SPECIAL TOPIC
Extended Alar Contour Grafts: An Evolution
of the Lateral Crural Strut Graft Technique
in Rhinoplasty
C. Spencer Cochran, M.D.
Summary: Modification of the lower lateral cartilage complex is the sine qua
David A. Sieber, M.D.
non of modern rhinoplasty, and the open approach to rhinoplasty has expand-
Dallas, Texas; and San Francisco, Calif. ed the number of techniques available to help achieve an aesthetically pleasing
tip. The ideal tip has been described as having a diamond-shaped configura-
tion, with the lateral points formed by the tip-defining points, the superior
point by the supratip, and the inferior point by the columellar break point.
Over the years, various techniques have been described to minimize isolation
of the tip and to help achieve the ideal tip configuration: lateral crural strut
grafts, alar contour grafts (i.e., rim grafts), alar strut grafts, subdomal grafts,
and suturing techniques such as alar flaring sutures. The authors present their
technique of the extended alar contour graft, which represents an evolution of
the lateral crural strut graft and its marriage with the alar contour graft. Lateral
crural abnormalities do not usually occur singularly, but rather are the result
of an interplay of several factors. Nevertheless, the recurring theme of orienta-
tion and alar support to prevent isolation of the tip by extended alar grooves
remains. Extended alar contour grafts are a versatile technique to optimize tip
shape and orientation by combining the many positive attributes of lateral cru-
ral strut grafts and alar contour grafts. (Plast. Reconstr. Surg. 140: 559e, 2017.)
M
odification of the lower lateral cartilage (normally positioned) lateral crura have been
complex is the sine qua non of modern noted that give rise to an aesthetically pleasing tip
rhinoplasty, and the open approach to lobule and a functionally intact external nasal valve.
rhinoplasty has expanded the number of tech- Gunter3 made several key anatomical observations
niques available to help achieve an aesthetically regarding the shape and orientation of the lower
pleasing tip. The ideal tip has been described as lateral cartilages: (1) the lateral crura frequently
having a diamond-shaped configuration, with the are connected to accessory cartilages, and the con-
lateral points formed by the tip-defining points, nective tissue linking them causes the cartilages to
the superior point by the supratip, and the infe- act as one structural and functional unit; (2) the
rior point by the columellar break point.1 Fur- lateral crura in their lateral extension often abut
thermore, Toriumi has eloquently described the directly against the piriform aperture; and (3) the
natural-appearing tip as one in which the contour lateral crura form only a small segment of the alar
of horizontal orientation of the tip-defining points rims. In addition, the short (craniocaudal) axis of
continues out to the alar lobule as a defined ridge
without a line of demarcation.2 Disclosure: The authors have no financial interest
The lateral crura are highly variable in their to declare in relation to the content of this article. No
shape, orientation, contour, and thickness, and sev- external funding was received.
eral key anatomical observations of the orthotopic
From the Dallas Rhinoplasty Center; the Departments Supplemental digital content is available for
of Plastic Surgery and Otolaryngology–Head and Neck this article. Direct URL citations appear in the
Surgery, University of Texas Southwestern Medical Center; text; simply type the URL address into any Web
and Sieber Plastic Surgery. browser to access this content. Clickable links
Received for publication August 23, 2016; accepted January to the material are provided in the HTML text
11, 2017. of this article on the Journal’s website (www.
Copyright © 2017 by the American Society of Plastic Surgeons PRSJournal.com).
DOI: 10.1097/PRS.0000000000003719
www.PRSJournal.com 559e
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Plastic and Reconstructive Surgery • October 2017
the lateral crura should lie in a plane approximately Over the years, various techniques have been
45 degrees relative to the sagittal plane. Toriumi described to minimize isolation of the tip and to
elaborated on this proper orientation of the lateral help achieve the ideal tip configuration: lateral cru-
crura. He describes that the caudal margin of the ral strut grafts, alar contour grafts (i.e., rim grafts),
lateral crura should lie close to the same level as alar strut grafts, and subdomal grafts, in addition to
the cephalic margin of the lateral crura. Without suturing techniques such as alar flaring sutures. Of
this proper orientation, the lack of lateral support these techniques, the lateral crural strut graft and
of the alar sidewalls causes inward movement of the the alar contour graft are two of the most important
alar rims, resulting in a vertical shadow that demar- and powerful techniques for improving tip shape.
