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COMMENT

A Simplified Approach to Alar Base Reduction

The history of alar base reduction reveals a great variety of surgical maneuvers. It has been known for some time that notching deformities may result from this endeavor. 1,6,9,10 We believe that incision location is the primary reason for notching and nostril deformity. One technique described by Peck et al24 preserves the vestibular skin when resecting a triangle of tissue from the cutaneous nasal base, resulting in an intranasal “dog ear.” The redundancy flattens over time, leaving a closure that is resistant to notching.

Another factor noted by some to contribute to notching is carrying the modified Weir incision into the deep muscle layer in the alar base,10 though some authors describe using this technique of muscle transection when performing the alar cinch procedure described by Millard. 25 This technique is used primarily for patients undergoing surgery for cleft lip, and it makes use of laterally pedicled alar flaps. The tissue is deepithelialized and inset medially in the nostril floor to effect narrowing of the nasal base. For stability of the closure, the flaps are sutured to the columella.2,25 We consider this to be a combination of a sill excision and an alar bunching technique.

Daniel2 discusses a nasal base reduction modification of the procedure described by Sheen11 that classifies wedge excisions according to postoperative objectives. A type I wedge excision is limited to the alar base and will reduce alar flare only. Type II wedge excisions involve both the alar base and the nostril sill, hence decreasing both the nasal base and the nostril size. Type III wedge excisions include the alar base and nostril sill and extend into the nostril floor to achieve a decrease in interalar width.2

An additional technique described to minimize postoperative asymmetry is the “Calibrated Weir Operation” as described by Cinelli.26 It involves drawing a midcolumellar line from the nasolabial angle to the midpoint of the upper vermillion border, then bisecting this line and the columella with another perpendicular line. From the intersection of the 2 lines, one may measure the distance to the medial and lateral borders of a nasal base excision.

Overall, our alar base reduction techniques of wedge excision, sill excision, and V-Y advancement have resulted in a high degree of patient satisfaction. We propose a simple algorithm (Figure 14) to yield a consistent and reliable tool for the rhinoplastic surgeon. Our goal is to accomplish a natural result and preserve the natural curvature of the lateral ala. Furthermore, preoperative counseling and adjusting patient expectations about the potential need for dermabrasion is critical to patient satisfaction. It is also important to realize that one may decrease nasal flare by increasing tip projection or by increasing tip rotation; hence, it is important to perform base reductions as the last maneuver in the procedure.

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

In our experience 15% to 20% of deprojection rhinoplasties require wedge resections. This is similar to what is reported by Rees27 and Gilbert.28 Additional nasal base reduction maneuvers described Tardy et al9 include excision of the nostril floor internal to the nose and without violating the sill region.

Outcomes in our patient series were improvedwith the use of dermabrasion in the alar-facial groove in 25% of patients. Increased density of sebaceous glands in the area of the alar-facial groove undoubtedly plays a role in the visibility of Weir incisions. We did not find that scarring incidence increased when adjusting for ethnicity or sex (Table 1).

Abbreviations: SE, sill excision; V-Y, V-Y advancement; WE, wedge excision. *Data are given as number (percentage) except where indicated. Average patient follow-up, 2 years.

In general, the literature also discusses skin incision placement 1 to 1.5mm anterior to the highly sebaceous alar-facial groove.1,2,8,9 However, we have found that these incisions may also be quite visible. This patient population underwent incisions placed within the alar-facial groove, which may have contributed to the increased need for postoperative dermabrasion. Of note, incisions placed in the nasal sill, when combined with wedge excisions, were most likely to require dermabrasion (Table 2). This emphasizes the importance of careful placement of sill incision and proper eversion of these wound edges.

*The X2 test was used to calculate the P values (compared with wedge excision alone).

One could speculate that the large ethnic population (44%) of our patient series may contribute to the increased use of dermabrasion. However, the data do not statistically support that premise because 19% of Caucasian patients also underwent dermabrasion. One may also consider that the ethnicity demographics could be skewed based on the lack of appropriate categorization. The increasing rise of interracial couples often blurs the lines of distinction between ethnic groups. Ethnicity declared by the patient may not fully reflect the ethnic diversity of their parents (Table 1).

