Alar batten cartilage grafting in nasal reconstruction: functional and cosmetic results

Nasal Reconstruction in Granulomatosis with Polyangiitis: A Two Decade Review

Background: Granulomatosis with polyangiitis (GPA) leads to progressive destruction of the nasal tissues resulting varying degrees of saddle deformity and nasal obstruction. Reconstructive techniques are numerous, but there are no large series reporting their results. Objective: This study sought to measure complications and outcomes after rhinoplasty for GPA. Methods: We conducted a retrospective review of 42 patients with GPA who underwent nasal reconstruction of saddle nose deformity between 2005 and 2019 using primarily costal cartilage and soft tissue grafts. Results: Thirty-six patients met the criteria for inclusion. All were followed for a minimum of 12 months. Six patients required revision surgery due to infection or GPA flare ups. Five patients had complications. All patients were given a questionnaire at 12 months to rate their degree of satisfaction with their appearance and breathing. Conclusion: The findings of this study suggest that the use of strong cartilage grafts and the timing of surgery result in improvement in breathing and appearance after rhinoplasty in patients with GPA. Clinical Trial Registration number: REB # 21-125.

Surgical Techniques Following Free Cartilage Grafting

BACKGROUND

Reconstruction of surgical defects with free cartilage grafts poses unique challenges.

OBJECTIVES

To characterize surgical techniques following free cartilage grafting.

MATERIALS AND METHODS

A literature review was performed using the Embase, PubMed Medline, Cochrane Library, ClinicalTrials.gov, and Web of Science databases from inception to May 21, 2021. Studies describing free cartilage grafts harvested from the ear or nose under local anesthesia, specifically for reconstruction of facial surgical defects, were selected for inclusion. Only surgical defects resulting from tumor resection were included.

RESULTS

In total, 34 studies involving 713 patients with 723 surgical defects met inclusion criteria. The mean age of patients was 63.3 ± 10.4 years. Free cartilage grafts were most commonly harvested from the ear (93.1%). The most common recipient site was the nose (90.3%), followed by the lower eyelid (6.7%) and ear (3.0%).

CONCLUSION

Free cartilage grafts are an effective reconstructive option for patients with deep or cartilaginous defects that have compromised structural support on the nose, ear, or eyelid.

Nasal Valve Insufficiency in Dermatologic Surgery

BACKGROUND

Few publications have addressed nasal valve (NV) insufficiency as a complication of Mohs micrographic surgery.

OBJECTIVE

To comprehensively review the literature and further characterize the causes, prevalence, evaluation, and management of NV insufficiency as it relates to cutaneous oncology.

MATERIALS AND METHODS

A PubMed search was completed to identify articles related to the NV in the context of Mohs micrographic surgery, cutaneous oncology, and reconstruction.

RESULTS

Nasal valve insufficiency may occur during tumor removal and/or reconstruction. Defect size larger than 1 cm; location on the ala, sidewall, or alar crease; lack of structural support; and poorly planned flaps are the main risk factors for NV insufficiency. Several surgical techniques have been described to avoid and correct this complication.

CONCLUSION

Nasal valve insufficiency may be an underrecognized and underreported complication of Mohs micrographic surgery. Nasal valve insufficiency may be identified with relatively simple tests. Knowledge of NV anatomy and preoperative function assessment is essential. Recognition of this potential complication and awareness of its prevention and management may decrease morbidity in patients undergoing cutaneous surgery.

Paramedian forehead flap combined with hinge flap for nasal tip reconstruction

The paramedian forehead flap is a great option for restoration of complex nasal defects. For full-thickness defects, it may be used alone or in combination with other methods. We present a patient with a basal cell carcinoma on the distal nose treated by Mohs micrographic surgery, and a resulting full-thickness defect repaired with paramedian forehead flap combined with a hinge flap. For optimal results with the paramedian forehead flap, adequate surgical planning, patient orientation and meticulous surgical technique are imperative.