cates the tip and causes isolation of the nasal tip. Lateral crural strut grafts, because of their fixation
Morphologically, this manifests as a pinched tip, to the lateral crura, are perhaps the most versatile
ball/bulbous tip, or parenthesis-like appearance of grafting technique for reshaping and reconstructing
the tip on frontal view. Although this phenomenon lateral crural abnormalities, whereas alar contour
can be seen in primary rhinoplasty patients, it is a grafts, because of their position along the alar mar-
frequent stigma of a prior rhinoplasty. gin, are the most effective in supporting the alar rim.
Fig. 1. Evolution of the lateral crural strut graft technique. (Above, left) Original lateral crural strut
graft technique with graft extending over the piriform aperture. (Above, right) Modified lateral
crural strut graft technique with graft shortened to extend only to the accessory cartilage junc-
tion. (Below, left) Current lateral crural strut graft technique with pocket created more caudally
within the alar sidewall like that of an alar rim graft. (Below, right) Extended alar contour graft
placed along the alar rim like an alar contour graft and fixated to the undersurface of the lateral
crus near the dome like a lateral crural strut graft.
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Volume 140, Number 4 • Extended Alar Contour Grafts
Lateral crural strut grafts are rigid cartilage and Gunter ultimately began creating the lateral
grafts sutured to the undersurface of the lateral crural strut graft pocket more caudally within the
crura that extend from the dome laterally into a alar sidewall, much like that of an alar rim graft
soft-tissue pocket within the alar sidewall.4 They (Fig. 1, below, left).
are useful for correcting the boxy nasal tip, alar Similarly, the uses of alar rim grafts were pop-
cartilage malposition, alar rim collapse, alar ularized by Rohrich’s description of alar contour
retraction, and convex/concave lateral crura. grafts for prevention of alar retraction, notching,
Since the publication of his landmark article on or collapse and for correction of nasal tip asymme-
lateral crural strut grafts in 1997, Gunter gradually tries.5,6 Alar contour grafts are placed in a subcuta-
modified the lateral crural strut graft technique. neous pocket immediately above and parallel to the
Gunter originally described that the grafts should alar rim and are most often used to correct or pre-
lie beneath the entire lateral crus and extend over vent alar retraction or collapse. These grafts require
the piriform aperture to help prevent medial dis- far less cartilage than the original lateral crural strut
placement of the lateral crus (Fig. 1, above, left). grafts and are usually composed of septal cartilage.
However, he quickly abandoned this, as it involved When placed into a pocked along the alar rim, the
transecting the accessory cartilage, required sig- alar contour grafts also help to create a smooth tip
nificant cartilage to create long grafts, and often lobule–to–alar lobule transition as described by
caused a palpable or visible bulge above the alar Toriumi.1 However, because the alar contour graft
crease at the alar-cheek junction. He subsequently is not secured to the lateral crus, it does not provide
shortened the graft to extend only to the accessory lateral crural support or influence lateral crural ori-
cartilage junction (Fig. 1, above, right).4 Although entation. We present our technique of the extended
this modification helped flatten overly convex or alar contour graft, which represents an evolution of
concave lateral crura, it was apparent that this still the lateral crural strut graft and its marriage with
left a considerable portion of the alar sidewall the alar contour graft.
caudal to the lateral crus, and more importantly
the alar rim, without support, which often necessi-
tated the concurrent use of alar rim grafts in addi- OPERATIVE TECHNIQUE
tion to the lateral crural strut grafts. To address Extended alar contour grafts are structural
these shortcomings, the senior author (C.S.C.) grafts that are placed along the alar rim like
Fig. 2. Extended alar contour graft. Gunter diagram depicting the location of
extended alar contour grafts placed along the alar rim like an alar contour graft
and fixated to the undersurface of the lateral crus near the dome like a lateral
crural strut graft.
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Plastic and Reconstructive Surgery • October 2017
Supplemental Digital Content 1, which demon-
strates technique for placement of extended alar
contour grafts, available in the “Related Videos”
section of the full-text article on PRSJournal.com
or, for Ovid users, available at http://links.lww.com/
PRS/C375.)
