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A Simplified Approach to Alar Base Reduction
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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).
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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. |
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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).
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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. |
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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).
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Figure 14. Algorithm to determine performing wedge excision alone, wedge
excision plus sill excision, or wedge excision plus sill excision plus V-Y
advancement |
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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).
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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. |
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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. |
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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.
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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. |
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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. |
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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. |
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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. |
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Sill excisions are most commonly performed with wedge excisions,
with or without V-Y advancement (Figure 14).
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Figure 14. Algorithm to determine performing wedge excision alone, wedge
excision plus sill excision, or wedge excision plus sill excision plus V-Y
advancement |
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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).
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Figure 4. Wedge and sill excisions. |
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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. |
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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.
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Figure 3. Wedge excision. |
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Figure 4. Wedge and sill excisions. |
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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.
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Figure 19. The V-Y advancement can narrow the alar base insertion while
placing incisions within the nasolabial fold. |
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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. |
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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. |
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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. |
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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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