Alar Flaring Research Articles

Nasal Base Modification in Asian Patients

The nasal characteristics of white persons and Asian persons represent the extremes of a spectrum. Typically, the common complaints of Asian patients include a dorsum that is wide and lacks anterior height and a tip that projects poorly and is not well defined. Large amounts of subcutaneous fat, thick skin, and a wide, flattened crura contribute to poor tip projection. Asians also have more excessive alar flaring and a wider nasal base.1-3

Alar Rim Grafting in Rhinoplasty

To determine the potential indications for placement of cartilaginous alar rim grafts in primary and revision septorhinoplasty. Retrospective medical chart analysis of all patients undergoing septorhinoplasty from March 2003 through June 2004 in a private facial plastic and reconstructive surgery center and a tertiary teaching hospital. Patients who received alar rim grafts were identified. The indications for placement of the alar rim grafts were deduced from their preoperative evaluation and intraoperative assessment as noted in their comprehensive operative notes. Preoperative and postoperative digital photographs as well as postoperative medical records were analyzed for alar contour, pertinent patient complaints, and complications. During the 15-month study period, 150 patients underwent septorhinoplasty performed by the senior author. Of these patients, 31 received alar rim grafts. The most frequent indications for placement of alar rim grafts were cephalic malposition of the lower lateral cartilage with inadequate alar support (9 patients [29%]), correction of alar flare (9 patients [29%]), and correction of dynamic alar margin collapse (8 patients [26%]). At a mean 6-month follow-up, there were no graft displacements or extrusion. Alar rim grafting is a simple and versatile approach to providing additional support to the external nasal valve and for improving nasal base contour.

Alar Rim Grafting in Rhinoplasty

To determine the potential indications for placement of cartilaginous alar rim grafts in primary and revision septorhinoplasty. Retrospective medical chart analysis of all patients undergoing septorhinoplasty from March 2003 through June 2004 in a private facial plastic and reconstructive surgery center and a tertiary teaching hospital. Patients who received alar rim grafts were identified. The indications for placement of the alar rim grafts were deduced from their preoperative evaluation and intraoperative assessment as noted in their comprehensive operative notes. Preoperative and postoperative digital photographs as well as postoperative medical records were analyzed for alar contour, pertinent patient complaints, and complications. During the 15-month study period, 150 patients underwent septorhinoplasty performed by the senior author. Of these patients, 31 received alar rim grafts. The most frequent indications for placement of alar rim grafts were cephalic malposition of the lower lateral cartilage with inadequate alar support (9 patients [29%]), correction of alar flare (9 patients [29%]), and correction of dynamic alar margin collapse (8 patients [26%]). At a mean 6-month follow-up, there were no graft displacements or extrusion. Alar rim grafting is a simple and versatile approach to providing additional support to the external nasal valve and for improving nasal base contour.

