Clinical Study of Alar Anatomy and Surgery of the Alar Base

Daniel G. Becker, MD; Mark S. Weinberger, MD; Brad A. Greene, MD; M. Eugene Tardy, Jr, MD

Objectives: To analyze and quantify specific aspects of alar base anatomy and to identify anatomic configurations that may be correlated with specific surgical manipulations.

Design: Analysis in a population of patients presenting for aesthetic nasal surgery.

Setting: Facial plastic surgery practice.

Interventions: On the base view of photographic slides, observations were made on the width of the alar base, recurvature of the alar base, thickness of the alar lobule, thickness of the alar wall, and flare of the alar wall. On the lateral view, observations were made on the vertical insertion of the ala on the face (cephalic, normal, or caudal), contour of alar rim in profile (gentle S-shape or straight), size of alar lobule (small, normal, or large), and alar-columellar relations.

From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia (Dr Becker), and the Tardy Facial Plastic Surgery Institute (Dr Tardy), and the Department of Otolaryngology-Head and Neck Surgery (Dr Greene), University of Illinois at Chicago. Dr Weinberger is in private practice in Merrillville, Ind. MATERIALS AND METHODS

The photographic slides of 120 white patients who presented for facial plastic consultation with one of us (M.E.T.) were reviewed. We noted any prior nasal surgery, and these patients underwent separate evaluation. Patients with mustaches that obscured evaluation of the alar base were excluded.

All 4 photographic views (frontal, base, lateral, and oblique) were reviewed. On the base view, observations were made on the following relationships: width of the alar base, recurvature of the alar base, thickness of the alar lobule, thickness of the alar wall, and flare of the alar wall.

The alar base was considered wide if its widest dimension exceeded the intercanthal distance (Figure I ). Recurvature of the alar base was defined as none (insertion straight into the face (Figure 2, C and D, and Figure 3), normal (Figure 4, A and B), excessive, and extreme (Figure 5), which represented insertion into columella. The alar lobule was judged to be thick if it occupied greater than one fifth of the total horizontal diameter of the nasal base measured across the ala as described by Crumley 19 and thin if it was nar­rower than this. The thickness of the alar wall was judged in relation to the overall aesthetics of the nasal base.

Flare, which refers to the lateral excursion of the alar wall, is best appreciated on base view. Excessive nostril flare has been described as a portion of the ala extending significantly laterally, typically (but not always) past the alar attachment to the cheek

On the lateral view, observations were made on the following relationships: vertical insertion of the ala on the face (cephalic, normal, or caudal), contour of alar rim in profile (gentle S-shape or straight), size of alar lobule (small, normal, or large), and alarcolumellar relation, with special attention to the presence of alar hooding.

As described by Crumley, 19 vertical insertion of the ala within 2 to 3 mm above the columellarlabial junction in profile was normal. 19 23 Size of the alar lobule was judged in relation to the overall aesthetics of the nasal base. The alar-columellar re­lation was evaluated as described by Gunter et al. 24 Their categorizations of the ala as normal, high arched, or hanging and of the columella as retracted, normal, or prominent suggest 9 different possible anatomic variants based on all combinations of ala with columella (Figures 1 and 2, Figure 4 through Figure 9).

Conclusions about each observation were made by unanimous decision. After data collection, a spreadsheet program (Excel, Microsoft, Inc, Seattle, Wash ) was used to analyze the incidence of each configu­ration and any association between various features of the alar base.

Of the 120 patients, 2 men were excluded due to mustaches that prevented evaluation of the alar base. There were 25 men and 93 women. Eighteen patients (3 men and 15 women) had undergone previous rhinoplasty elsewhere and were therefore excluded from this study. One hundred patients therefore were included for analysis.

We found the following distribution of alar base features. Twenty-five patients had minimal recurvature, 60 had normal recurvature, 10 had excessive recurvature, and 5 had extreme recurvature. Twenty-seven patients had minimal alar flare, 61 had normal flare, and 12 had excessive flare. The alar lobule was thick in 5 patients, normal in 73, and thin in 22; the alar margin was thick in 7 patients, normal in 73, and thin in 20. The alar base was narrow in 7 patients, within normal limits of width in 55, and wide in 38. Thirty-seven patients had a caudal insertion of the ala, 61 had a normal insertion, and 2 had a cephalic insertion. The alar margin in lateral view had a gentle S-shape in 60 patients but was straight in 29 and excessively curved with retraction of the alar rim in 11. Twenty-one patients had a hanging ala; of these, 1 patient displayed alar hooding. Table 1 reveals the distribution with regard to alar-columellar relationship (Figures 1 and 2, Figures 4-9).

