Concerned about nostril notching? Understanding the extent and limitations of alar rim lowering surgery

Alar rim lowering surgery lowers the elevated edge of the nostril to make the notching less noticeable when viewed from the front or at an angle[1]. How much can be lowered depends on the degree of retraction. Mild cases may be resolved by adding cartilage alone. On the other hand, when the inner mucosal lining is insufficient, the procedure becomes one that requires supplementing the tissue itself[1].

What causes the notching appearance?

The condition where the nostril rim appears elevated is called alar rim retraction (alar rim posterior displacement). There are two causes: the natural anatomical structure from birth, and changes that occur after previous surgery when too much cartilage was removed or the inner mucosal lining was damaged[2]. Severe retraction can make the nasal tip appear pinched. Additionally, the external nasal valve—the passage for breathing—can become collapsed, making it difficult to breathe[1].

Who is it suitable for? The dividing line between mild and severe retraction

The dividing line is determined by the severity of retraction and the amount of missing tissue. For mild to moderate cases with minimal tissue deficiency, the shape can be corrected by transplanting cartilage along the alar rim[1]. When the outer edge of the rim is elevated more severely, simple transplantation alone may not reach far enough. In such cases, we may extend the transplant area or add procedures to advance the inner mucosal lining[1]. If excessive resection of the nasal base (root of the nose) from previous surgery has caused scar contracture, the correction involves transplanting skin and cartilage as a single unit[3].

How much can it be lowered? Factors that determine the extent of descent

There are two answers: where the cartilage supporting the rim is located, and how much slack there is in the inner mucosal lining[2]. If the cartilage is displaced toward the head (cephalad) from its normal position, there is less force to lower the rim. In that case, we combine the procedure with repositioning the cartilage itself[2]. If you try to lower the rim without sufficient mucosal lining, the contractile force will prevent the desired result. Therefore, the sequence is to supplement the deficiency first, then lower the rim[1].

Will breathing difficulty improve?

It can improve conditionally. When retraction is severe and the external nasal valve is collapsed, lowering the rim and adding support can restore the proper shape of the airway[1]. However, nasal obstruction often has multiple contributing causes, such as deviated nasal septum or mucosal swelling. Correcting only the external aspect may leave some obstruction[2]. If breathing difficulty is the primary concern, we place the diagnostic stage before addressing the appearance

What should we watch for regarding risks and recurrence?

Points of concern include the transplanted cartilage edge appearing elevated, asymmetry in height between sides, and the rim retracting upward over time[1]. In patients with thin skin and weak cartilage, the transplant itself used to provide support may lead to distortion of the nasal tip shape, as has been noted[3]. In rhinoplastic surgery overall, there is a retrospective study showing that 9.8% (approximately 1 in 10 patients) underwent revision surgery. Planning with the possibility that one surgery may not be sufficient allows for sound decision-making[4].

What to confirm during consultation

The consultation examines three things: the degree of retraction, how much slack is in the inner mucosal lining, and where the graft material will be harvested from[1]. If you have had previous nasal surgery, what was done at that time affects which tissues can be used. If records are available, bringing them will expedite the discussion[4]. The appearance of notching changes with angle and facial expression, so communicating which view concerns you helps the doctor make an individual assessment