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Y-V alar base reduction.

Alar base reduction is an important technique for narrowing the frontal view of the nose. Candidates for alar base narrowing may have either a predisposition to excess width or a surgically created flaring of the ala as a result of tip deprojection. Historically, alar modification has consisted of the removal of tissue from inside the nostril to decrease width or from the lateral aspect of the ala to decrease flare. Although these techniques work well in many patients, they may be susceptible to an unnatural result. Internal excisions have a scar oriented perpendicular to the nostril sill, which can cause a visible notch. (1) External excisions may excessively flatten the contour of the ala, making it appear to be "stuck onto" the cheek. (2)

This article describes a new technique for narrowing the alar base that decreases the interalar width, avoids a transverse scar, and preserves the natural relationship of the ala to the cheek. In addition, because no tissue is removed, the procedure is adjustable and reversible.

First, it is necessary to mark the intended incision placement (figure 1). The design of the tissue movement is a Y-to-V advancement. Using a fine pen, decide where the new end point of the alar advancement should be. The advancement should be directed toward the anterior edge of the medial crus in order to avoid an unnatural tucking of the nasal sill into the nostril. Be sure to mark these symmetrically.

Next, use the pen to extend a line laterally that is the length of the intended advancement. From the end of this line, continue around the exterior of the ala 1 mm anterior to the alar-facial groove. This is an important detail as the groove is not a crease--it is a gentle curve. Placing the incision in the depth of the groove will result in the creation of a crease that will be a telltale sign of an incision. Putting the incision slightly onto the ala will preserve the curve of the groove while still hiding the incision in the subunit border.

Finally, return to the point at the end of the advancement and create a new limb into the vestibule, remaining in the skin.

Next, inject no more than 0.5 ml of 1% lidocaine with 1:100,000 epinephrine into the planned incision. After waiting several minutes for hemostasis, use a number 11 blade with a gentle sawing motion to incise the line just anterior to the alar-facial groove. Follow this with incisions along the other lines using a number 15 blade. Connect the vestibular incision with the alar-facial incision to completely mobilize the ala. The incision on the columella should be deep enough to accept the full thickness of the alar flap. Do not cauterize any bleeding vessels as this may cause necrosis of the fibrofatty alar tissue, resulting in deformity. The wound closure will tamponade any bleeding.

Inset the flap by placing a single 5-0 PDS suture from the base of the flap to the apex of the columellar incision. Follow this with 7-0 nylon vertical mattress sutures in the columella and alar-facial incisions. Use 5-0 fast-absorbing gut to close the incision in the vestibule. Dress the wound with petroleum jelly and instruct the patient to clean the sutures with peroxide twice per day and to apply petroleum jelly often enough to keep the wound moist. Remove the sutures after 5 to 7 days.

Figure 2 shows the result of the Y-V alar base reduction technique.

References

(1.) Warner JP, Chauhan N, Adamson PA. Alar soft-tissue techniques in rhinoplasty: Algorithmic approach, quantifiable guidelines, and scar outcomes from a single surgeon experience. Arch Facial Plastic Surg 2010;12(3):149-58.

(2.) Kridel RW, Castellano RD. A simplified approach to alar base reduction: A review of 124 patients over 20 years. Arch Facial Plastic Surg 2005;7(2):81-93.

From the Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minn.
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Title Annotation:FACIAL PLASTIC SURGERY CLINIC
Author:Hamilton, Grant S., III
Publication:Ear, Nose and Throat Journal
Date:Mar 1, 2014
Words:656
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