Possible correlations between various aspects of alar base anatomy were evaluated. We evaluated for a potential relation between the vertical insertion of the ala and alar-columellar relation, between the degree of recurvature of the alar margin and the width of the alar base, and between recurvature and alar flare (Table 2 and Table 3). Patients with excessive or extreme recurvature had an increased tendency to excess alar base width (Table 3); 8 (53%) of 15 patients with excessive or extreme recurvature, 23 (38%) of 60 with normal recurvature, and 7 (28%) of 25 with minimal recurvature had a wide alar base. Also, patients with minimal alar flare had an increased tendency toward minimal recurvature (Table 3). Fourteen (52%) of 27 patients with minimal alar flare, 10 (16%) of 60 with normal alar flare, and 1 (8%) of 13 with excessive alar flare had minimal recurvature. However, the data were most remarkable for the anatomic diversity seen in the study population.

Cadaver nasal dissection has shown that the alar lobule is primarily a fibrofatty structure. 25 In our report, histologic cross section demonstrated the absence of any cartilaginous structure within the alar lobule (Figure IO).

While there was a bias based on our selection of patients (albeit random) from a single surgeon's practice, our review demonstrates an anatomic diversity that precludes a routine or "by the numbers" approach to alar base reduction. Rather, the planned surgical interven­tion requires careful tailoring to fit the patient's unique anatomy. Our sampling of patient photographs demonstrates better than illustrations the diversity that exists and that must be recognized for optimal alar base reduc­tion. As with other aspects of rhinoplasty, careful analysis with precise identification of the anatomic configuration leads to the selection of an appropriate surgical approach. Our time-tested approach using this technique suggests that expected outcomes and patient satisfaction are improved by careful preoperative analysis and selection, where indicated, of an appropriate surgical approach to the alar base.

Gunter et al 24 recently described the importance of the alar-columellar relation in rhinoplasty (Figures 1 and 2, Figures 4-9). When the ala inserts caudally on the face, alar-columellar disproportion with hooding may occur. Internal fusiform resection to reduce excess alar bulk can correct this problem. Other modifications to the ala or columella can be tailored to the specific anatomic abnormality. 26 " 28

The surgeon must recognize precisely the degree of flare. This is often a characteristic that one intends to alter when performing an alar base reduction. Precise anatomic diagnosis is a prerequisite to any determination of how much alteration is required to balance the nose.

Distinctive configurations of recurvature and of vertical insertion were observed that have special implications for the surgical approach to the alar base. Farkas et al 13 described alar base configuration qualities in considerable detail in their morphometric studies and described subclasses 1A, IB, and 1C that correspond to the variation in insertion of the alar base that we have observed. However, the plastic surgical literature has made little note of these distinct variations in the white alar base. For example, whereas absence of recurvature is an unnatural appearance suggestive of operation, clearly the alar insertion in the nose not undergoing any operation can occur either straight into the face, with normal recurvature or with complete recurvature to insert into the columella.

The vertical location of the insertion has an impact on the alar-columellar relation. Furthermore, the alar subunit may insert at differing vertical heights on the face. This asymmetry should be pointed out to the patient pre-operatively (Figure 11). It was rare in our series for there to be a cephalic insertion of the ala, but it did occur (Figure 11).

The percentage of patients in a clinical practice re­quiring alar base reduction varies depending on the patient population. In our series of 100 patients, 38 had a wide alar base. Asymmetry of the alar base should be identified preoperatively so that surgical maneuvers can be directed toward improving it.

Thin alar sidewalls must be recognized. Many patients in our study had normal sidewalls, but 22 of these were thin. It is important for the surgeon to recognize this subset of patients, because patients with thin and weak alar sidewalls are at relatively higher risk for alar collapse and alar retraction with excisional maneuvers of the lateral crura (Figure 2, A and B).

While recognizing the bias inherent to the study population, the diversity of anatomic configurations that was observed and quantified herein confirms the impression developed during a 30-year surgical and clinical experience. We continue to advocate a graduated anatomic approach that relies on a precise analysis of the anatomic configuration of the patient's alar base.

Alar reduction and sculpture techniques have been well described elsewhere. 2 " 12 However, the choice of the best technique ultimately relies on a full understanding of the anatomic configuration of the patient's alar base.

To determine the planned approach and site of incisions, it is helpful to consider the following anatomic factors: the internal (medial) length, shape, thickness, and flare of the alar margin); the external (lateral) length, shape, thickness, and flare of the alar margin; the width and shape of the nostril floor and sill; the shape of the nostril aperture; the shape (anatomy) of the columella and related medial crural footplates, including the length of the medial crura and lateral flare of the medial crural footplates; and the length of the lateral sidewalls of the nose, determined by the site of insertion of the alae into the face.

