Alar reduction: techniques and scarring

A wide-looking nose base can have several causes

The lower part of the nose, where the nostril wings and nostrils are, is called the nasal base. One review classified deformities of the nasal base into horizontal excess or deficiency, vertical excess or deficiency, an alar base that sits too high or too low, a nostril floor that is too wide or too narrow, and deformities at the base of the columella, the strip of tissue between the nostrils ^[2].

The same review listed common deformities that call for alar surgery: a wide nasal base, nostril wings that flare out to the sides (alar flaring), large nostrils, and nostrils or nostril wings that are asymmetric ^[2]. Even when noses look similarly spread out from the outside, different causes call for different methods.

What changes alar reduction can bring

The literature notes that surgery on the nasal base can help improve the shape and direction of the nostrils, reduce alar flaring, adjust the width of the lower nose, correct nostril wings that appear to hang over the nostrils (nasal hooding), and improve symmetry for better overall facial harmony ^[1].

Changes to the nostril wings also affect how other parts of the nose look. A literature review summarizing the effects of individual rhinoplasty techniques noted that alar reduction can create the illusion of a more projected nasal tip ^[6]. Because a change in one area can alter how another area looks, it is important to plan with the whole nose in view.

A review of trends in nasal tip surgery stated that managing cartilage with sutures is preferable to cutting it away, and explained that alar reduction is being performed more and more widely ^[5].

Types of surgical techniques

Methods for treating a wide nasal base and alar flaring are summarized into three types: sutures that pull the nostril wings inward (cinching suture), excision that removes tissue from the nostril wings and the inside of the nostrils, and moving nearby tissue into place (flap advancement) ^[3].

Excision methods are further divided into three basic types ^[2]. Other authors have described inner excision, outer excision, combined excision, flare excision, and correction of drooping nostril wings, yet stated that there is still debate about the best method for this surgery, which was first described in 1892 ^[4].

• Alar wedge excision: an elliptical piece of tissue is removed at the crease of the nostril wing to reduce the size and vertical length of the wing and correct flaring seen from the front
• Nostril sill excision: reduces the distance between the two nostril wings, the length of the nostril floor, and the size of the nostrils
• A combination of the two: used when a wide base occurs together with alar flaring and large nostril wings

Where do the scars go?

Where the incision is placed depends on the method. In alar wedge excision, the incision is placed in the crease where the nostril wing meets the face, while excisions that reduce width work on the tissue inside the nostril ^{[2, 3]}. Creases and the inside of the nostrils are places where scars are less visible, but how much of a scar remains varies from person to person depending on skin type and how healing progresses.

There is little evidence that examines scar outcomes in detail. One group of authors reported that their method produced consistent results, acceptable scars, and high patient satisfaction ^[4]. However, the research summary does not state the number of patients or how outcomes were assessed, so it is hard to generalize from it. It is a good idea to ask during your examination how long your scar may look red and what its final appearance is likely to be, based on your own skin.

Complications and precautions

One review stressed that nasal base surgery is not a routine step in rhinoplasty and should be performed conservatively to prevent complications such as narrowing of the nostrils (nasal stenosis) ^[3]. Because this surgery removes tissue, it is important to decide carefully how much to remove.

The same review explained that alar surgery should be the last step of rhinoplasty, because changes to the nostril wings can be properly assessed only after all the other steps are complete ^[3]. Another review explained that addressing the base of the columella before alar excision is important for both the shape of the nose and the function of the external nasal valve ^[2].

Other problems, such as asymmetry between the two sides or noticeable scars, can also occur, and how quickly swelling goes down varies from person to person.

What to check during your consultation

Careful examination, consultation, analysis, and consideration of skin condition have been described as essential for a good result ^[1]. Understanding the nostril wings and surrounding tissue, supporting the lower lateral cartilages, and choosing the right method are described as leading to good results in both function and appearance ^[1].

• Whether the wide look comes from alar flaring, the width of the base, or the size of the nostrils
• Where the incisions will be and what scarring to expect
• The order and plan if it is combined with other nose surgery
• Possible effects on breathing, such as narrowing of the nostrils