Can a surgeon tell me if these techniques might lead to alar retraction/notching?

Question

Hello! I have chosen a surgeon for my rhinoplasty but I have seen a few of his patients have retracted or notched nostrils. I have acquired the surgical notes from several of his primary patients, to see if his techniques are to be blamed for this. I have read that notching occurs with over-aggressive cephalic trim. It appears he cuts 3mm cephalic resection and 3mm caudal resection for most of his patients, and doesn't add alar rim. Could I get someones opinion about these techniques?

Ronald J. Edelson, MD · Answer

Alar notching or retraction has to do with the techniques used in dealing with the tip cartilage and nasal lining. I’ve had this happen a few times. I figured out that it was from one stitch inside the nostril. I changed what I was doing and it hasn’t happened since.  I don’t know idea what specifically may have caused alar notching in the case you mentioned because it can be caused by a variety of things. I’m just relating my own experience and how I altered what I was doing to improve my results.

Jeffrey Lisiecki, MD · Answer

Any maneuver that weakens the lateral crura can set up for alar retraction or notching, even if you leave "enough" lateral crus by traditional standards. Saying how much of a cephalic trim was removed isn't really helpful information--the real information that matters is how much lateral crus was left behind after cephalic trim (has to be at the very least 6mm). The good news is that the risk of alar retraction/notching can be significantly lessened by adding support to the alar rim with an alar rim contour graft (among a few other maneuvers). If a surgeon is frequently getting retraction or notching and not using a rim graft, that would be my first thought for how to improve results. Caudal septal trim is not really related to alar retraction/notching.

David M. Kowalczyk, MD, MBA, FACS · Answer

Hi there! Great question. Yes, notching can definitely occur if too much of the caudal aspect of the lower lateral cartilage is removed. The reason is because there becomes a lack of support and the tissues want to retract cephalically. Ways to prevent this in open structure rhinoplasty involve lateral crural strut grafts with repositioning, rim grafts, and composite grafts from the ear if needed. It's best to avoid aggressive resection of the lower lateral cartilages to avoid this outcome. If you're in Denver, we'd love to chat more if you're interested in a consult. Hope this is helpful!

Can a surgeon tell me if these techniques might lead to alar retraction/notching?

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