Systematic Surgical Approach to Alar Base Surgery in Rhinoplasty

Refinements in Extended Alar Contour Grafts: Retrograde Approach in Conjunction with Alar Base Surgery

SUMMARY

Alar contour grafts are an excellent adjunct in both primary and revision rhinoplasty for correction and prevention of alar rim irregularities. They are traditionally placed at the conclusion of a rhinoplasty through a vestibular incision along the underside of the alar rim. Alternatively, alar base resection provides an opportunity for precise retrograde placement of alar contour grafts. The purpose of this article is to describe an efficient, five-step technique for retrograde placement of alar contour grafts in the setting of concomitant alar base surgery.

Comparison of Transalar Suture Technique and External Wedge Resection for Alar Base Narrowing

BACKGROUND

Alar narrowing is indicated in some rhinoplasty operations. This study compared transalar sutures and external wedge resection for alar narrowing in patients undergoing rhinoplasty.

METHODS

This study was a single-blind randomized controlled trial with a parallel design. Participants were allocated randomly to the transalar suturing technique group or the external wedge resection group (one-to-one allocation ratio). Primary outcomes were scar formation and satisfaction score (Rhinoplasty Outcome Evaluation questionnaire and patient component of Patient Scar Assessment Questionnaire) after 12 months. Secondary outcomes were the duration of procedure, amount of bleeding, and need for bleeding control.

RESULTS

In total, 44 and 46 patients completed the study in the transalar suture and external wedge resection groups, respectively. The postoperative assessment showed a significantly lower scar formation rate in the transalar suture group (75.0% versus 37.0%; P < 0.001). The Rhinoplasty Outcome Evaluation questionnaire revealed no statistically significant difference in patient satisfaction between two groups. The Patient Scar Assessment Questionnaire results showed that patients who received transalar sutures had a lower overall score (1; interquartile range, 1 to 1) compared with the external wedge resection group (2; interquartile range, 1 to 4.50) ( P < 0.001). The duration of the procedure ( P < 0.001), amount of bleeding ( P < 0.001), and need for bleeding control ( P = 0.009) were significantly lower in the transalar suture group than in the external wedge resection group.

CONCLUSIONS

Transalar sutures result in high postoperative patient satisfaction. This approach has a decreased incidence of scarring, operation time, bleeding, and necessity for bleeding control.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Beyond Alar Base Resection: Contouring of the Alar Rim and Base

SUMMARY

Alar base surgery is approached with hesitancy and is often avoided by many surgeons because of inexperience and a lack of understanding. However, with a thorough knowledge of the anatomy and dynamic nature of the lower third of the nose, alar base resection can achieve favorable and reproducible results. Beyond correcting alar flare, an appropriately diagnosed and performed alar base procedure serves to contour both the alar rim and the alar base. The following article presents a case series of 436 consecutive rhinoplasties from a single surgeon, 214 of which underwent alar base surgery. The outcomes demonstrate that the procedure is safe and yields desirable results without a single revision being required. As the third in a series of three articles on alar base surgery by the senior author (R.J.R.), this article unifies the management of the alar base. An intuitive approach to the classification and management of alar flare and the implications of alar base surgery on contouring of the alar base and alar rim is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Management of Wide Alar Lobule Using Preservation Rhinoplasty Philosophy: Alar Coring Technique

A broad alar base disrupts nasal harmony and facial aesthetic balance and is an aesthetic concern for many patients. This wide appearance may be related to excessive nostril sill, alar flare, wide alar lobule, or a combination. Many techniques are described in literature to address the alar base with resultant scars to a variable degree. Management of alar lobule thickness is particularly challenging. Our technique presented here introduces a novel method to reduce the thickness of the alar lobule with excellent aesthetic outcome.

Application of Modified V-Y Advancement Flap in Alar Base Reduction

BACKGROUND

A variety of techniques for alar base modification have been described in the literature. Limitations of these techniques include scars, recurrence, asymmetry, etc. An incorrect excision of the lateral alar wall can result in a tear-drop or Q-shaped deformity.