Open Rhinoplasty in the Korean Nose

Differences between the Asian and Western nose have been well described in the literature. The typical Asian nose is characterized by a broad lower dorsum, decreased tip projection, thick lobular skin, wide lobule, abundant subcutaneous fatty tissue, alar flaring, a retracted columella, and small osteocartilaginous framework. The lower lateral cartilages are often weak and thin. Because of these anatomical features and aesthetics between different racial and ethnic group there are different types of rhinoplasties which patients demand according to the racial and ethnic group. Augmentation rhinoplasty, nasal tip surgery for decreased tip projection and lengthening the short nose are the most performed rhinoplasties in Korea. For the augmentation rhinoplasty, I personally use alloplastic material such as silicone and Goretex for dorsal augmentation, autogenous materials such as septal or ear cartilage for tip augmentation. For the surgical approach, I use endonasal approach for the dorsal augmentation, open rhinoplasty for the dorsal and tip surgery. For the correction of decreased tip projection not only various suture technique but also grafts such as strut graft, cap graft, and shield grafts are used. For the lengthening of the short nose, extended septal graft (ESG) is used. In this symposium, I would like to present and discuss the characteristics of the Korean nose, the surgical approach and technique of augmentation rhinoplasty, implant materials, surgical techniques and methods for nasal tip surgeries which are applied to Korean nose and extended septal graft for correction of short nose. Differences between the Asian and Western nose have been well described in the literature. The typical Asian nose is characterized by a broad lower dorsum, decreased tip projection, thick lobular skin, wide lobule, abundant subcutaneous fatty tissue, alar flaring, a retracted columella, and small osteocartilaginous framework. The lower lateral cartilages are often weak and thin. Because of these anatomical features and aesthetics between different racial and ethnic group there are different types of rhinoplasties which patients demand according to the racial and ethnic group. Augmentation rhinoplasty, nasal tip surgery for decreased tip projection and lengthening the short nose are the most performed rhinoplasties in Korea. For the augmentation rhinoplasty, I personally use alloplastic material such as silicone and Goretex for dorsal augmentation, autogenous materials such as septal or ear cartilage for tip augmentation. For the surgical approach, I use endonasal approach for the dorsal augmentation, open rhinoplasty for the dorsal and tip surgery. For the correction of decreased tip projection not only various suture technique but also grafts such as strut graft, cap graft, and shield grafts are used. For the lengthening of the short nose, extended septal graft (ESG) is used. In this symposium, I would like to present and discuss the characteristics of the Korean nose, the surgical approach and technique of augmentation rhinoplasty, implant materials, surgical techniques and methods for nasal tip surgeries which are applied to Korean nose and extended septal graft for correction of short nose.

Nasal Base Narrowing

To evaluate the role of the combined alar base excision technique in narrowing the nasal base and correcting excessive alar flare. The study included 60 cases presenting with a wide nasal base and excessive alar flaring. The surgical procedure combined an external alar wedge resection with an internal vestibular floor excision. All cases were followed up for a mean of 32 (range, 12-144) months. Nasal tip modification and correction of any preexisting caudal septal deformities were always completed before the nasal base narrowing. The mean width of the external alar wedge excised was 7.2 (range, 4-11) mm, whereas the mean width of the sill excision was 3.1 (range, 2-7) mm. Completing the internal excision first resulted in a more conservative external resection, thus avoiding any blunting of the alar-facial crease. No cases of postoperative bleeding, infection, or keloid formation were encountered, and the external alar wedge excision healed with an inconspicuous scar that was well hidden in the depth of the alar-facial crease. Finally, the risk of notching of the alar rim, which can occur at the junction of the external and internal excisions, was significantly reduced by adopting a 2-layered closure of the vestibular floor (P = .01). The combined alar base excision resulted in effective narrowing of the nasal base with elimination of excessive alar flare. Commonly feared complications, such as blunting of the alar-facial crease or notching of the alar rim, were avoided by using simple modifications in the technique of excision and closure.

Rhinoplastic techniques for the nasal valve for the patient with sleep apnea

Treatment of nasal blockage is necessary to facilitate therapy of obstructive sleep apnea and improve continuous positive airway pressure tolerance. The importance of the nasal valve in controlling inspiratory airflow has been well documented. Defining the nasal valve region and correlating physiology with its anatomic and surgical findings can be confusing. Reliable interpretation of the different types of nasal valve dysfunction can be correlated with effective surgical repair to reduce nasal airway resistance. A simplified approach to standardizing surgical treatment of nasal valve problems is presented.

A Simplified Approach to Alar Base Reduction

To simplify the approach and diagnosis of alar base reduction, suggest a treatment algorithm, and evaluate the long-term outcomes of 3 different techniques used separately or in conjunction with one another. Retrospective review of 124 patients seen in a private practice by a single surgeon. Patients ranged in age from 15 to 59 years (mean age, 30.4 years). Patients were undergoing primary (83.9%) or revision (16.1%) procedures. Of the 124 patients undergoing alar base reduction, 31 (25%) were male and 93 (75%) were female. Average follow-up was 2 years. All patients underwent wedge excision, and for 64 patients (51.6%), this was the only technique used on the alar base. Alar wedge and nasal sill excisions were performed in 21 patients (16.9%); 19 (15.3%) underwent alar wedge excision with V-Y advancement, and 20 (16.1%) underwent alar wedge excision, nasal sill excision, and V-Y advancement. Thirty-one patients (25.0%) received dermabrasion for notable postoperative incision scars. The data represent the senior author's outcomes of alar base reductions over the past 20 years. The 3 techniques we describe have been effective when used alone or in combination in reducing alar flare and in narrowing the nasal base. Patients should be counseled that dermabrasion of the wedge excision areas in the alar-facial groove may be necessary to diminish visible scars.

