UCLA Plastic Surgeon, Jason Roostaeian, MD, presents the benefits of alar contour grafts to achieve natural looking results in cosmetic and functional rhinoplasty

1. ALAR CONTOUR GRAFT
Refinements & Advances
Jason Roostaeian, MD l Division of Plastic Surgery
David Geffen School of Medicine at UCLA

2. ALAR CONTOUR GRAFTS
Structural cartilage grafts placed in a non-anatomic position at the level of the alar rim
Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim
deformities in rhinoplasty. Plast Reconstr Surg. 2002 Jun;109(7):2495-505; discussion 2506-8.

3. ALAR CONTOUR GRAFTS
Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim
deformities in rhinoplasty. Plast Reconstr Surg. 2002 Jun;109(7):2495-505; discussion 2506-8.
Aesthetic and Functional Benefit

4. IDEAL ALAR AESTHETICS
Background I Ideal aesthetics and common deformities
Ideal Alar Aesthetics
Alar Rim is <2mm from long axis of nostril
“Gull in Gentle Flight” on AP view
Equilateral Triangle; Alar to Lobular Ratio 2:1
Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-
columellar discrepancies in rhinoplasty. Plast Reconstr Surg. 1996 Mar;97(3):
643-8.

5. NATURAL CONTOURS & SHADOWS
Avoid Pinching
Avoid undesirable shadow between the tip
lobule and alar lobule.
Strength and position of Lower Lateral
Cartilages is key
Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006May-Jun;8(3):156-85.
Background I Avoid Pinching

6. ALAR DEFORMITY EXAMPLES
01 Example of Alar Notching

7. ALAR DEFORMITY EXAMPLES
02 Example of Retraction

8. ALAR DEFORMITY EXAMPLES
03 Example of Alar Collapse

9. ALAR DEFORMITY EXAMPLES
04 Example of Alar Asymmetry

10. TECHNIQUE
Open Approach Technique
Open Approach Preferred
Subcutaneous pocket parallel to alar rim
Dome to Ala
Technique I Common steps

11. Grafts of equal strength and length
Septal cartilage preferred
~2-3 mm wide
~15 mm long (depending on projection)
Placed just prior to closure
Technique I Common steps
TECHNIQUE

12. TECHNIQUE

13. Jacob G. Unger, M.D.
Jason Roostaeian, M.D.
Kevin H. Small, M.D.
Ronnie A. Pezeshk, M.D.
Michael R. Lee, M.D.
Ryan Harris, B.A.
Rod J. Rohrich, M.D.
Dallas, Texas
Background: Alar rim deformities such as retraction, notching, collapse, and
asymmetry are common problems in rhinoplasty patients. Although alar rim
deformities may be improved through rhinoplasty, this area is prone to late
changes because of scarring of the soft triangles and a paucity of native struc-
tural support. The purpose of this study was to analyze the effect of alar con-
tour grafts on primary rhinoplasty.
Methods: Fifty consecutive primary rhinoplasty patients with preoperative and
postoperative photographs who received alar contour grafts were evaluated for
alar aesthetics; 50 consecutive primary rhinoplasty patients without such grafts
served as controls. Differences among alar retraction, notching, collapse, and
asymmetry from anterior, lateral, and basal views were evaluated. Follow-up
ranged from 1 to 4 years and was graded on a four-point scale.
Results: The average difference between the two groups’ aggregate preop-
erative scores was 0.21 (p = 0.24). The average preoperative and postopera-
tive scores in the nongraft group were significant for worsening retraction,
notching, and collapse but insignificant for asymmetry. The preoperative and
postoperative scores for the graft group were insignificant for retraction but
improved significantly for notching, collapse, and asymmetry. Postoperatively,
the aggregate average of the scores in the nongroup was 0.32 points worse
(p < 0.01), whereas the graft group had a 0.33-point improvement (p < 0.01).
Conclusions: Alar contour grafts have a clear and important impact on cosmetic
results of primary rhinoplasty. Use of alar contour grafts has been shown to
improve aesthetics, whereas there is a worsening of the measured parameters
postoperatively without use of these grafts. (Plast. Reconstr. Surg. 137: 52, 2016.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Alar Contour Grafts in Rhinoplasty:
A Safe and Reproducible Way to Refine
Alar Contour Aesthetics
DIGITAL CONTENT IS AVAIL-
XT.
COSMETIC

14. ALAR CONTOUR GRAFT STUDY
Study & Results I Improved outcomes in primary rhinoplasty
Retrospective Study Methods
50 pts with ACG vs. 50 pts without ACG
Single surgeon (R.JR.), minimum 1 year
3 blinded plastic surgeons evaluated results
Retraction
Collapse
Pre and Post-Op Photos graded on 4 point scale
Notching
Symmetry

15. RESULTS: ALAR NOTCHING
Study & Results I Improved outcomes in primary rhinoplasty
NoACGvs.ACG
AlarNotching
1
1.5
2
2.5
3
3.5
4
Preoperative
Post-Operative
No Alar Contour Graft +Alar Contour Graft
p<0.01p<0.01

16. RESULTS: RETRACTION
Study & Results I Improved outcomes in primary rhinoplasty
RetractionScore
(Average)
1
1.5
2
2.5
3
3.5
4
Preoperative
Post-Operative
No Alar Contour Graft +Alar Contour Graft
p<0.01 p=0.08

17. RESULTS: ALAR COLLAPSE
Study & Results I Improved outcomes in primary rhinoplasty
AlarCollapse
1
1.5
2
2.5
3
3.5
4
Preoperative
Post-Operative
No Alar Contour Graft +Alar Contour Graft
p<0.01 p<0.01

18. RESULTS: ALAR SYMMETRY
Study & Results I Improved outcomes in primary rhinoplasty
AsymmetryScore
(Average)
1
1.5
2
2.5
3
3.5
4
Preoperative
Post-Operative
No Alar Contour Graft +Alar Contour Graft
p<0.01p=0.70

19. RATIONALE FOR USE OF ALAR CONTOUR GRAFTS
Weak /Asymmetric Alar Rims
Ptotic/Boxy/Bulbous Tip
Tension Nasal Tip
Aging Nose
Adjunct to Other Alar Grafts
Secondary Rhinoplasty
Nasal Reconstruction

28. ADVANCES & REFINEMENTS
Suture medially to deep surface of dome
Provides additional support and helps prevent
unfavorable lateral crural position
Care should be taken to prevent palpable
edges, trim or crush as necessary
Can be performed closed

30. 04

42. CONCLUSIONS
Improved outcomes in Primary rhinoplasty
with routine use of ACGs
Along a Spectrum of Lower Vault Support
• ACG —> Lateral Crural Strut Grafts
Expanded use of ACGs
• Ease of placement
• Low complication profile
• Minimal cartilage requirement

43. THANK YOU
Jason Roostaeian, MD l Division of Plastic Surgery
David Geffen School of Medicine at UCLA