Alar base modification

What repeats

Five findings that hold across the literature.

Flaring and base width are separate measurements, and each has its own excision

The base of the nose is read from below. Alar flare is the rim of the nostril bowing outward past the alar crease. Alar base width is the distance across the face between the two creases. Rohrich sorts flare into three types by the shape of the rim on that view and designs the excision pattern from the type, so that the lower third narrows without an operated look. A wide base, a malpositioned columella and a low tip are treated on a separate algorithm, because all three change the same view.

Rests on: Rohrich et al., managing alar flare · Rohrich et al., systematic approach to alar base surgery · nasal anatomy.

The excision carries the name of an 1892 paper

Weir's paper on restoring sunken noses, reprinted in Aesthetic Plastic Surgery in 1988, is where the wedge taken from the base of the nostril gets its name, and the review literature dates alar base reduction to that 1892 description. The Weir excision is still the operation being modified: recent papers vary the flap design, the depth of the cut and the order of the steps, and one series treats the sequencing of the base reduction as the technique in its own right. The first attempt to calibrate it came from a series of 1500 rhinoplasties, in about 20% of which the excision was used as the final step. That series sorted the noses it treated by what was in excess: 95% lateral wall, 2% nostril floor, 2% both, 1% thick nostril rims, with a different excision drawn for each.

Rests on: Weir, 1892 · McKinney et al., calibrated alar base excision · Carniol and Adamson, managing the wide nasal base · Freire and Maniglia, surgical sequencing.

The measured narrowing is small and the change in nostril shape is larger

Seventy-three consecutive patients had a combined sill and alar excision. The ratio of interalar distance to intercanthal distance moved from 1.07 to 1.04. Of the 60 patients with flaring, 45 lost it. Nostril symmetry rose from 38 patients to 46. Horizontally shaped nostrils fell from 21 patients to 2, and pear-shaped nostrils rose from 20 to 35. Four patients had a complication: one alar deformity, one uncorrected asymmetry, two with flaring still present.

A larger series put a caliper on the exchange rate. In 268 Asian patients, mean external alar excision was 4.7 mm and mean internal sill excision 6.9 mm. External alar flare width fell from 37.6 mm to 33.0 mm, and the sill excision was the stronger of the two effects: on average 3.2 mm of sill removed 1.0 mm of external flare, and smaller excisions bought proportionally less. Extreme dissatisfaction with nasal base width fell from 66.1% of patients to 4.3%.

Rests on: Chen et al., quantitative analysis of combined sill and alar excision · Kim et al., aesthetic outcomes of alar base resection.

The scar is the standing objection, and it is scored

Seventy-five women operated with a modified excision were compared with 67 operated with the classical excision. Scar quality was scored on a modified Stony Brook Scar Evaluation Scale and differed between the groups, as did rated naturalness. Rated symmetry did not differ. A separate series of 423 patients using a two-step sequential resection reports minimal morbidity at the resection site and no complication specific to the technique.

A third series counted the scars. Fifty patients had an internal reduction built on triangle flaps, with a mean sill width reduction of 4.8 mm and a mean lateral alar width reduction of 4.4 mm in the ten who also had a flare excision. No nostril notched at the suture site. Thirteen patients were left with a short oblique scar under the sill and one with a trap door deformity.

Rests on: Kamburoglu, a new alar base reduction technique · Ohba and Ohba, preservation of nostril morphology · Pozzi et al., sequential alar base resection.

American plastic surgeons are doing it less often

Board tracer data on 730 rhinoplasties compares 2012 to 2016 against 2017 to 2021. Alar base resection fell from 17% of cases to 10% over that decade, while spreader grafts, columellar struts and tip rotation manoeuvres all rose.

Rests on: Stein et al., ten years of ABPS tracer data · open versus closed rhinoplasty.

By what the base needs

The same incision answers several different complaints, and one of them runs the other way.

The rim flares, or the base is wide, or both

Flare alone is treated by a wedge taken from the alar lobule outside the nostril, cut to the flare type, leaving the opening alone. Width alone is treated from inside at the nostril sill, so the distance across the base shortens and the rim is untouched. The combined excision is what the Asian series measured.

Rests on: Rohrich et al., managing alar flare · Kim et al. · Rohrich et al., systematic approach.

The alae can be pulled together instead of cut

A cinching suture is passed under the base of the nose and tied to draw the two alar feet toward each other, with no skin removed. The review literature puts it alongside excision and flap advancement as one of the three ways to narrow a wide base. A systematic review of twenty-two studies covering 1599 patients found excision used in 728 patients, cinching sutures in 642, excision with a flap in 189, and all three together in forty. Cinching was the choice when the flare came with a vertical alar axis, a wide base, or jaw surgery in the same sitting. Nostril surgery ran alongside a rhinoplasty in 795 of those patients.

