How do you choose between nostril-rim lowering surgery, cartilage grafting, and composite tissue grafting?

Nostril-rim lowering surgery is not a single fixed method. It is performed by combining three types: cartilage grafting to the alar margin (the edge of the small nostril), grafting targeting the lateral crura (the cartilage that supports the edge), and composite tissue grafting harvested from the ear (a method of transferring skin and cartilage as a single unit)[1]. Which type is used is not a matter of preference. It is determined by whether what is lacking is "structural support" or "tissue volume"[2][3].

The three types of grafting differ

The three types differ in the location where material is added. Cartilage grafting to the alar margin places a thin strip of cartilage just inside the edge to maintain the shape of the rim. Grafting to the lateral crura works directly on the cartilage that supports the edge. Composite tissue grafting supplements both skin and cartilage as a single unit, filling in the deficiency in internal lining (the mucous membrane inside the nose)[1][2]. Even though they are described as "nostril-rim lowering," the actual methods are quite different[3].

How far can it work for mild retraction?

It can work. For mild retraction, the method of grafting cartilage to the alar margin will restore the shape[2]. However, this method is less effective when the outer aspect of the rim is elevated. Even with repeated grafting using the same method, the rim may not descend[2]. When it is determined that the case exceeds the range this method can address, we move to the next type.

When the outer aspect is strongly elevated

When the outer retraction is severe, we either broaden the grafting area or perform an operation to move the lateral crura itself (the cartilage supporting the rim) in the caudal (downward) direction[2]. In textbooks, lateral crura extension grafting is considered more stable than alar margin grafting and allows for more precise targeting of the area to be corrected[3]. In cleft lip and palate nasal surgery as well, lateral crura strut extension grafting (grafting to support and extend the lateral crura) and extended alar margin grafting are cited as methods to increase support for the nasal tip and rim[4].

What is added when internal lining is deficient?

When internal lining (the mucous membrane inside the nose) is deficient, simply adding structural support will not lower the rim[3]. For severe retraction, the standard approach is to combine lateral crura strut grafting to rebuild support with composite skin-cartilage grafting to supplement the internal lining[3]. There are reports of skin and cartilage harvested from the ear being sutured to match the internal shape of the nose, restoring both form and function. However, this pertains to reconstruction for full-thickness defects of the alar base (where all layers from skin to mucosa are absent). Extending this directly to standard retraction requires caution[5].

Is there a method to lower the rim without adding graft material?

Yes, there is. A method called "lateral V-Y advancement" has been reported, in which a triangular flap (tissue moved while keeping its base intact) is raised full-thickness (all layers from skin to mucosa) from the level of alar creases and advanced in the caudal (downward) direction[6]. It is said that a single procedure can restore a natural rim contour. An additional advantage is that the scar can be placed in a depressed area, making it less noticeable[6]. However, this report represents a limited case series from a single institution and is not a comparative trial with other techniques. How widely it can be applied remains unclear[6].

How is the choice made in my case?

The decision process begins by assessing the severity of retraction. Next, we differentiate whether what is lacking is structural support or internal lining. Then we confirm what graft material is available[1][3]. Whether it is the first surgery or a revision procedure affects what tissue can be used. It is helpful to mention early in the consultation whether you have had previous surgery[1]. Which type is suitable is determined individually by the surgeon after examining the inside of the nose.