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TECHNIQUE

A Simplified Approach to Alar Base Reduction

Modification of the nasal base is not a routine part of rhinoplasty and should be implemented in a conservative manner as overresection is extremely difficult to correct. When in doubt, we do not perform the excision at the time of the initial rhinoplasty. Rather, in such cases it is best to wait until the nose heals and if the patient desires, the procedure is performed in the office several weeks or months afterward. This should always be the last maneuver in rhinoplasty as deprojection may increase the appearance of flare (Figure 11 and Figure 12).

Figure 11. A, The preoperative nostril axis is vertically oriented; B, the postoperative axis is more oblique. Deprojection of the nose widens the nasal base and alters nostril shape. The vertical alar redundancy (A) has been repositioned (B), resulting in an almond-shaped nostril with a shift in axis. No wedge or sill excision was performed.

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Figure 12. Deprojection and wedge excision. A, Preoperative view. B, Two-year postoperative view: the nostril has not been violated, and there is no excess nasal flare. C, Seven-year postoperative view shows a consistent result.

Conversely, projection of the nose may reduce the need to perform alar base reduction. Of note, deprojection will not change the nostril sill size, except when there is a significant tension septum. The “tent pole” effect of the septum on the nasal skin can stretch the nostrils to a larger size; hence, release of this tension may diminish nostril size.

When incisions of the nasal base are strategically placed, scars can become imperceptible. However, incisions may be visible
for a variety of reasons, especially if they violate the internal alar border and go into the nostril. We strongly disagree with techniques described in the literature that enter the nostril opening via the lateral ala (Figure 13).

Figure 13. A “tear-drop” or “Q” deformity (A; arrow) may result from excisions of the lateral alar wall (B; adapted from Szachowicz and Kridel6). One must “preserve the curve” of the alar rim when performing wedge excisions. In this patient, too much alar flare has been removed, resulting in a straightened lateral ala, and the base reduction incision has violated the internal alar rim.

Incisions into the nostril should only be placed when excess nasal sill is present, and then only through the horizontal portion of the nasal sill and not via a lateral approach. One must always consider the effects of nostril reduction on the nasal aperture so that nasal sill excision does not contribute to nasal airway obstruction. Therefore, we recommend thorough evaluation and meticulous technique when undertaking base reduction.

To simplify the approach to the nasal base, we recommend focusing on alar flaring, sill excess, and overall nasal base width. As mentioned previously herein, nasal base width should roughly approximate the intercanthal distance in the Caucasian nose and should be larger in the African American or ethnic nose. Once it has been determined that the alar base is too wide, one can tailor their approach (Figure 14).

Figure 14. Algorithm to determine performing wedge excision alone, wedge excision plus sill excision, or wedge excision plus sill excision plus V-Y advancement

When performing wedge excisions (Figure 15), mark out skin incisions in the alar-facial groove to “preserve the curve” as diagrammed in Figure 3, or a teardrop deformity may result (Figure 13).

Figure 15. Alar wedge excision. Deep 5-0 Vicryl [polyglactin 910] suture placement decreases skin edge tension. Closure is accomplished with simple interrupted 6-0 Prolene sutures.

Figure 13. A “tear-drop” or “Q” deformity (A; arrow) may result from excisions of the lateral alar wall (B; adapted from Szachowicz and Kridel6). One must “preserve the curve” of the alar rim when performing wedge excisions. In this patient, too much alar flare has been removed, resulting in a straightened lateral ala, and the base reduction incision has violated the internal alar rim.

To ensure a balanced excision, preoperative marking and calipers are very useful in the planning of wedge and sill excisions. Caution must be taken to avoid excising too much flare or the alae will look straight as they join the alar-facial groove. If sill excisions are not being done, make sure the incision does not violate the nostril. After injection (lidocaine hydrochloride with 1:100000 epinephrine), a No. 15 blade is used to incise the wedge of tissue. Care is taken not to violate the muscle deep to the skin. Needle-point cautery is used for hemostasis. Careful reapproximation is necessary to avoid a step-off deformity (this is more common with sill excisions than with wedge excisions). An absorbable braided suture (5-0 Vicryl [polyglactin 910]) is placed in the deep tissue layer to relieve any tension on the edges of the incision, and 6-0 Prolene sutures are used for the cutaneous layer (Figures 12, 15,16, and17). Particular attention is paid to everting wound edges along the sill region. If reapproximation of the incisional edges results in flattening or overstraightening of the ala, consider a modest V-Y advancement as described later in this article.

Figure 12. Deprojection and wedge excision. A, Preoperative view. B, Two-year postoperative view: the nostril has not been violated, and there is no excess nasal flare. C, Seven-year postoperative view shows a consistent result.

Figure 15. Alar wedge excision. Deep 5-0 Vicryl [polyglactin 910] suture placement decreases skin edge tension. Closure is accomplished with simple interrupted 6-0 Prolene sutures.

