that efficacy
will improve as technical refinements ensue.
Summary
The AARG is a structurally integrated graft that appears to
significantly enhance alar rim support. Graft efficacy is opti-
mized when used in conjunction with an SEG to stabilize the
central tip complex, LCT to tension and stabilize the lower
nasal sidewalls, and lysis of adhesions to release the contrac-
tured inner lining. This multifaceted approach produced ini-
tially favorable results in our hands. In primary rhinoplasty
cases, this approach resulted in satisfactory prophylaxis
against secondary rim deformities and/or eliminated all pre-
existing rim deformities. In secondary rhinoplasty applica-
tions, surgically acquired rim deformities including PSAR were
substantially improved or eliminated. This method also en-
hanced stability of the tip framework while safeguarding
airway patency and minimizing bulk within the lower nasal
sidewall. Although further evaluation of the AARG is needed to
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confirm long-term efficacy, early outcomes suggest the AARG
is easy to use, largely devoid of complications, and a highly
useful adjunct for preserving and/or restoring alar rim contour.
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