The Long-term Effects of Alar Base Reduction

To statistically analyze the long-term results of alar base reduction after rhinoplasty. Among a consecutive series of 100 rhinoplasty cases, 19 patients required alar base reduction. The mean (SD) follow-up time was 11 (9) months (range, 2 months to 3 years). Using preoperative and postoperative photographs, comparisons were made of the change in the base width (width of base between left and right alar-facial junctions), flare width (width on base view between points of widest alar flare), base height (distance from base to nasal tip on base view), nostril height (distance from base to anterior edge of nostril), and vertical flare (vertical distance from base to the widest alar flare). Notching at the nasal sill was recorded as none, minimal, mild, moderate, and severe. Changes in vertical flare (P<.05) and nostril height (P<.05) were the only significant differences seen in the patients who required alar reduction. No significant change was seen in base width (P=.92), flare width (P=.41), or base height (P=.22). No notching was noted. It would have been preferable to study patients undergoing alar reduction without concomitant rhinoplasty procedures, but this approach is not practical. To our knowledge, the present study represents the most extensive attempt in the literature to characterize and quantify the postoperative effects of alar base reduction.

Primary Correction of Unilateral Cleft Lip Nasal Deformity in Asian Patients: Anthropometric Evaluation

Previously it was thought that primary correction of nasal deformity in cleft lip patients would cause developmental impairment of the nose. It is now widely accepted that simultaneous correction of the cleft lip nasal deformity has no adverse effect on nasal growth. Thus, the authors tried to evaluate the results of primary correction of cleft lip in Asian patients. Of 412 cases of cleft lip, 195 cases were corrected by means of the conventional method from June of 1992 to June of 1997, and 217 cases were corrected by simultaneous rhinoplasty from July of 1997 to October of 2001. The average patient age was 3 months. Photographs and anthropometric evaluation were used to evaluate the results. Nasal tip projection, columellar length, and nasal width were measured in 60 randomized normal children, 30 randomized children treated with the conventional method, and 30 randomized children with primary nasal repair. Data were analyzed using t tests, and the level of significance was 5 percent (p < 0.05). In cases of simultaneous repair, nasal tip projection and columellar length were increased 24.8 percent and 28.8 percent, respectively. Nasal width was increased 12.3 percent in the cases of simultaneous repair and 12.6 percent in the cases without primary rhinoplasty. Simultaneous repair of cleft lip and nasal deformity in Asian patients showed that more symmetry of nostril and nasal dome projection and better correction of buckling and alar flaring were achieved. More balanced growth and development of the alar complex was achieved, and no interference with nasal growth was encountered.

A more effective alar cinch technique

Secondary changes of the nasolabial region after the Le Fort I osteotomy procedure are well known and include widening of the alar base of the nose, upturning of the nasal tip, flattening and thinning of the upper lip, and downturning of the commissures of the mouth. Of these postsurgical changes, widening of the alar base of the nose probably is the most common. Surgical techniques can modify undesirable secondary changes.1,2 To reorient the displaced perinasal musculature and to control alar base width after maxillary osteotomies, many have advocated that an alar-base cinch suture be used in addition to other adjunctive procedures (eg, anterior nasal spine reduction, nasal floor reduction, and V-Y suturing) before incision closure.1-5 The cinch procedure that is commonly recommended involves the use of a slowly absorbed or nonabsorbable suture such as polyglycolic acid to engage the periosteum and nasalis muscles lateral and inferior to each ala of the nose. The suture is then tied down firmly beneath the nasal aperture in the midline approximating the alars and reorienting these structures.3-5 Tension placed on this suture is judged by comparison with presurgical measurements made after nasal intubation. Performing the cinch as described, however, is often difficult and has several pitfalls. First, to perform a proper and symmetric cinch, the surgeon must not only first find the fibroareolar tissue, grasp it with an Adson forceps, and engage it with the suture but must also perform the procedure in exactly the same way for the opposite alar. Otherwise, after placing tension on the suture, the alars will not be pulled symmetrically. In our experience, we have noted that failure to engage either the proper site or equal bulks of tissue on both sides results in unequal traction on the alars, leading to horizontal discrepancies. This will yield asymmetric nostrils. In addition, if the suture needle engages the fibroareolar tissue at higher or lower levels in comparison to each other, tightening the suture will result in one alar base being pulled down lower than the other, leading to vertical discrepancies of the alar bases. We present a modified and more reliable symmetric cinch technique to prevent alar flaring after maxillary surgery.