Abbreviations: SE, sill excision; V-Y, V-Y advancement; WE, wedge excision. *Data are given as number (percentage) except where indicated. Average patient follow-up, 2 years.

The V-Y advancement described by Bernstein29 has been particularly useful when additional narrowing of the nasal base cannot be accomplished by the wedge and sill excisions alone. The wedge excision may reduce the appearance of the nasal base width from the frontal view; however, it does not significantly change the interalar distance. Surprisingly, there has been little mention of this technique in the literature since 1975. In our series we used this technique in 31% of patients.

Measuring before removal of tissue and careful reapproximation of skin edges can minimize asymmetry. Exact symmetry may not always be possible.8 To avoid this problem, we feel that deep sutures are helpful to appropriately reapproximate the mobilized ala. Caution should be exercised in the nasal base that has a preoperative asymmetry. We feel that with the exception of cleft lip and trauma, most nostril asymmetries are attributable to correctable causes (tip or columellar deflection, nasal masses).23 Asymmetrical alar flare without history of trauma, surgery, or congenital cleft lip or mass is extremely rare.

Unilateral alar base reduction may be of use in patients with cleft lip, particularly if the nasal floor is too wide or if excessive flare is present. In addition to the techniques described in this section, Mazzola30 describes a Z-plasty that appears to effect a similar change. Using vestibular lining, a columellar-based flap Z-plasty is designed to move the alar insertion medially. The rotated flap places the intranasal skin lateral to the ala, allowing significant medialization.

Bafaqeeh and Al-Quattan31 present an interesting discussion on the potential devascularization of the nasal flap when open rhinoplasty is combined with alar base resections. Recognizing the 5 major arteries of the nose (Dorsal nasal artery, external nasal branch of the anterior ethmoidal artery, lateral nasal artery, alar branches of the angular artery, and the columellar artery), he recommends keeping the alar base excision below the alar groove and degloving the nasal skin superficial to the lateral crura to avoid damage to the lateral nasal arteries. Also, defatting of the nasal tip was discouraged to preserve the nasal tip plexus. We have not found devascularization of the nasal tip to be an issue in this patient series. To preserve nasal blood supply, we recommend leaving the deep musculature intact.

The rhinoplastic surgeon must also take into consideration the risk of further nasal airway obstruction when narrowing the nasal base or nostrils. It has been shown via acoustic rhinometry that reduction rhinoplasty can reduce the cross-sectional area at the nasal valve 22% to 25%.32 To maintain the nasal airway, the rhinoplastic surgeon is encouraged to consider the use of spreader grafts and turbinate reductions. An interesting study performed by Khosh et al33 noted that in a series of 53 patients with nasal valve obstruction, 79% of the obstructions were determined to be caused by previous rhinoplasty.

In addition to the inherent risk of nasal airway obstruction that comes with rhinoplasty, one must be aware of the potential for worsening the airway by narrowing the opening into the nostrils with sill excision or V-Y advancement. If any doubt exists concerning postoperative functional or cosmetic outcomes from nasal base excision, defer this portion of the procedure for 6 to 8 weeks. At that time the nose may be reevaluated, and minor nasal base excisions can be performed in the office if deemed necessary.9,10

In conclusion, conservative wedge excisions are useful for the appropriately selected patient with excess alar flare. Nasal sill excisions are effective for decreasing the size of a nostril and converting horizontal nostril axes to those that are more vertically oriented. Moreover, the V-Y advancement techniques described by Bernstein29 are reliable and predictable methods of medializing the nasal base. What makes the ala look natural is a preservation of the lateral curve without a visible incision that violates the nostril laterally. As this is a procedure of millimeters, subtlety and conservatism are paramount. When appropriately implemented, reduction of the nasal base is a valuable adjunct for advanced rhinoplasty.

Accepted for Publication: November 16, 2004.
Correspondence: Russell W. H. Kridel, MD, 6655 Travis
St, Suite 900, Houston, TX 77030 (rkridel@todaysface .com).
Previous Presentation: This study was presented at the
Combined Otolaryngology Spring Meeting; May 1, 2004;
Scottsdale, Ariz.

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