Alar batten grafts are the first line treatment of alar retraction and nasal valve collapse (Fig. 18-5).10,11,16 Batten grafts have been very well described in the literature. Alar retraction may be treated by cartilage batten grafts in less severe cases (1-2 mm).10 The area of retraction is marked before injection, and a small marginal incision allows dissection of a precise pocket. (If an open approach is elected, a precise pocket may still be created for the batten graft, but suture fixation also may be required.) A contoured cartilage graft (commonly of auricular or septal cartilage) may
be inserted into the precise pocket, which should extend inferiorly to the sesamoids and should be wide enough to simulate the normal shape of the lateral crus at the dome.

Figure 18-5 Nasal valve collapse may be apparent on normal inspiration, (A) Patient at rest. (B) Patient at normal inspiration. (C) Patient after
placement of alar batten grafts. Alar batten grafts may be placed via an external rhinoplasty approach or into a precise pocket made through an
endonasal incision, as shown here (D,E). This graft is nonanatomic and is typically placed caudal to the lateral crura, where there is maximal
collapse of the lateral nasal wall and supra-alar pinching. If alar batten grafts are placed too far cephalic, excessive fullness over the middle vault
will be noted. Patients should be told that there will be temporary fullness in the area of the graft. This fullness will typically decrease over 2 to
3 months. For maximal support, the alar batten graft should extend over the bone of the pyriform aperture.

Auricular composite grafts are commonly used in more severe cases (Fig. 18-6).22,23 It has been my experience that the skin and cartilage of the anterolateral surface of the ear, just inferior to the inferior crus, of the opposite ear (example, left ala, right ear) provides the best donor site and the best contour. An incision several millimeters from the nostril rim is followed by careful dissection with freeing of adhesions, creating a defect and displacing the alar rim inferiorly. Volume and support must be restored to hold the nostril rim in position; this role is fulfilled by the
composite graft. The fashioned composite graft is carefully
sutured into place.22,23 Typically, I use 5-0 chromic suture. I place a cotton ball or other light dressing intranasally to apply light pressure for 1 to 3 days.

Figure 18-6 Composite grafts are useful in the treatment of severe alar retraction. (A,B) Preoperative and (C,D) 1 year postoperative photos.
(E) Technique.

Composite grafts are easiest to place when undertaking a limited, precise pocket approach. When more extensive rhinoplasty is being performed, with wider elevation undertaken, the surgeon may be concerned that the composite graft will not stay in position. However, I have not found this to be the case. Composite grafts may be used in conjunction with alar batten grafts.

Alar-Columellar Disproportion

An alar-columellar disproportion may be caused not only by alar retraction but also by a hanging columella or a combination of both (Fig. 18-7).10,25 Retrodisplacement of the columella may effectively address the columellar contribution to the abnormality. Depending on the anatomy encountered, the medial crura may be retrodisplaced onto the caudal septum. Alternatively, excision of excessive caudal septum may be appropriate in selected cases.
When redundant septal mucosa exists, excision and suture
reapproximation also can be effective.

Figure 18-7 (A) Alar-columellar disproportion, treated with alar batten grafts to address the alar retraction and retrodisplacement of the columella in "tongue-in-groove" fashion to address the columellar component of the abnormality. (B) One year postoperative.

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