Treatment of nasal ala nodular congenital melanocytic naevus with carbon dioxide laser and Q-switched Nd:YAG laser

Total excision of congenital melanocytic nevi (CMN) is not always feasible. We here present our experience of using carbon dioxide laser and Q-switched neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser to treat nodular CMN of the nasal ala. Q-switched Nd:YAG laser and/or carbon dioxide laser were used to treat eight cases of nasal ala nodular CMN. Carbon dioxide laser was utilized to ablate all visible melanocytic tissue within one session. Ablation was performed so as to reproduce the original anatomical contours as closely as possible. Recurrences were treated in the same way. Q-switched Nd:YAG laser was also used to irradiate all target lesions to achieve the desired end point within one session. The intervals between treatments were at least 8 weeks. Recurrence of melanocytic tissue, scar formation, pigmentation, depigmentation, and the degree of patient satisfaction were recorded at every visit. Two of the eight patients were treated with Q-switched Nd:YAG laser. Although, the lesion lightened in one of them, the hyperplastic tissue persisted. Eventually, these two patients, along with the remaining six patients, were successfully treated with a carbon dioxide laser. We recommend carbon dioxide laser treatment for nodular nasal CMN. This simple treatment does not involve skin flap transplantation and has good cosmetic outcomes. Although Q-switched Nd:YAG laser does lighten some nasal nodular CMNs, it does not eradicate the hyperplastic tissue, and is therefore not an effective treatment for nodular nasal CMN.

Repair of Full-Thickness Nasal Alar Defects Using Nasolabial Perforator Flaps

BACKGROUND

The repair of full-thickness nasal alar defects presents difficulties because of their complex 3-dimensional structure. Reconstructions using inappropriate methods may lead to asymmetries and dissatisfying functional results. In this study, our aim was to present the repairs of full-thickness alar defects performed using cartilage-supported nasolabial perforator flaps.

MATERIALS AND METHODS

Eight patients who presented to our clinic between January 2011 and April 2014 with full-thickness defects in the alar wings were included in this study. The nasolabial perforator flap was prepared on the basis of the closest perforator to the defect area and in a way to include 2 to 3 mm of subcutaneous adipose tissue. The medial section of the flap was adapted to form the nasal lining. In the 7 patients in whom cartilage support was used, the cartilage graft was obtained from the septum nasi. After the cartilage was placed on the flap, the lateral section of the flap was folded over the medial section and the defect was repaired. In 1 patient in whom cartilage support was not required, the flap was folded over itself before the repair was performed. The flap donor area was primarily repaired.

RESULTS

No detachment around the suture lines, infection, venous insufficiency in the flap, or partial or total flap losses were observed in any of the patients. Retraction developed in 1 patient in whom no cartilage support was used. No retraction was observed in any of the patients in whom cartilage support was used. The results were functionally and esthetically satisfying in all the patients.

CONCLUSIONS

The greatest advantage of perforator-based nasolabial flaps is the greater mobilization achieved in comparison with the other nasolabial flaps. Thus, full-thickness defects can be repaired in 1 session in some patients, no revision is required around the flap pedicle, and much less donor area morbidity occurs. Nasal alar reconstructions performed using this type of flap lead to both esthetically and functionally satisfying results.

Titanium mesh in reconstructive surgery of the nasal pyramid. Follow-up of our 11 initial cases

BACKGROUND

Titanium mesh has been employed in neurosurgery, plastic surgery, and maxillofacial surgery as a bone replacement in diverse conditions. We first reported on its use as a substitute for osteocartilaginous nasal structure with satisfactory functional and aesthetic results in 2009.

OBJECTIVES

To assess the utility and tolerance of titanium mesh as a substitute of the osteocartilaginous portion of the nose.

MATERIALS AND METHODS

Eleven patients were identified who had a nasal reconstruction with titanium mesh. We retrospectively searched for infection, extrusion, nasal valve collapse, second surgery, and patient satisfaction in the patients' records. All patients presented with various types of non-melanoma skin cancer in the nasal pyramid. In the reconstruction of full-thickness nasal defects, local flaps were used, employing titanium mesh as a support structure.

RESULTS

No mesh extrusions, infections, or collapse of the nasal valve were noted in patients with a mean follow-up of five years. Only one patient needed a second surgery to debulk the flap. Patient satisfaction achieved a mean score of 7.5 out of 9 in 10 patients.

CONCLUSIONS

As cartilage grafts need a second surgical site, with consequent morbidity, the use of titanium mesh proves useful and safe in the reconstruction of nasal full-thickness defects. The results of our series of patients demonstrate the suitability of this material in the repair of nasal osteochondral defects, as well as its low rate of complications.