One centre compared the two directly. From 560 alar base reductions, seventy-three patients had base narrowing alone: 42 by cinching with subcutaneous flaps and 31 by vestibular floor excision with a cinching suture. The flap method narrowed the alar width more, held the alar axis better where that axis was vertical, and had a complication rate of 5.7%.

Rests on: Lima et al., update in alar base reduction · Gandolfi et al., systematic review of nostril surgery · Hirohi et al., alar cinching with subcutaneous flaps.

The alar lobule itself is thick

Some noses look wide because the wall of the nostril is thick rather than because the base is broad. Alar coring removes thickness from within the lobule and leaves the surface intact, on preservation principles.

Rests on: Abdulraheem et al., alar coring · preservation rhinoplasty.

The base is sunken rather than wide

The opposite complaint is a hollow beside the nostril, which deepens the nasolabial fold and flattens the middle of the face. Fifty-two patients had fascia grafted there during open rhinoplasty, and grayscale analysis of the hollow fell from 0.720 to 0.583 while alar and base width barely changed. A systematic review screened 269 articles, included 6 covering 165 patients, and compared diced cartilage against a solid block for the same defect.

Rests on: Zhao et al., fascial grafting for alar base depression · Xiang et al., systematic review · diced cartilage grafts.

The nose is African, Asian or Latin American in shape

Reducing the alar base is named as one of the three main objectives of rhinoplasty in African descendants, alongside tip definition and dorsal augmentation. In 392 African American patients planned with three-dimensional morphing and 392 planned without it, alar base resection was one of the listed manoeuvres, and revisions ran at 8% against 19%.

Rests on: Patrocinio et al., rhinoplasty in African descendants · Albert et al., ethnic preferences and AI morphing · the ethnic rhinoplasty archive.

What to ask about alar base modification

Questions the evidence supports asking.

Which excision am I having, and where does the scar sit

Outside the nostril, inside the floor, or both. The answer decides which measurement changes and where the line falls. Ask to see the surgeon's own basal view photographs at six months and at a year.

Rests on: Rohrich et al., systematic approach · Kim et al..

How is the scar graded, and what did the last hundred look like

Published series score the scar on the Stony Brook Scar Evaluation Scale rather than describing it. Ask which scale the surgeon uses and what the scores were.

Rests on: Kamburoglu · Pozzi et al..

What happens to my breathing

The nostril is the external nasal valve. Narrowing it too far, or carrying the excision into the vestibule, is how stenosis and external valve obstruction happen, and both are listed among the complications this operation is designed to avoid.

Rests on: Rohrich et al., systematic approach · nasal airway obstruction.

Can it be undone

Tissue that has been cut out cannot be put back, which is the reason the published techniques compete on how little they remove. Ask what the plan is if the base ends up too narrow.

Rests on: Kamburoglu · revision rhinoplasty.

The terms, defined

The words used about the base of the nose.

• Alar base: the foot of the nostril where it meets the cheek and the lip. [33234955]
• Alar flare: the rim of the nostril bowing outward past the alar crease, read from below. [29068925]
• Nostril sill: the floor of the nostril, where an internal excision narrows the base. [27441889]
• Weir excision: the wedge cut from the base of the nostril, named after the 1892 paper. [3068968]
• Interalar distance: the width across the base, compared against the intercanthal width. [27441889]
• Alar coring: removal of thickness from inside the wall of the nostril, surface uncut. [36423627]
• Cinching suture: a stitch under the base of the nose that draws the two alar feet together, with no skin removed. [32812083]
• External nasal valve: the nostril opening itself, narrowed by the same excision. [33234955]
• Stony Brook Scar Evaluation Scale: the scored scar assessment used as the endpoint. [38977456]
• Alar base depression: the hollow beside the nostril, treated by adding tissue. [41813990]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess and document before operating, whichever excision is planned.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries two chapters bearing on the base of the nose. They are written for surgeons and go further into technique than a patient page should.

• Alar Base Modification
• African American Rhinoplasty

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy, the indications and the complication list in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.

The trials in progress

• Aesthetic and Functional Results of Alar Base Modifications in Rhinoplasty, status unknown, 50 participants.

What is not settled

• No randomised trial compares the outside excision with the inside excision, or either against a cinching suture. Every technique paper is a single-surgeon series, and the largest are retrospective. [38977456] [42554673] [30511969] [32812083]
• The published outcome series are in Asian and Latin American patients. What the same excision does to a European or African nose is described rather than measured. [27441889] [34579839]
• The scar is scored at six months in most series. What the line looks like at five years is not reported. [38977456]
• The fall from 17% to 10% of American cases is recorded without a reason. [37605029]
• Alar base depression is treated with fascia, diced cartilage or a solid block. The systematic review comparing them found six studies covering 165 patients. [38609657] [41813990]