ALAR BASE REDUCTION IS AN intriguing and often inadequately
described technique
of rhinoplasty. Numerous
approaches to
narrow the nasal base have been discussed.
It is generally agreed that reduction
of nasal base width should be considered
when the interalar distance exceeds
the intercanthal distance in the Caucasian
patient1-6 (Figure 1).
Figure 1. Classic Caucasian vertical fifths of the face (adapted from Powell
and Humphries7).
However, ethnic
differences and personal preference may necessitate significant variation from
this standard.8 Another common indication
for reducing the alar width is to correct
the sidewall flaring that retrodisplacement
of the nasal tip may cause.9,10 Alar
flaring is defined as the lateral aspect of
the ala extending significantly beyond the
alar-facial groove (Figure 2).2,3,6,11
Figure 2. Classic Caucasian alar base anatomy (adapted from Powell and
Humphries7).
Once the need for alar base reduction has
been ascertained, we use a combination of
3 basic techniques to effect this change.
Classically described by Weir,12 with subsequent
modification by Joseph13 and Aufricht,
14 the modified Weir incision (or alar
wedge excision) (Figure 3) is our technique
of choice for excessive flaring of the
ala for the frontal appearance of awide nasal
base.
Figure 3. Wedge excision.
Our wedge excision technique
spares entering into the nostril and violating
the naturally curved internal nostril border.
The goals of the wedge excision are to
avoid overstraightening the ala, to preserve
the natural curvature of the ala, and
to avoid telltale incisions into the nostril opening.
This maneuver may be used in concert
with nasal sill excision, initially described
by Aufricht,14 for correction of the
excessive flare with enlarged nasal sill width
(Figure4).
Figure 4. Wedge and sill excisions.
A relative indication for sill reduction
is when the nostril is enlarged and
has a horizontal axis. When the alar base
is wide because of a large nasal sill and no
flaring is present, the sill alone is directly
narrowed, though this is very rare. If the
lateral insertion of the ala is responsible for
excessive nasal base width, then we reposition
the alar insertion with a V-Y advancement,
as defined by Bernstein (Figure5).15
Figure 5. V-Y Advancement. A, The hook is placed in the lateral aspect of the wedge incision in the area of the nasolabial fold. B, After suturing, this creates the
stem of the “Y,” which is aligned with the nasolabial fold.
The purpose of this article is to further explore the
techniques available for alar base reduction by discussing
the experiences of the senior author (R.W.H.K.), examining
outcomes in 124 patients, and comparing this
with what is presented in the current rhinoplasty literature.
While this procedure is not appropriate for most
rhinoplasties, it is still an essential tool for the rhinoplastic
surgeon and deserves a thorough analysis. Overall,
we intend to provide a review of this topic, simplify
the analysis and approach, and aid the surgeon in achieving
the most natural result attainable.
