Alar base surgery

Anatomy

• The alar base is a complex three dimensional shape, with intimate relationships with the medial cheek, nostril, columella, and upper lip.

• alar base is typically composed of fibrofatty tissues and may assume a variety of shapes and sizes

• nasal sill: is the intranostril region between the medial crural footplate/columella complex and the alar facial groove. The nasal sill may be notched or smooth depending on the interface with the alar facial groove

• The alar crease (alar facial groove) is the junction between the nose and cheek and is an important landmark to be preserved in rhinoplasty surgery.

• A cephalically positioned alar facial junction will lead to a snarled appearance to the nose,

• while a caudally positioned alar facial junction can lead to alar hooding.

• the ideal relationship of the alar facial junction is 2 mm caudal to the normally placed subnasale on lateral view.

AESTHETICS & PRE-OPERATIVE ANALYSIS

basal view:• ideal Caucasian tip takes on the shape of an equilateral triangle. • The infratip lobule comprises about one-third of the height of the

triangle.• the columella and nostrils compose the remaining two-thirds.• The ideal nostrils are elliptical or pear shaped, symmetric, slightly

wider than the columella and inclined medially at about 30 to 45 degrees to the vertical axis of the columella.

• The columellar width should equal one fifth of the entire nasal base distance.

• The alar sidewall is about one-fifth of the width of the nasal base.

frontal view:the width of the alar base should extend about 1mm wider than the intercanthal distance on each side.The appearance of the nostril rims and the columella are ideally arranged like a "seagull in flight."

variation that can be seen in the axis of the nostril in different races

Problems of alar base

Problem Treatment Option

Excessive Nostril Sill Nasal sill reduction via internal alar base reductionExcessive Alar Flare Alar flare reduction via external alar base reductionExcessive Nostril Sill and Alar Flare

Sliding alar flap (Both excisions of the nostril sill and alar lobule with medialization of the ala)

Excessive Alar Rim Width Alar sidewall excisionExcessive Alar Hooding Alar hooding reductionPersistent Alar Base Width – Adjunctive Procedures

V-Y advancement & suture cinching techniques

Excessive Nostril Sill

• the width of the alar base extend more than 1mm wider than the intercanthal distance on each side

• Sill reduction technique mainly address two problems :

1. Wide alar base.2. Wide nostrils .

sill crease

ala

Technique

• , the columellar midline ‘ the alar-facial groove, and the sill crease are marked.

• the amount of reduction of the outer alar width and The contralateral side is marked at the same distance so the resulting sill creases are bilaterally symmetric.

Technique

• The desired amount of narrowing of the outer diameter of the ala is determined and calipers are used to sharply stab the skin from the desired sill crease to the ala. Medial and then lateral sill incisions are made with a no. 11 blade cutting upward from the stab

• The starting point of the lateral cut will determine the outside nostril diameter, while the angle of cut into the nasal vestibule determines the ultimate inner nostril diameter. The amount and location of the nostril resected will lead to reduction in either nostril size or alar base size

Excessive Alar Flare

• refers to the lateral aspect of the ala extending beyond the alar-facial groove, often the widest point of the nostril on base view.

• it is significant if the alar rim extends greater than 2mm beyond the alar-facial groove.

• Treated by : Crescenteric Wedge Excision

• The incision is typically made 1 mm anterior to the alar facial junction. A calculated wedge of nostril is removed. The incision is made with a number 11 blade and tissue is handled delicately with a bishop tissue forceps.

• Warner and colleagues warn that excisions carried out too far laterally along the natural curve of the ala may result in an unnatural curve, a notch, or an unnatural insertion of the alar base

A “tear-drop” or “Q” deformity may result fromexcisions of the curve” of the alar rim when performing wedge

excision .

• incisions may be visible for a variety of reasons, especially if they violate the internal alar border and go into the nostril.

• 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.

• In general, the literature also discusses skin incision placement 1 to 1.5mmanterior to the highly sebaceous alar-facial groove.

• However, it had been found that these incisions may also be quite visible.

• patient population underwent incisions placed within the alar-facial groove, may have contributed to the increased need for postoperative dermabrasion.

Excessive Nostril Sill and Alar Flare

• Wedge excisions improve excessive alar flare. These excisions will not narrow the nostril.

• Sill excisions narrow the alar base and nostrils. Sill excisions will not improve alar flair and occasionally may increase it.

Combination sill/wedge excision

Excessive Alar Rim Width

• The rim of the ala can be abnormally thickened.

• A thickened alar rim cannot be completely corrected by traditional alar, sill excision.

• The treatment of alar sidewall thickening involves a fusiform wedge excision, or a diamond shaped excision, to narrow a thickened alar sidewall.

Excessive Alar Hooding (hanging ala)

• occurs when the ala descends more than 2mm inferior to the columella.

• Alar hooding should be evaluated on direct lateral view.

ETIOLOGY:• developmental: excessively thick skin, or

tissue softening.• iatrogenic: caudal alar insertion.

Treatment

options include:• trimming the caudal rim of the lateral crus along with

the lining vestibular skin, allowing for upward movement of the alar margin. This may lead to an external scar.

• A modern treatment approach removes an ellipse from the inner portion of the ala such that the natural curve of the ala is not disrupted. This is advantageous if alar hooding is combined with a thickened alar rim.

• direct external excision of the caudal border of the ala along the ideal visual border.

Persistent Alar Base Width – Adjunctive Procedures

• Once the surgeon has tried to achieve alar base narrowing though one of the procedures listed above and there continues to be a persistently wide alar base, alternate procedures may be considered.

• If the lateral insertion of the ala is responsible for a persistently wide nasal base, a V to Y advancement of the facial skin, just lateral to the alar-facial junction, can be employed to narrow the alar base. Together with sill and wedge resection with or without cinch suture.

Postoperative Care

• applies antibiotic ointment to the wound immediately after the procedure three times a day.

• Patients are given hydrogen peroxide solution and instructed to gently clean any crusts forming on the sutures.

• Typically, sutures are removed from the wedge excision on postoperative day five. However, consider removal at day seven or eight if wound healing is not sufficient. Steristrips can be used to reinforce the wound to assist healing. Sutures along the sill may be left in place for up to two weeks.

Complications

• Unsightly scarring :Scars which are visible can be dermabraded at 8 weeks or re-excised at a later date

• notching .• Asymmetries : Achieving perfectly symmetric nostrils

with preexisting nostril asymmetries is nearly impossible.

• Nostril stenosis.• Tear drop or Q deformity may result from overly

aggressive excisions of the lateral alar wall.

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