Alar reduction is a compromise operation in which greater reductions potentially exact the penalty of a larger scar. The surgeon must balance this with experienced aesthetic judgment and proven scar camouflage techniques. Indications for alar base reduction exist when the anatomic proportions of the alar base are out of balance with the patient's anticipated postoperative nasal anatomy. Such a reduction is undertaken as a part of the overall plan to achieve the result desired by the patient, based on thorough preoperative evaluation and discussion with the patient. Alar modifications are typically indicated when alar flaring or excessive width of the nasal base is present, or when retropositioning of excessive tip pro­jection results in a displeasing postoperative flare. Excessively wide nostril floor dimension may also dictate the need for alar sill or nostril floor modifications.

When minimal alar reduction is needed, excision of a wedge of epithelium and soft tissue from the nostril floor.

*Does not include 1 revision.

*Does not include 1 revision rhinoplasty with this anatomy.

will only reduce the slight alar flare by reducing the dimensions of the internal (medial) border (Figure 12). The outward curve of the ala is altered, but no medial re­positioning of the alar-facial junction occurs. The dimensions of the lateral alar border remain unchanged. Subtle conservative but effective improvements are possible.

Further reduction of alar flare is accomplished by carrying the incision across the sill into the alar-facial junction. Reduction of alar flare and alar bulk can be achieved (Figure 13).

When the external (lateral) alar margin is excessive with appropriate or small internal alar margin length, conservative excision with external narrowing greater than or even without internal narrowing can reduce the flare and length of the external margin while preserving the length of the nostril and the size of the nostril aperture.

Similarly, wedge excisions that include alar base, sill, and nostril floor can reduce the external and internal diameters in a precise fashion as dictated by the anatomy (Figure 14 and Figure 1 5). Maximal alar reduction with medial repositioning is effected with a sliding alar flap (Figure 16). Reduction of the volume, curve, and flare of internal and external margins will result from this procedure, the extent of each depending on the angulation of the alar incision.

Figure 16. Sliding alar flap procedure, in which generous amounts of internal floor and external alar margin may be reduced. Often a back cut is necessary to allow the alar sidewall to advance medially.

Direct insertion of the ala into the face is an unnatural appearance that should be avoided. This appearance can be created by overexcision of the ala. However, this configuration occurs naturally (Figure 3). When the ala inserts directly into the face, anatomic configuration of the alar base may allow the surgical creation of some degree of recurvature.

If an incision across the alar-facial junction is believed to be necessary, as in patients with a cleft lip nasal deformity 11 or, occasionally, with a wide alar base inserting directly into the face, the key to avoidance or ideal camouflage of alar and nostril sill scars lies in exacting approximation of the cut edges with fast-absorbing catgut sutures, supplemented with histoacryl glue. If the excised tissue gap is large, buried, interrupted 5-0 absorbable sutures (Polydioxanone, Ethicon Inc, Somerville , NJ ) are initially placed subcutaneously to appose accurately the wound edges and relieve tension on the delicate catgut sutures. Nonabsorbable sutures are best avoided, since suture marks almost inevitably result.

Precise plastic repair of the resultant scar is essential in alar sculpturing. Abundant sebaceous glands of the alar-facial junction tend to compromise precise healing. Imprecise opposition of the cut edges may result in level discrepancies that catch shadows and diminish scar cam­ouflage. Skin sutures placed across the junction often lead to permanent suture marks, typical of any incision or overtight sutures that traverse an epithelial concavity.

Effective camouflage at the alar-facial junction may be facilitated by positioning incisions 1 to 2 mm above the alar-facial crease. The 1to 2-mm cuff facilitates exact edge-to-edge closure and avoids the problem of suturing across a concavity. This simple but critical approach to incision placement almost completely eliminates visible scars, suture marks, and widely visible sebaceous gland openings. Tissue glue may reinforce the gentle suture closure.

A basal bunching suture can help to narrow the nasal base. 12 26 This has been described in the treatment of the nasal base in nonwhite noses, which typically have a wide base and an acute nasolabial angle. The suture is placed by making small stab incisions just within the alar bases about 3 mm from the alar rim. A 3-0 polypropylene suture on a large curved needle is inserted, advanced below the medial crura just above the nasal spine to exit a stab wound at the opposite alar base, brought back, and tied at the subcutaneous site of entry. If bilateral alar base reductions are performed, the basal bunching suture not only narrows the alar base but it also blunts the nasolabial angle, making it less acute. If the suture is too tight, it will result in deformity. If it is unsatisfactory, it can be removed easily.

Accepted/or publication April 18, 1997.

Presented at the Scientific Session of the American Acad­ emy of Facial Plastic and Reconstructive Surgery, Wash­ington , DC , September 26, 1996.

Reprints: Daniel G. Becker, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolar- yngology—Head and Neck Surgery, University of Pennsylva­ nia Medical Center, 5 Ravdin Bldg, 3400 Spruce St, Phila­ delphia, PA 19104 (e-mail: beckerd@upenn.mail.med.edu).

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