To place an extended alar contour graft, the
vestibular skin must first be undermined from the
undersurface of the lateral crus from the dome
to the lateral crus–accessory cartilage junction.
Using the existing marginal incision, a pocket is
created along the alar rim from the soft triangle to
the alar-cheek junction along the alar rim (Fig. 3,
Video. Supplemental Digital Content 1 demonstrates technique
above, left). Narrow-tip scissors such as Converse
for placement of extended alar contour grafts, available in the
scissors or tenotomy scissors are placed at the cau-
“Related Videos” section of the full-text article on PRSJournal.com
dal aspect of the marginal incision and the skin
or, for Ovid users, available at http://links.lww.com/PRS/C375.
of the anterior half of the nostril is undermined.
The scissors tip is then reoriented posteriorly and
a narrow pocket is created along the posterior half
an alar contour graft but are also fixated to the of the nostril rim. Care should be taken to not
undersurface of the lateral crus near the dome perforate the overlying skin of the nostril rim or
like a lateral crural strut graft (Fig. 2). (See Video, alar-cheek junction as the scissors are advanced.
Fig. 3. Extended alar contour graft technique. (Above, left) A pocket is created along the alar rim from
the soft triangle to the alar-cheek junction along the alar rim. (Above, right) The extended alar contour
graft is advanced into the pocket. (Below, left) The extended alar contour graft is insinuated beneath the
undermined dome. (Below, right) The graft is secured to the caudal margin of the lateral crus with a 5-0
Vicryl suture.
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Volume 140, Number 4 • Extended Alar Contour Grafts
Next, an extended alar contour graft is fash- graft, as it has both the ideal thickness and flex-
ioned from autogenous cartilage and should ibility. Rib cartilage or auricular cartilage can be
measure approximately 1.5 × 20 mm. The graft is used when a paucity of available septal cartilage
advanced into the pocket (Fig. 3, above, right) and exists. However, auricular cartilage tends to be too
then insinuated beneath the undermined dome flaccid, whereas costal cartilage tends to be too
(Fig. 3, below, left) before being secured to the rigid and also has the tendency to warp when the
caudal margin of the lateral crus with a 5-0 Vic- surgeon is attempting cut/shave it into the appro-
ryl (Ethicon, Inc., Somerville, N.J.) suture (Fig. 3, priate size graft.
below, right). Because extended alar contour grafts To avoid imparting asymmetry to the tip, it
occupy the same space under the dome as a lat- is important that pockets on each side be of the
eral crural strut graft and also occupy the same same depth and in the same orientation. Similarly,
pocket of both the lateral crural strut graft and it is imperative that each of the extended alar con-
the alar contour graft, these grafts are not used in tour grafts be of the same length, strength, and
the same patient. flexibility to prevent iatrogenic tip asymmetry.
Septal cartilage is the ideal source of grafting Discrepancies in these cartilaginous characteris-
material for fabricating the extended alar contour tics will be evident by a subtle asymmetry in the
Fig. 4. Preoperative (left) versus 1-year postoperative (right) photographs
of a primary rhinoplasty patient in whom the extended alar contour graft
technique was used to prophylactically support the alar rim and to facilitate
proper orientation of the lateral crura.
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Plastic and Reconstructive Surgery • October 2017
alar shape and contour. It is important that the rim and create a defined ridge that extends from
pocket be only wide enough to accommodate the the tip lobule to the alar lobule. However, tra-
graft to ensure that the grafts remain in the alar ditional alar contour grafts simply camouflage
pockets at the time of closure, as any manipula- the medial collapse of the lateral crus caused by
tion after securing the grafts to the dome may dis- its caudal rotation. In addition, the transdomal
lodge them. suture technique, when used in the correction
of the boxy nasal tip, often displaces the lateral
crus–accessory cartilage junction medially and
DISCUSSION obstructs the airway.4,8 The use of lateral crural
Both Guyuron and Behmand7 and Toriumi2 strut grafts has been recommended to avoid this
have noted that caudal rotation of the lateral complication.4,7
crus can occur when a transdomal suture is The extended alar contour graft combines
placed toward the lower half of the dome. With- many of the positive attributes of the alar contour
out the alar rim support, the caudal rotation of graft and the lateral crural strut graft. As with the
the lateral crus frequently results in a pinched lateral crural strut graft, extended alar contour
nasal tip with the characteristic demarcation grafts provide support to the caudal edge of the
between the tip and the alar lobule. An alar rim peridomal lateral crus, causing a lateral rotation
graft can be used to effectively support the nostril of the caudal edge, and force the lateral crus in
Fig. 5. Additional preoperative (left) versus 1-year postoperative (right) photo-
graphs of the patient shown in Figure 4.