Full-thickness skin grafts for surgical defects of the nasal ala - a comprehensive review, approach and outcomes of 186 cases over 9 years

BACKGROUND

Skin cancers of the nasal ala are commonly encountered in dermatological surgery. Various techniques have been described to reconstruct surgical defects of the ala, including melolabial transposition flaps, interpolated melolabial flaps, bilobed and trilobed transposition flaps, island pedicle flaps and spiral flaps. Full-thickness skin grafts have received little attention in the reconstructive literature.

OBJECTIVES

We present our experience with full-thickness skin grafts for the reconstruction of partial thickness defects of the nasal ala in the largest series to date.

METHODS

A retrospective analysis of the Mohs micrographic surgery database over a 9-year period was performed. All cases of full-thickness skin grafts for reconstruction of the nasal ala were identified. Defect location, size and any postoperative complications were noted. All patients were reviewed at the time of suture removal, at 3 and 6 weeks postoperatively and at 1 year.

RESULTS

There were 186 cases in total in 181 patients (88 men and 93 women). Their ages ranged from 31 to 88 years with a mean of 65 years (median 66). Defect size varied from 0·3 × 0·4 cm to 2·0 × 2·7 cm, with the average defect size measuring 1·0-1·2 cm in diameter. Thirty-six per cent (67 of 186) of cases underwent postoperative dermabrasion, and 8% (14 of 186) received postoperative intralesional triamcinolone. The incidence of graft failure and infection was low. Good-to-excellent cosmetic results were seen in all patients and postoperative complications were uncommon and minor.

CONCLUSIONS

The use of full-thickness skin grafts for defects of the nasal ala is a simple and versatile reconstructive option with excellent functional and aesthetic outcomes.

Reconstruction of full-thickness defect of the alar rim with a combined advancement chondro-mucous and bilobed myocutaneous flap

BACKGROUND

The nasal pyramid is frequently affected by nonmelanoma skin cancer. In full thickness defects of the nose, reconstruction of all the layers results in better outcomes.

METHODS

We present a case in which the combination of two flaps adequately reconstructs a full thickness defect of the nasal ala.

RESULTS

The images provide proof of the excellent functional and aesthetic results.

CONCLUSIONS

Our technique is a simple, one-stage procedure, with no distant donor site morbidity that achieves good coverage of the internal nasal lining with good external aesthetic result.

Internal nasal valve incompetence is effectively treated using batten graft functional rhinoplasty

Introduction. Internal nasal valve incompetence (INVI) has been treated with various surgical methods. Large, single surgeon case series are lacking, meaning that the evidence supporting a particular technique has been deficient. We present a case series using alar batten grafts to reconstruct the internal nasal valve, all performed by the senior author. Methods. Over a 7-year period, 107 patients with nasal obstruction caused by INVI underwent alar batten grafting. Preoperative assessment included the use of nasal strips to evaluate symptom improvement. Visual analogue scale (VAS) assessment of nasal blockage (NB) and quality of life (QOL) both pre- and postoperatively were performed and analysed with the Wilcoxon signed rank test. Results. Sixty-seven patients responded to both pre- and postoperative questionnaires. Ninety-one percent reported an improvement in NB and 88% an improvement in QOL. The greatest improvement was seen at 6 months (median VAS 15 mm and 88 mm resp., with a P value of <0.05 for both). Nasal strips were used preoperatively and are a useful tool in predicting patient operative success in both NB and QOL (odds ratio 2.15 and 2.58, resp.). Conclusions. Alar batten graft insertion as a single technique is a valid technique in treating INVI and produces good outcomes.

Alar batten cartilage graft: treatment of internal and external nasal valve collapse

BACKGROUND

The aim of this study was to describe the efficacy of alar batten graft in correcting internal and external nasal valve collapse (i.n.v. and e.n.v.) and evaluate the functional and aesthetic results.

METHODS

From July 2006 to September 2008, 80 patients (54 females and 26 males) underwent alar batten cartilage grafting. The patients were divided into three groups: (1) 55 patients with iatrogenic nasal valve collapse (80% i.n.v., 20% e.n.v.), (2) 15 patients with posttraumatic nasal valve collapse (45% i.n.v., 55% e.n.v.), and (3) 10 patients with congenital nasal valve collapse (100% e.n.v.). Patients were evaluated at 6, 12, 24, and some at 36 months after surgery. The final follow-up was at least 24 months.