OBJECTIVES

In this study, a modified V-Y advancement flap will be introduced that will avoid the complications discussed above as well as adjust the positional relationship between the nasal alar and the columella using this technique. In addition, this method is reversible; once the nostril is narrow due to excessive advancement of the flap, the reverse V-Y advancement method can be used to enlarge the nostril.

METHODS

In this study, a retrospective review of wide nasal bases in the past 3 years was conducted. A blind analysis of anthropometric points was conducted. There were 3 outcome variables: the width of the alar base, the width of the flare, and the distance between the alar base and columellar base.

RESULTS

The alar base was reduced with a modified V-Y advancement flap on 65 female patients ranging from 18 to 45 years of age. In 10 cases, an "Inclined Y-arm flap" was used to narrow alar bases and adjust columella-alar positions. In the remaining cases, a "Horizontal Y-arm flap" was performed to narrow the simple nasal alar width. In all cases, the nasal base was reduced without distortion. In the postoperative period, all the effects were seen to persist for a long time, and patients were generally satisfied with the results of the procedure.

CONCLUSION

By using this modified V-Y advancement flap technique, the incision can be concealed as thoroughly as possible, thereby avoiding "tear-drop" or "Q" deformities as well as narrowing the nasal alar effectively. Furthermore, this method, in combination with rhinoplasty surgery, will greatly enhance the nasal appearance.

Reducing the Alar Base While Minimizing Visible Sequalae: A Review of Three Alar Base Reduction Techniques over 35 Years

Importance: Although classically described and routinely performed, alar base reduction remains nuanced without consensus as to the gold standard. Objective: To compare the measurement of alar base reduction among three techniques and the incidence of postoperative dermabrasion in rhinoplasties performed for 35 years. Methods: A retrospective cohort study of patients who underwent rhinoplasty with alar base reduction between 1983 and 2020 by one surgeon. Dermabrasion rates for visible incisions were evaluated based on patient demographics and surgical technique. Results: Of 312 patients, 82% (258) were women. The mean age was 33 years (SD 11.9). Patients self-identified as White (54.5%), Hispanic (22.4%), African American (8.3%), Middle Eastern, (5.2%), Asian (4.8%), Indian (2.2%), Mediterranean (1.3%), or unspecified (1.3%). Alar flare reduction was used alone in 202 (64.7%) patients. Eighty-two (26.3%) patients underwent postoperative dermabrasion to visible incisions. Patients self-reporting Middle Eastern race were offered dermabrasion at a rate 3.7 × higher than other race groups (OR = 3.73, CI 1.23-11.194, p = 0.02). Conclusion and Relevance: Alar flare reduction, sill reduction, and V-to-Y advancement are techniques that can be used to narrow the alar base. Visible incisions are the most common downside but can be addressed with postoperative interventions including dermabrasion.

An Innovative Method for Nasal Alar Reduction Surgery Based on the Equilateral Triangle Design Theory

At present, there is no unified and accurate method to design the amount of tissue to be removed in alar reduction surgery. The authors present the experience that the crescent-shaped alar resection is based on the innovative equilateral triangle theory. It can accurately estimates the amount of alar tissue to be removed and conforms to the 3-dimensional esthetic concept of the nose. Followed up for 6 to 12 months, took 6 and 12 months postoperative photos, measured the postoperative nasal base width, and conduct a questionnaire satisfaction survey. The width of the nasal base was reduced by an average of 4.4±2.1 mm. The mean visual analog scale score showed: 4.8±1.6 before operation and 7.6±1.2 after the operation ( P <0.05), which revealed satisfactory patient outcomes. This method provides a new idea for the evaluation of nasal alar resection volume and is worthy of clinical application.

Alar Flare Preservation Using the Sandwich Technique as an Adjunct to Alar Base Reduction

Achieving an aesthetic balance and natural appearance when modifying soft tissues of the nasal tip, alae, and nostrils is fundamental to the success of rhinoplasty surgery. The present study aimed to investigate the ability of a simple “sandwich” technique combined with external alar base reduction to preserve the alar flare and achieve a natural and appealing alar contour.