Figure 16. Alar wedge resection. A, Wedge excision completed on the left and planned on right. Note the alar flare, the incision in the alar-facial groove, and the preservation of the nostril sill. B, Wedge excision. C, Placement of deep stitch. D, Simple interrupted closure. E, Reduced flare (base view). F and H, Preoperative photos showing alar flare. G and I, Incisions are well healed at 1-month follow-up. Note that some of the curvature of the lateral ala is preserved to maintain a natural appearance. Too great a removal causes lateral alar straightening. At no point does this incision enter the nostril opening.

Figure 17. A and C, Preoperative views of alar flaring; B and D, minimal evidence of incisions (wedge incisions only) at 10-day follow-up.

Sill excisions are most commonly performed with wedge excisions, with or without V-Y advancement (Figure 14).

Figure 14. Algorithm to determine performing wedge excision alone, wedge excision plus sill excision, or wedge excision plus sill excision plus V-Y advancement

Though sill excisions could theoretically be performed alone or with a V-Y advancement, none of the procedures performed in our alar base series were done without wedge excisions. When planning the incision for the enlarged nasal sill, the most natural appearing results occur when the resection of the sill does not extend laterally past the long axis of the nostril or does not include too much of the vestibular lining (Figure 3). Care should be taken to avoid the mesial crus of the lower lateral cartilage. Additional undermining of the tissues is recommended at the nasal sill to avoid nostril notching. A 6-0 Prolene suture is used to precisely reapproximate the nostril border, and a deep 5-0 Vicryl suture is used, particularly to evert the skin edges at the nasal sill (Figures 4 and 18).

Figure 4. Wedge and sill excisions.

Figure 18. Intraoperative views of alar wedge and sill excisions. A, Both alar flaring and sill excess are present. B, Open rhinoplasty is performed with increased tip projection and a modest change in the nostril shape. C, Incisions are placed to remove flare and to enter the nasal sill medially to the alar insertions, preserving the lateral ala. On the patient’s left (C), flare and sill excisions have been carried out, and markings show the planned excision on the patient’s right. The oblique marking line (C) is useful for realigning the alar segment after the sill excess has been removed. D, Flare and sill reduction are completed bilaterally.

V-Y advancement is performed after either of the 2 maneuvers described herein (wedge or wedge with sill excision) (Figures 3 and 4). If sill excisions have been performed, the nostril sill must first be reapproximated with a single 6-0 Prolene suture. The lateral aspect of the open alar wedge incision is then drawn into the nasolabial fold with a single-pronged skin hook.

Figure 3. Wedge excision.

Figure 4. Wedge and sill excisions.

Simple, interrupted 6-0 Prolene sutures approximate the ”V” to create the stem of the “Y” within the nasolabial crease (Figure 5B). The more sutures that are placed along the stem of the “Y,” the further the ala will be medialized. In 3 days every other suture is removed, and at 5 days all sutures are removed (Figures 19, 20, 21, 22, and 23). Healing is surprisingly good, despite the density of sebaceous glands in this region. Indications for dermabrasion are noticeable or irregular scars present after 6 weeks.

Figure 19. The V-Y advancement can narrow the alar base insertion while placing incisions within the nasolabial fold.

Figure 20. The V-Y advancement after wedge and sill excisions. A, After the nostril rim is reapproximated, a single-prong skin hook is used to draw skin excess into the nasolabial fold. B, Usually three to four 6-0 Prolene sutures are used to create the stem of the “Y.” This will medialize the alar rim. C, At least 2 mm of medialization is achieved on the right side with V-Y advancement. Sill and flare excision and ala medialization with the V-Y advancement have been accomplished on the patient’s left side. Incisions are planned on the patient’s right side. Note the reduced sill width on the left side. D, Postoperative V-Y medialization of the alar insertion. E, The number of sutures in the stem of the “Y” will determine the degree of medialization.

Figure 21. Wedge excision, sill excision, and V-Y advancement. A and C, Preoperative views; B and D, 6 months after the procedure. Increased projection has also been achieved with a columellar strut, a medial crural base plumping graft, and a tip graft. Notice the change in nostril axis (A and B) with increased tip projection and narrowing of the interalar distance. The horizontal nostril axis is a general indication for nasal sill excision. No dermabrasion of incisions was performed postoperatively as the stem of the “Y” is well hidden in the nasolabial fold.

Figure 22. This patient underwent increased tip projection, alar wedge excision, sill excision, and V-Y advancement. A and E, Preoperative views reveal increased alar flare, sill, and interalar distance. B and F, Seven months after the procedure. The interalar distance has decreased postoperatively. C and D, No dermabrasion was performed because the stem of the “Y” is almost imperceptible in the nasolabial fold.

Figure 23. This patient underwent increased tip projection, wedge excision, and V-Y advancement with postoperative dermabrasion for scarring. A and E, Preoperative views reveal increased alar flare, sill, and interalar distance. B and F, Postoperative views. C and D, Incisions are imperceptible after dermabrasion.

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