RESULTS

The results of this study revealed a significant increase in the size of the aperture at the internal or external nasal valve after the application of alar batten grafts. All the patients noted improvement in their nasal airway breathing and in their cosmetic appearance. No major complication was observed.

CONCLUSION

The alar batten graft is a simple, versatile technique for long-term reshaping, repositioning, and reconstruction of the nasal valve collapse.

Reconstruction of the distal third of the nose with composite ear-helix free flap

Full-thickness defects of the nose result in severe esthetic and functional problems. Regardless of the etiology of such defects, the complexity of the reconstruction process of full-thickness defects of this region is not correlated with the size of the defect. Local flaps are frequently used for reconstruction but often yielding facial scarring and bulky alae. Composite helical grafts are used for relatively small defects but defects of more than 2.0 cm in diameter require vascularized tissue transfer. Composite free flap from the root of the auricular helix has been used to reconstruct an anatomically diverse set of defects of the distal third of the nose, with satisfactory success in our series of 6 patients.

Current techniques in skin grafting

A thorough knowledge of the techniques used in skin grafting is a necessity for successful soft-tissue reconstruction. Careful attention to detail and planning should ensure an excellent outcome. Current research in the fields of tissue engineering and skin substitutes continues to evolve with the ultimate goal being tissue-engineered skin that matches the quality of the autologous skin graft.

El colgajo en “J” de la crus lateral del cartílago alar en el tratamiento del colapso de la válvula nasal

INTRODUCTION

Nasal valve collapse is a common cause of nasal airway obstruction. Although many techniques have been devised to treat this problem, the outcomes of most of them have been disappointing. The aim of this study is to report our experience using the lateral crural J-flap repair to correct the nasal valve collapse. This technique is based on a new view of the structural etiology of nasal valve collapse and it offers excellent functional and aesthetic outcomes.

MATERIAL AND METHODS

We present a retrospective study of 19 patients diagnosed of nasal valve collapse that underwent lateral crural J-flap repair from 2003 to 2005.

RESULTS

28 lateral crural J-flap repairs were made. Six patients underwent concomitant nasal surgery. Mean follow-up was 428 days All the patients have reported improvement of the subjective sensation of inspiratory collapse and there has been no noticeable decrement in benefit over time. No complications due to the procedure were observed.

CONCLUSION

The lateral crural J-flap repair is an efective treatment for nasal valve collapse with minimal morbidity and a high success rate.

Alar reconstruction with subcutaneous pedicled nasolabial flap: difficulties, considerations, and conclusions for this procedure

BACKGROUND

The subcutaneous pedicled nasolabial flap is a useful material for alar reconstruction.

OBJECTIVE

This article describes the difficulties and considerations in this procedure and discusses the procedural problems involved, drawing conclusions from them.

METHODS

Case 1: a folded flap was used with a conchal cartilage strut sandwich. Case 2: only a folded flap was used. Case 3: the flap was used to cover the outer surface of the ala, and a mucoperiosteal graft from the hard palate was used for the ala lining.

RESULTS

The cartilage strut was not sufficient to support the shape of the ala in case 1. Harvesting a sufficiently wide flap is thought to be important. However, a folded flap had some drawbacks, with the formation of a thick alar rim.

CONCLUSIONS

The combination of a flap for the outer surface and a mucoperiosteal graft as a lining is thought to be an excellent option for alar reconstruction.

Staged cheek-to-nose and auricular interpolation flaps

BACKGROUND

Staged interpolation flaps are priceless options in skin cancer reconstruction. Their value lies in their flexibility, reach, reliability, and ability to repair distant, complex facial defects. Familiar interpolation flaps to dermatologic surgeons include the paramedian forehead flap, cheek-to-nose interpolation flaps, and auricular staged flaps.

OBJECTIVE

In this special reconstructive issue, the paramedian forehead flap is discussed separately. This article highlights the cheek-to-nose and auricular interpolation flaps as applied to skin cancer defects. Design considerations, anatomic basis, execution, and the distinctions of each repair are presented.

MATERIALS AND METHODS

Patients with facial defects from Mohs micrographic surgery serve to illustrate the surgical techniques of each repair.

RESULTS

With meticulous planning and thoughtful execution, cheek-to-nose and auricular staged flaps are capable of restoring both function and cosmesis. Several surgical stages are necessary, and an adequate supporting infrastructure is essential for an optimal outcome.