Alar setback technique: a controlled method of nasal tip deprojection.

To describe an alar cartilage-modifying technique aimed at decreasing nasal tip projection in cases with overdeveloped alar cartilages and to compare it with other deprojection techniques used to correct such deformity. Selected case series. University and private practice settings in Alexandria, Egypt. Twenty patients presenting for rhinoplasty who had overprojected nasal tips primarily due to overdeveloped alar cartilages. All cases were primary cases except for one patient, who had undergone 2 previous rhinoplasties. An external rhinoplasty approach was used to set back the alar cartilages by shortening their medial and lateral crura. The choice of performing a high or low setback depended on the preexisting lobule-to-columella ratio. Following the setback, the alar cartilages were reconstructed in a fashion that increased the strength and stability of the tip complex. Subjective evaluation included clinical examination, analysis of preoperative and postoperative photographs, and patient satisfaction. Objective evaluation of nasal tip projection, using the Goode ratio and the nasofacial angle, was performed preoperatively and repeated at least 6 months postoperatively. A low setback was performed in 16 cases (80%) and a high setback in 4 (20%). The mean follow-up period was 18 months (range, 6-36 months). The technique effectively deprojected the nasal tip as evidenced by the considerable postoperative decrease in values of the Goode ratio and the nasofacial angle. No complications were encountered and no revision surgical procedures were required. The alar setback technique has many advantages; it results in precise predictable amounts of deprojection, controls the degree of tip rotation, preserves the natural contour of the nasal tip, respects the tip support mechanisms, increases the strength and stability of nasal tip complex, preserves or restores the normal lobule-to-columella proportion, and does not lead to alar flaring. However, the technique requires an external rhinoplasty approach and fine technical precision.

Surgery of the nasal tip.

The nasal tip is considered most difficult area in entire rhinoplasty. The shape of the nasal tip is altered primarily by changes of lower lateral cartilages. or by badly performed surgery. For the assessment of the tip, its shape must be considered in relationship to the rest of the nose and face. Various types of tip deformities may be encountered. Tip may be overprojected, underprojected, bulbous or retruded columella may be deformed or there may be alar flaring. Tip surgery should be properly planned and accomplished meticulously to achieve pleasing results. Delivery flap technique provides excellent exposure and can deal with most of the tip deformities successfully.

Nasolabial morphology after Le Fort I osteotomies Effect of alar base suture

This paper describes the effect of an alar base suture in an attempt to gain control of the alar base flaring associated with maxillary advancement and/ or maxillary impaction. The suture did reduce alar flaring but it also increased the nasolabial angle. The suture did not significantly influence nasal tip projection.

Dome Truncation for Management of the Overprojected Nasal Tip

The nasal tip highlights the facial profile, and in its most aesthetic configuration subtly projects anterior to the dorsum to create a soft supratip break. Overprojection of the tip in relation to the vertical facial plane and the nasal dorsum represents one variant of nasal-facial disproportion that can adversely affect an otherwise pleasant facial appearance. Several strategies for reducing either the lateral or the medial crus to deproject the tip have been suggested. This article describes a method of direct truncation of the dome using an external rhinoplasty approach that can reliably produce tip retrodisplacement while maintaining, or enhancing, tip rotation. Tip definition and projection are optimized by precise, direct reduction of the overprojected dome region and accurate sculpting and realignment of the remaining crural units. When the tip is retrodisplaced, alar flaring can occur; therefore, alar base reduction can substantially enhance the final outcome.