Reduction of wide or flaring nostrils is often done as part of a rhinoplasty and occasionally as a stand alone nose reshaping procedure. When done as part of a rhinoplasty, it is always done as the last step in the procedure as nostril flare may appear less when nasal tip projection or rotation is increased. It is not precisely known how many rhinoplasty patients would benefit by alar reduction and its potential use in many cases is influenced by the artistic eye of the surgeon. But it clearly is of greater use in many ethnic rhinoplasties.
Known as alar base reduction, it has been done with a variety of techniques. They are most classically described as wedge excisions (curvilinear comma incision along the alar facial groove) of which there are three types. A type I wedge excision is limited to the alar base and will only reduce alar flaring. Type II wedge excisions involve both the alar base and extend into the nostril sill, which by so doing decreases both the nasal base and the nostril size. A Type III wedge excision is a Type II that extends into the nostril floor to achieve a reduction in interalar width.
There is also the simplest form of alar base reduction which is the classic wedge sill excision. (Weir wedge) The Weir technique is an alar reduction technique where 3 to 4 mms of skin is removed from the bottom and the floor sill of the nose. Weir wedges will both reduce the flare of the nostrils; however, the alar base reduction is often better as it actually removes a portion of the alar lobule as well.
Besides selection of the appropriate alar reduction method, careful surgical technique is also needed. The biggest risk of the procedure is notching and nostril deformity which can be a direct result of the incision location/tissue removal. The incisions need to be placed in the alar facial groove, proper eversion of the wound edges done and small sutures used to close the skin. Scarring is always an issue in nostril narrowing and some patients may need revisional dermabrasion for adverse scar improvement.
Beyond the issue of scars, the most common alar reduction problem is asymmetry regardless of the technique used. Measuring with calipers and loupe magnification before removal of tissue and careful reapproximation of skin edges can minimize the asymmetry risk. In some patients, exact symmetry may not always be possible. Reapproximation of the mobilized ala/nostril with deeper sutures can help prevent any wound separation which can also lead to a nostril asymmetry.
Not overly done (conservative) wedge and sill excisions are useful for the rhinoplasty patient with excessive nostril flare. Nasal sill excisions are effective for decreasing the size of a nostril and converting horizontal nostril axes to those that are more vertically oriented. What makes the nostril look natural is keeping the lateral curve of the nostril without a visible incision at the alar facial groove. Nostril reduction is a technique of millimeters that must both be done carefully and not excessively.
Dr. Barry Eppley
Indianapolis, Indiana