CONCLUSION

Skin cancer patients with complex facial wounds from Mohs micrographic surgery may be assured of the highest possible cure rate. Further, their esthetic and functional reconstructive goals may be achieved with staged flaps for the nose and ear.

Grafts in dermatologic surgery: review and update on full- and split-thickness skin grafts, free cartilage grafts, and composite grafts

BACKGROUND

Skin grafting has evolved in the past centuries to encompass numerous well-established reconstruction techniques that are uniquely able to restore structure, function, and cosmesis to a variety of surgical wounds.

OBJECTIVE

To provide a detailed overview of the general principles of skin grafting geared for the dermatologist and the dermatologic surgeon.

METHODS

Comprehensive review of the literature.

RESULTS

A summary of the different applications and techniques of full- and split-thickness skin grafts, free cartilage grafts, and composite grafts is presented. Indications, advantages, disadvantages, techniques, and complications are discussed in depth.

CONCLUSION

Skin grafting is a dynamic and versatile method of cutaneous reconstruction that can be accomplished successfully with a thorough understanding of the principles and techniques of grafting.

Prefabricated nasolabial flap for reconstruction of full-thickness distal nasal defects

BACKGROUND

The reconstruction of full-thickness nasal tip and alar defects is challenging owing to the distal nose's triple-layer structure: skin, cartilage, and mucosa.

OBJECTIVE

In the reconstruction of wounds of the distal half of the nose involving the rim, the most important issue to be considered is to provide a good functional and an acceptable esthetic result. Various local and distant flaps have been described for this purpose. The nasolabial flap is one of the most frequently used flaps in reconstruction of small- to moderate-size distal nasal defects. Its reliable blood supply, minimal donor site morbidity, and excellent texture and color match are some of the advantages of this local flap.

METHODS

In this study, superiorly based subcutaneous pedicled nasolabial flaps have been prefabricated with cartilage and skin grafts. This method has been used in 10 cases.

RESULTS

One patient had partial flap necrosis, and two patients experienced hyperpigmentation on the suture line. Scar revision was performed in one patient for hypertrophic scar tissue at the flap margins. No other complications were seen in the remaining patients. None of the patients experienced a skin graft loss or cartilage exposure.

CONCLUSION

The prefabricated nasolabial flap offers a superior esthetic and functional result and may be an appropriate reconstructive option in reconstruction of small- to moderate-size distal nasal defects.

Interpolation flaps

Interpolation flaps provide an excellent method for reconstruction of large or deep defects where adjacent local tissue cannot supply sufficient donor tissue for repair. These flaps use tissue imported from nonadjacent sites with an inherent blood supply (vascular pedicle) to support the flap while attached to the recipient defect until neovascularization has been ensured between the flap and recipient bed. Hence, they can supply the thickness or bulk needed for large or deep defects and can survive on exposed bone or cartilage. The main disadvantage of these flaps is that they require two stages to complete because the delayed second stage releases the pedicle after inosculation and neovascularization render the tissue independent of the pedicle. This article describes three major interpolation flaps useful in repair of the nose and ear. The forehead, melolabial, and postauricular interpolation flaps are excellent methods that will add to the dermatologic surgeon's reconstructive armamentarium for the repair of large or deep defects.

Composite and free cartilage grafting

The nasal ala and helical rim of the ear are common sites for the development of skin neoplasms. Removal of skin cancers from these aesthetically delicate areas may leave defects that free skin grafts alone may not adequately repair. The contractural forces of scarring within and around the skin graft during healing may produce elevation or notching of the rim and may lead to functional compromise. The use of a composite graft or the inclusion of a free cartilage graft in conjunction with a skin graft or flap repair can provide structural support, which may help to prevent undesirable outcomes. This article focuses on the use of composite or free cartilage grafts harvested from the ear to repair nasal alar or helical rim defects within a single surgical session. Preoperative considerations, surgical technique, and postsurgical complications are discussed.