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Volume 140, Number 4 • Extended Alar Contour Grafts
the favorable orientation described by Toriumi that migration of the graft is prevented because
rather than simply camouflaging the inward of the fixation of the graft onto the underside of
movement and medial rotation of the caudal edge the dome. Furthermore, traditional alar contour
of the lateral crus as seen with traditional alar con- grafts are not long enough and do not have a
tour grafts. As with lateral crural strut grafts, the medial point of fixation to act as a strut for malpo-
support of the caudal edge of the lateral crura sitioned lateral crura.
provided by extended alar contour grafts is also The senior author prophylactically places
able to mitigate the inward collapse of the lateral extended alar contour grafts routinely in pri-
crus–accessory cartilage junction that is seen in mary rhinoplasty to prevent isolation of the tip,
lateral crura that are internally recurvate or that alar retraction, and alar collapse, and to facilitate
collapse because of transdomal suturing. Like alar proper orientation of the lower lateral cartilage
contour grafts, extended alar contour grafts are (Figs. 4 and 5). Many patients requesting sec-
placed low along the alar rim and are able to help ondary rhinoplasty often present with multiple
prevent and correct alar notching, retraction, or indications for extended alar contour grafts and
collapse. However, an advantage of the extended have excellent long-term results through the use
alar contour graft over a traditional rim graft is of extended alar contour grafts (Figs. 6 and 7).
Fig. 6. Preoperative (left) versus 1-year postoperative (right) photographs of
a secondary rhinoplasty patient in whom extended alar contour grafts were
used to correct alar retraction, collapse, and asymmetry because of weakened
and unfavorably oriented lateral crura resulting from prior surgery.
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Plastic and Reconstructive Surgery • October 2017
Fig. 7. Additional preoperative (left) versus 1-year postoperative (right) photo-
graphs of the patient shown in Figure 6.
Although there is some overlap of situations cartilage necessary to create a lateral crural strut
in which alar contour grafts versus lateral cru- graft. Two extended alar contour grafts can be
ral strut grafts should be used, we have iden- fashioned from the same amount of cartilage
tified these indications for using extended required for a single lateral crural strut graft. Also,
alar contour grafts in primary or secondary lateral crural strut grafts can be overly strong or
rhinoplasty: rigid and can widen the tip lobule. Being made
of flexible cartilage allows the extended alar
1. Prophylactic to prevent alar rim collapse contour graft to retain many of the positive attri-
and alar retraction. butes of the lateral crural strut graft: correction
2. Correction of alar retraction. of the boxy nasal tip, prevention of alar cartilage
3. Correction of alar notching. malposition, alar retraction, and straightening of
4. Correction of alar collapse. convex/concave lateral crura while maximizing
5. Correction of the bulbous/boxy tip (mild). their effect of correcting and preventing alar rim
6. Cephalically orientated/malpositioned lower collapse.
lateral cartilages. As with any graft used in rhinoplasty,
extended alar contour grafts share poten-
One of the major difficulties in fashioning tial shortcomings. Although an extended alar
lateral crural strut grafts is the large amount of contour graft can attenuate mild convexity or
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Volume 140, Number 4 • Extended Alar Contour Grafts
concavity in the long (anteroposterior) axis of C. Spencer Cochran, M.D.
the lateral crus, lateral crura that are overly con- Dallas Rhinoplasty Center
vex or concave in their short (craniocaudal) axis 8144 Walnut Hill Lane #170
may require traditional lateral crural strut grafts Dallas, Texas 75231
or lateral crural turnover grafts to adequately
flatten their contour because the extended alar PATIENT CONSENT
contour graft influences only the lower por- Patients provided written consent for the use of their
tion of the lateral crura. Also, if not adequately images.
secured at the dome, the graft may roll out or
stick out from under the caudal border of the
dome, creating an irregularity in the peridomal REFERENCES
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