Alar cartilage malposition — Pinched, bulbous and boxy tip
The alteration to recognise before operating: why it causes valve collapse, how it looks on the frontal view, and what happens if a tip is refined without diagnosing it.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- It is one of the most important things to recognise before operating: if the axis of the lateral crura points to the medial canthus instead of the lateral, there is malposition.
- It is far commoner than assumed: described in two of every three primary rhinoplasties and almost nine of every ten secondary ones.
- The frontal sign: two shadows flanking the lobule, the so-called parenthesis tip.
- Refining a tip with undiagnosed malposition is the most direct route to alar pinching and external valve collapse.
- The pinched tip is no longer accepted. It was once considered almost normal; today it is a defect requiring correction.
What primary malposition is
In a normal tip, the axis of the lateral crura runs towards the lateral canthus. In cephalic malposition, that axis becomes vertical and points towards the medial canthus. It is an anatomical variant, not a sequela: it is there before anyone operates. And it matters because a misdirected axis cannot support the external nasal valve — formed by the alar rim, columella and nostril floor — so on deep inspiration the lateral walls offer no resistance and tend to collapse.
Diagnosing it changes the whole operation
The sign is on the frontal view: two shadows flanking the tip lobule, known as the parenthesis tip. Finding it forces a rethink of the plan, because the default manoeuvre — refining the tip by cephalic resection — is precisely what worsens it. In a malpositioned tip, conventional resection produces alar pinching and can end in valve collapse. This is why the alteration is sought before anything is decided.
Secondary malposition: alar pinching
It is one of the commonest problems in rhinoplasty, and its usual origin is an unrecognised primary malposition. To the initial verticalisation is added descent and infero-medial rotation of the caudal border of the alar cartilage, which ends up lying beneath the cephalic border. The result is a loss of continuity between the tip lobule and the ala.
How a pinched tip looks
- Frontally: an abnormal shadow or groove between the tip lobule and the alar lobule.
- The alae lose their natural convexity and the tip seems to continue as a tube towards the dorsum.
- From below: the tip appears trilobed. As if a clamp had been placed on the lobule, between it and the alae.
The four mechanisms that produce pinching
| Manoeuvre | What it causes |
|---|---|
| Excessive resection of the cephalic portion of the lateral crura | The remaining cartilage strip is what resists cutaneous and cicatricial retraction. Over-reduced, it stops resisting and alar retraction follows |
| Mucosal resection | Creates cicatricial retraction that alters alar position from within |
| Over-tightened domal sutures | They narrow the tip, increase alar tension and verticalise it. They can deform the cartilage and leave the alar rim unsupported |
| Deforming dressing | It moulds during healing: badly placed, it fixes the pinching |
Where you resect changes where it rotates
One detail decides the outcome: cephalic border resection may be limited to the medial portion or extend along the whole upper border. Limited medially, the rotation produced is medial. Extended along the whole cephalic border, rotation is also superior. And the final degree of deformity depends on four variables: how much is resected, where, the shape and quality of the alar cartilages and the characteristics of the skin.
Treatment by degree
- Mild or moderate primaryPrerimal or alar contour grafts, restoring rim support without dismantling the tip
- Marked primaryRebuild the supporting framework: alar strut grafts, placed beneath the alar cartilages or above as onlay
- Secondary (established pinching)Restore alar continuity with sutures or cartilage grafts
- Extreme alar collapseA rigid graft may be required: the perpendicular plate of the ethmoid
Repositioning the cartilage, not just propping it
When malposition is the underlying problem, beyond reinforcing the rim one can correct the axis itself. Sheen described mobilisation and repositioning of the lateral crura, later opting for complete resection and caudal replacement as free grafts. Gunter and Friedman described the lateral crural strut graft, with or without repositioning, reporting 95.5 % success in 88 patients and indicating it also for alar concavity, retraction and collapse. Repositioning by cartilage Z-plasty has also been described, dividing the lateral crus and suturing the anterior segment to the caudal border of the posterior one.
The alar batten graft and where it goes
The alar batten graft serves both the external and the internal valve. The key is placement: a pocket is fashioned at the point of maximal collapse of the lateral wall, and the graft should span from the pyriform aperture to the medial portion of the lateral crus. Placed short it props nothing; placed away from the collapse point, likewise. Hence the value of marking the point of maximal collapse before infiltration, with the patient inspiring forcefully.
Bulbous or ball tip
This is an alteration of position and of shape at once. It is characterised by convex, firm lateral crura and by a divergence angle between the intermediate crura of less than 60°. The appearance is highly recognisable: the shadows cast by the lateral cartilage borders resemble two parentheses flanking the tip, their visibility depending on skin thickness. A particular case is the tip with lateral convexity of the alar cartilages, which gives the same appearance by another route.
Boxy tip
A primary alteration in which the alar cartilages are rigid and show a divergence angle between the intermediate crura greater than 60° — that is, excess distance between the domes. It is best appreciated on the basal view: the tip lobule looks flat and wide. As in the bulbous tip, thin skin reveals the cartilage borders. It frequently accompanies very long intermediate crura and firm, rigid domes, and is not rarely found in secondary rhinoplasties when it was not corrected at the first operation.
Bulbous and boxy: the divergence angle separates them
| Bulbous tip | Boxy tip | |
|---|---|---|
| Divergence angle | Less than 60° | Greater than 60° |
| Lateral crura | Convex and firm | Rigid, with firm domes |
| Key view | Frontal: two parentheses | Basal: flat, wide lobule |
| Main manoeuvre | Correct stiffness and curvature | Approximate the domes |
Treatment of bulbous and boxy tips
- Both require direct cartilage manipulation: full exposure of the alar cartilages — combining prerimal and intercartilaginous incisions — or open rhinoplasty. Thick skin makes treatment harder.
- In the bulbous tip, correct stiffness and curvature. Stiffness with border incisions or crushing; curvature with intradomal sutures or alar strut grafts acting as a splint.
- If convexity stems from cartilage shape: intra-alar sutures — the lateral crural spanning suture — intradomal sutures, or division of the lateral crura.
- In very thick alae giving tip convexity: thinning through a direct incision in the ala or the alar base.
- In the boxy tip: approximate the domes with interdomal sutures and frequently weaken their rigidity as well.
References
- 1.Arquero P. Alteraciones nasales: posición de los alares. rinoplastia.eu.
- 2.Constantian MB. The boxy nasal tip, the ball tip, and alar cartilage malposition: variations on a theme — a study in 200 consecutive primary and secondary rhinoplasty patients. Plast Reconstr Surg. 2005;116(1):268-281.
- 3.Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99(4):943-952.
- 4.Toriumi DM, Josen J, Weinberger M, Tardy ME. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997;123(8):802-808.
- 5.Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas. Cham: Springer; 2018.
Related specialty: Rhinoplasty