Dr. Kridel in Vogue Magazine, where he was
the only facial plastic surgeon noted for Texas.
Dr. Kridel voted top doc for women by H Texas Magazine.
Dr. Kridel named as a Super Doctor in Texas Monthly Magazine.
IN THIS ISSUE OF THE ARCHIVES the 2 articles “A Simplified Approach to Alar Base Reduction:AReview of 124 Patients Over 20 Years” by Kridel and Castellano1 and “The Long-term Effects of Alar Base Reduction” by Bennett and colleagues2 are laudable in that they both explore the authors’ experience with a technique that has had a long, sometimes confusing, and oftentimes controversial history in rhinoplasty.
The article by Bennett et al2 presents a genuine attempt to statistically analyze the effects of alar base reduction. The results are somewhat surprising because they do not show a statistical difference in the effect of alar base reduction on flare width in particular. One can intuitively rationalize that there may be little or no change in base width (between alar facial grooves) and base height (distance from the base to nasal tip). Although in the latter case, one would expect that this would decrease with deprojection. However, I note that in the results the average base height decreased from 97% to 90%, presumably from deprojection of the tip. Was this not statistically significant? The authors comment correctly on the reasons why they believe there may have been no change in flare width.
It remains somewhat difficult to rationalize the objective findings stated in the article by Bennett et al2 with the esthetic assessment that most surgeons would agree occurs with alar base reduction. It may be that a more accurate assessment could be obtained by intraoperative photographs along with postoperative photographs as well to analyze the effects. One also must presume that the mathematical model for calculation of the base view and flare widths and base heights are accurate. This is a very interesting study that will likely incite discussion and, hopefully, further objective studies to better determine the objective effects of alar base reduction.
The article by Kridal and Castellano1 also presents a large series with a long follow-up. It contributes nicely to our detailed understanding of the surgical anatomy involved in alar base reduction and appropriate terminology. It also outlines a stepwise approach that has been successful for its authors and includes some excellent admonishments for its readers such as “preserve the curve” and do not make any incisions directly from the ala into the nostril. The authors state a very low complication rate, which is of note in view of their 44% of patients who were nonwhite and in whom many would advise that alar incisions form unsatisfactory scars. However, it is also our experience that well-placed and closed incisions in such patients are usually satisfactory. An incidence of postoperative dermabrasion at 25% seems high, as one might expect that this would create its own pigmentation problems in a high percentage of nonwhite patients. The high incidence of the use of the V-Y incision (31%) is partially reflective of the high incidence of African American and Middle Eastern patients who might require this more aggressive technique.
Kridal and Castellano1 state that caution is necessary to avoid potentiating nasal airway obstruction; however, the most restrictive anatomical region of the airway is the internal valve, and in most cases it would likely require a significant alar base reduction or concomitant external valvular pathologic features for the reduction to have any impact on the nasal airway. The article correctly admonishes practitioners to be conservative in these excisions because there is no return once the tissue is removed. Although the authors recommend this technique as a secondary procedure if there is any question about its use in the primary procedure, they do not state their incidence of deferring the technique. I suspect that more experienced surgeons in most cases will be able to make this decision at the primary procedure. Although the article states that asymmetry of the ala and sill is unusual without a history of trauma, surgery, congenital cleft, or mass, in reality 85% of humans have asymmetrical faces. It is our experience that this extends to the nasal base and that it is not infrequent that at least minor asymmetries of the alar wall, nostril, or sill are present. The authors correctly caution that patients should be advised that these may not always be completely correctable.
This well-referenced article by Kridal and Castellano1 illustrates the reality that there are many different techniques to narrow the alar base, just as there are a variety of techniques for most aspects of rhinoplasty. This article presents sound principles, as does the article by Bennett and colleagues2 on the longterm effects of alar base reduction, that every advanced rhinoplasty surgeon should be aware of. Our own individual proclivities for innovation and creativity will then determine the eclectic technique that each of us will apply to this anatomical condition.
REFERENCES
Kridel RWH, Castellano RD. A simplified approach to alar base reduction: a review of 124 patients over 20 years. Arch Facial Plast Surg. 2005;7:81-93.
Bennett GH, Lessow A, Song P, Constantinides M. The long-term effects of alar base reduction. Arch Facial Plast Surg. 2005;7:94-97.
