A Rare Case of Near-Total Congenital Absence of the Lower Lateral (Alar) Cartilage: A Novel Multistage Reconstruction Technique

Background Congenital absence of the lower lateral cartilage is an exceedingly rare nasal anomaly. Most cases present partial hypoplasia rather than complete or near-total absence. Case Presentation We present a 23-year-old woman with near-total congenital agenesis of the right lower lateral (alar) cartilage. The patient declined external facial flaps to avoid scars, so a multistage internal reconstruction was designed. In the first stage, reduction rhinoplasty and structural framework reconstruction were performed using septal and cephalic alar cartilage grafts. The second stage involved a novel alar down-rotation and advancement flap toward the columella to correct nostril asymmetry. The final stage employed donor rib cartilage grafts to augment the nasal dorsum and for tip projection, with refinement of alar contour and base symmetry. Results At 24-month follow-up, the patient demonstrated stable aesthetic and functional results with no airway compromise or graft resorption. Conclusion This staged technique provides a scar-free, reproducible approach for congenital alar cartilage agenesis and introduces a novel concept of alar advancement and downrotation for major alar defects.