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A Simplified Approach to Alar Base Reduction Page 01 Page 02 Page 03 Page 04 Page 05 Page 06

Patients were selected from a review of medical charts from the senior author’s (R.W.H.K.) practice spanning almost 20 years of experience (May 3, 1983 to April 17, 2003). Inclusion criteria were history ofwedgeresection, nasal sill excision, and/orV-Yadvancementduring rhinoplasty.Theexclusion criterionwaspatientswho did not follow-up at the practice. Data were collected on length of follow-up, procedures performed, age, ethnicity, and sex. Procedures were also classified as primary or revision septorhinoplasty. Filemaker Pro (Macintosh, Cupertino, Calif) and Excel (Microsoft, Redmond, Wash) were used for database management.

NASAL ANATOMY

Preoperative evaluation of the base of the nose should include the size, shape, symmetry of the nostrils, the width and length of the columella, the relationship between the columellar length and height of the lobule, and the thickness and contour of the alae. The classic Caucasian nasal base width should approximate the intercanthal distance (Figure 1).

	Figure 1. Classic Caucasian vertical fifths of the face (adapted from Powell and Humphries7).

The Caucasian nasal base resembles an equilateral triangle, with the length of the columella being twice the height of the lobule and equal in length to the height of the upper lip (Figure 2). The nostrils should be pear-shaped, about the same width as the columella, and have their long axis oriented at approximately a 45° angle to the vertical axis of the columella.6,16,17 Farkas et al¹⁸ demonstrated the degree of variation that can be seen in the axis of the nostril in African American, Asian, or Mestizo subjects (Figure 6).

	Figure 2. Classic Caucasian alar base anatomy (adapted from Powell and Humphries7).

	Figure 6. Ethnic variations in the nostril axis (adapted from Farkas et al18).

The base of the classic Caucasian nose is most aesthetically pleasing when it is slightly taller than wide and has minimal alar flare. Porter⁸ together with Olson¹⁹ discuss at length the anthropomorphic features of African American women and men, noting that in men, the interalar ratio compared with the intercanthal distance is approximately 1.3:1, whereas the female ratio is 1.25:1 (Figure 7).

	Figure 7. Variations in nostril axis on an ethnic face based on observations by Porter8 and Sim et al.20 Note that the interalar vs intercanthal distance is roughly 1:1.25 for women or 1:1.3 for men.

Sim et al20 reviewed the facial features of 100 southern Chinese women and compared them with white North American women. They found that it was more common for the southern Chinese face to have a nasal width greater than the intercanthal distance. In addition, the alae were more flared, and the nostrils were more horizontally oriented. Choe et al21 describe that it is more common for the nasal base width in Korean Americans to actually be more narrow than the intercanthal distance. Bernstein15 elaborates further on the wide variability of the nasal base that may be encountered (Figure 8).

	Figure 8. Variability of the nasal base (adapted from Bernstein15).

An additional anatomic consideration for alar base reduction is that of the alar axis. Sheen11 defined the alar axes to be Figure 1. Classic Caucasian vertical fifths of the face (adapted from Powell and Humphries7). Nasal Vestibule Alar-Facial Groove Nasal Sill Nasal Flare 1/3 1/3 1/3 Interalar Distance Figure 2. Classic Caucasian alar base anatomy (adapted from Powell and Humphries7). Wedge Approach Figure 3. Wedge excision. Figure 4. Wedge and sill excisions divergent, straight, or convergent (Figure 9).

	Figure 9. Axis of alar insertion. A, Divergent; B, normal; C, convergent (adapted from Brissett and Sherris22).

Brissett and Sherris22 noted that the convergent alar axis is not amenable to alar base reduction and should be avoided. Flaring, or the lateral aspect of the ala extending significantly beyond the alar-facial groove, may result for a variety of reasons. Ethnicity, trauma, cocaine use, or previous rhinoplasty (ie, reduction rhinoplasty with retrodisplacement of the tip or derotation) (Figure 10) may yield a widened nasal base.

	Figure 10. The deprojected nose is predisposed to alar flaring. Conversely, increased tip projection decreases alar flare. Adapted from Adamson et al.1

Flaring may also take on the appearance of the lateral ala, assuming a more circular shape than that of a gentle curve. Nostril asymmetry, often unnoticed by the patient, may be caused by a wide columella, caudal septal deviation, prominent medial crural feet, congenital defects, or nasal masses.23 The nasal sill is the posterior portion of the nostril between the ala and the columella. The nasal sill is often greater than or equal to the columellar width. Internal to the nasal sill is the nasal floor, which is continuous with the nasal vestibule (Figure 2).

	Figure 2. Classic Caucasian alar base anatomy (adapted from Powell and Humphries7).

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