The examination of several common misconceptions in nasal reconstruction

Because the nose is a very prominent aesthetic feature of the face, wounds located here are particularly challenging from a reconstructive perspective. Poor tissue availability and the potential for introducing anatomic distortion certainly increase surgical complexity. There are common misconceptions regarding nasal reconstruction that may impede the physician's ability to deliver optimal care. Understanding that these commonly held assumptions about nasal wound repair are incorrect should increase the surgeon's nasal reconstructive abilities. The basic principles of reconstructive surgery are not uniquely applicable to the repair of nasal defects; the consequences of surgical misjudgments on the nose are simply magnified in comparison to surgical problems in other less visually prominent locations. To handle nasal surgical wounds with expertise, the dermatologic surgeon should first realize that there are common misconceptions that often hinder effective clinical decision making. By realizing that these incorrect assumptions can reduce success in nasal reconstruction, the surgeon should be able to more appropriately select nasal repair procedures that will accomplish the common goals of any facial reconstructive surgery: to preserve function, to restore appearance, and to minimize surgical risk.

Skin grafting

Knowledge of the indications, techniques, donor site considerations, and complications of all types of skin grafting is invaluable for the dermatologic surgeon who performs soft tissue reconstruction on a regular basis. With proper defect assessment, reconstructive planning, and attention to detail pre-, intra-, and postoperatively, optimal cosmetic and functional results using skin grafting techniques can be achieved.

The Lateral Crural J-flap Repair of Nasal Valve Collapse

OBJECTIVES: Nasal valve collapse is a common cause of nasal airway obstruction. Although many techniques have been devised to correct both the functional and aesthetic aspects of this problem, none is uniformly successful. I propose that the true locus and solution to the problem lies lateral to the nasal valve angle in the fibroareolar tissue that connects the lateral aspect of the lateral crus to the bony pyriform aperture. Age-related or surgically induced weakening and loosening of these structurally important, fibroareolar connections result in a prolapse of the lateral aspect of the lateral crura away from the pyriform margin and toward the septum with a consequent narrowing of the nasal valve region. A new method of repair is described.

METHODS: Bilateral marginal incisions are made following the curvature of the palpated caudal edge of the lower lateral cartilage starting at the dome region medially. The incision is extended laterally until the entire lateralmost aspect of the lateral crus is freed, generating a J-shaped chondrocutaneous flap that is medially and superiorly based. Following this, supraperichondrial dissection of the lateral crus is carried out, exposing the dome region and the upper lateral cartilage. The J-flap is then pulled caudally and laterally, and the excess overlapping tissue is evaluated. Two composite strips of vestibular skin and cartilage are resected: one parallel to the marginal incision and the second at the lateral edge of the J-flap. The flap is transposed and sutured into position, pulling open the nasal valve angle.

RESULTS: Preliminary results are presented for 18 patients who underwent 19 lateral crural J-flap repairs of nasal valve collapse. Nine patients underwent concomitant septal, sinus, or turbinate procedures. Two patients underwent unilateral J-flap repair. One patient required revision. Eighty-nine percent of patients reported markedly improved nasal airway patency and elimination of the subjective sensation of inspiratory collapse. Mean time to follow-up was 257 days. There has thus far been no noticeable decrement in benefit over time.

CONCLUSION: This new technique for the treatment of nasal valve collapse may offer a simple and effective approach to the problem of nasal valve collapse with minimal morbidity and a high rate of success. The technique is based on a new view of the structural etiology of nasal valve collapse.

The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty

One of the most common problems affecting both the primary and secondary rhinoplasty patient is deformity of the alar rim. Typically, this deformity is caused by congenital malpositioning, hypoplasia, or surgical weakening of the lateral crura, with the potential for both functional and aesthetic ramifications. Successful correction and prevention of alar rim deformities requires precise preoperative diagnosis and planning. Multiple techniques of varying complexity have been described to treat this common and challenging problem. Over the past 6 years (1994 through 2000), the authors have employed a simple technique in 123 patients for alar retraction that involves the nonanatomic insertion of an autogenous cartilage buttress into an alar-vestibular pocket. Among the 53 patients who underwent primary rhinoplasty in this study, 91 percent experienced correction or prevention of alar notching or collapse. However, correction was achieved for only 73 percent of the patients who underwent secondary rhinoplasty; many of whom had alar retraction secondary to scarring or lining loss. In patients with moderate or significant lining loss or scarring, a lateral crural strut graft is recommended. The alar contour graft provides the foundation in the patient undergoing primary or secondary rhinoplasty for the reestablishment of a normally functioning external nasal valve and an aesthetically pleasing alar contour. This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indications and the surgical technique for the alar contour graft.