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 configura­ tions 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 relation-

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 sepa­ rate 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, ob­ servations were made on the following relation­ ships: 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 de­ fined 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 colu­ mella. The alar lobule was judged to be thick if it oc­ cupied 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 na­ sal base.

Flare, which refers to the lateral excursion of the alar wall, is best appreciated on base view. Exces­ sive 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 (Fig­ ure 1 and Figure 2, A and B) . 20 ~ 22 Flare of the alar wall was normal if the lateral excursion of the alar wall on base view was within the aesthetically accepted normal. Minimal lateral excursion of the alar wall was also recorded (Figure 3).

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

As described by Crumley, 19 vertical insertion of the ala within 2 to 3 mm above the columellar- labial 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, nor­ mal, or prominent suggest 9 different possible ana­ tomic 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 spread­ sheet 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 mus­ taches 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 else­ where and were therefore excluded from this study. One hundred patients therefore were included for analysis.

We found the following distribution of alar base fea­ tures. Twenty-five patients had minimal recurvature, 60 had normal recurvature, 10 had excessive recurvature, and 5 had extreme recurvature. Twenty-seven patients had mini­ mal 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, nor­ mal 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 poten­ tial relation between the vertical insertion of the ala and alar-columellar relation, between the degree of recurva­ ture 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 recurva­ ture had an increased tendency to excess alar base width (Table 3); 8 (53%) of 15 patients with excessive or ex­ treme recurvature, 23 (38%) of 60 with normal recur­ vature, 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, histo- logic cross section demonstrated the absence of any car­ tilaginous structure within the alar lobule (Figure IO).

While there was a bias based on our selection of pa­ tients (albeit random) from a single surgeon's practice, our review demonstrates an anatomic diversity that pre­ cludes 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 demon­ strates better than illustrations the diversity that exists and that must be recognized for optimal alar base reduc­tion. As with other aspects of rhinoplasty, careful analy­ sis with precise identification of the anatomic configu­ ration leads to the selection of an appropriate surgical approach. Our time-tested approach using this tech­ nique suggests that expected outcomes and patient sat­ isfaction are improved by careful preoperative analysis and selection, where indicated, of an appropriate surgi­ cal approach to the alar base.

Gunter et al 24 recently described the importance of the alar-columellar relation in rhinoplasty (Figures 1 and 2, Fig­ ures 4-9). When the ala inserts caudally on the face, alar-columellar disproportion with hooding may occur. Inter­ nal 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 al­ ter when performing an alar base reduction. Precise ana­ tomic diagnosis is a prerequisite to any determination of how much alteration is required to balance the nose.

Distinctive configurations of recurvature and of ver­ tical insertion were observed that have special implica-

Figure 3. Patient with no recurvature of the alar base r

in Figure 2, C and D). This patient also has minimal alar flare.

tions for the surgical approach to the alar base. Farkas et al 13 described alar base configuration qualities in consid­ erable detail in their morphometric studies and described subclasses 1A, IB, and 1C that correspond to the varia­ tion in insertion of the alar base that we have observed. How­ ever, the plastic surgical literature has made little note of these distinct variations in the white alar base. For ex­ ample, whereas absence of recurvature is an unnatural ap­ pearance suggestive of operation, clearly the alar insertion in the nose not undergoing any operation can occur ei­ ther 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 sub- unit 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 (Fig­ ure 11).

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

Thin alar sidewalls must be recognized. Many pa­ tients in our study had normal sidewalls, but 22 of these were thin. It is important for the surgeon to recognize

Figure 5. Patient with hanging alar rim and retracted columella as seen on lateral view. This patient has extreme recurvature of the ala on base view; the ala recurve to insert essentially on the columella.

this subset of patients, because patients with thin and weak alar sidewalls are at relatively higher risk for alar col­ lapse 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 impres­ sion developed during a 30-year surgical and clinical ex­ perience. We continue to advocate a graduated ana­ tomic 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 inci­ sions, it is helpful to consider the following anatomic fac­ tors: 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 aper­ ture; the shape (anatomy) of the columella and related me­ dial 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 tech­ niques. 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. Ex­ cessively 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 di­ mensions 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 junc­ tion. Reduction of alar flare and alar bulk can be achieved (Figure 13).

When the external (lateral) alar margin is exces­ sive 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 di­ ameters 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 pro­ cedure, 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 un­ natural appearance that should be avoided. This appear­ ance 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 be­ lieved to be necessary, as in patients with a cleft lip na­ sal deformity 11 or, occasionally, with a wide alar base in­ serting 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 cat­ gut sutures, supplemented with histoacryl glue. If the ex­ cised tissue gap is large, buried, interrupted 5-0 absorb- able sutures (Polydioxanone, Ethicon Inc, Somerville , NJ ) are initially placed subcutaneously to appose accurately the wound edges and relieve tension on the delicate cat­ gut sutures. Nonabsorbable sutures are best avoided, since suture marks almost inevitably result.

Precise plastic repair of the resultant scar is essen­ tial 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 over- tight 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 1- to 2-mm cuff facilitates ex­ act edge-to-edge closure and avoids the problem of su­ turing across a concavity. This simple but critical ap­ proach to incision placement almost completely eliminates visible scars, suture marks, and widely visible seba­ ceous gland openings. Tissue glue may reinforce the gentle suture closure.

A basal bunching suture can help to narrow the na­ sal 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 polypropyl­ ene suture on a large curved needle is inserted, ad­ vanced 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 bilat­ eral alar base reductions are performed, the basal bunch­ ing 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 unsatisfac­ tory, 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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