The alar base is a crucial component of the nose and plays a vital role in achieving an aesthetically balanced appearance. Rhinoplasty can help achieve this balance in Asian patients who often have a broader alar base [1].

Alar base surgery is predominantly performed, because the tip position needs to be finalized before definitively evaluating nasal base width and alar flaring [2].

Prior to the procedure, evaluation of the nose base is essential to assess nostril size, shape, and symmetry, as well as columella width and length, alar thickness and contour, and the relationship between columella length and lobule height. Thorough examination of the caudal septum is important to avoid nasal base distortion or tip projection loss. In the frontal view, the nasal base should approximate the intercanthal distance, comprising approximately one-fifth of the total facial width, and equal to the width of an eye. Nasal base modifications can improve nostril shape and orientation, reduce alar flaring, correct nasal hooding, and create facial symmetry and harmony. The orientation and shape of the nostrils and nasal base vary significantly among different ethnic groups, highlighting the need for customized approaches to achieve optimal results for each patient [1].

A total of 53 patients underwent alar base reduction between January 2016 and December 2022, and with regularly scheduled observations for more than 6-months were included in the study. The exclusion criteria were as follows: those who underwent alar base reduction combined with alar rim graft, alar batten graft, lateral crural strut graft, or alar reconstruction and those with a history of facial surgery or injury. Among these 53 patients, only 41 (primary: 34 cases; revision: 7 cases) were included following selection based on the abovementioned criteria. The study included 19 male and 22 female with an average age of 25.3 years (range: 17–45 years). The mean observation period was 8.3 months (range: 6–14 months; Table 1). Preoperative and 6-month postoperative photographs were obtained. Analyses were conducted regarding patients’ complications, including hypertrophic scarring, nostril asymmetry, notching, loss of alar creases, and revision. The patients’ hypertrophic scars were evaluated subjectively (unnoticeable, noticeable but acceptable, or noticeable and unacceptable) and objectively by rhinoplasty surgeons using the modified Stony Book Scar Evaluation Scale scores (Table 2) [3].

Table 1 . Demography.

	Male	Famale	Total
Number (%)	19 (46.3)	22 (53.7)	41 (100)
Mean age (yr)	22.5 (17–42)	27.9 (20–45)	25.3 (17–45)
Mean follow-up (mo)	9.36 (6–12)	7.85 (6–14)	8.3 (6–14)

Values are presented as n (%) or mean (range)..

Table 2 . The modified stony brook scar evaluation scale.

Scar category	Point
Width
Scar widening prominent, width >2 mm	0
Scar widening present, width ≤2 mm	1
No scar widening	2
Height
Prominent scar elevation	0
Scar elevation present	1
No scar elevation	2
Color (redness)
Scar prominently more red than the surrounding skin	0
Scar more red than the surrounding skin	1
Scar of the same color or lighter than surrounding skin	2
Incision line
Prominent incision line	0
Incision line present	1
Incision line absent	2

Calculations were performed using Statistical Package for the Social Sciences statistical software (version 23; IBM Corp., Armonk, NY, USA). The group demographics were compared using the independent samples t-test. Statistical significance was set at p<0.05.

Surgical technique

When performing alar base reduction, achieving symmetry is crucial and surgeons must consider the type of excision and the amount of tissue to be removed. To achieve optimal results, it is important to determine the segment of the alar base that needs to be reduced, the type and location of the excision, and the amount of tissue to be removed. There are two common types of alar base reduction and they are lateral alar reduction (type 1), which corrects long, flaring alars without a wide alar base, and nasal sill reduction (type 2), which corrects wide alar bases or excessive nostril sills without flaring.

During the procedure, the surgeon first marked the position of the sill, which was the most inferior lateral position of the nostril, and measured the width of the alar base from the center to the sill while checking for alar symmetry. The intercanthal distance was compared with alar width to determine the degree of alar flaring. If alar flaring was present, a reference line was drawn along the alar-facial sulcus (first line) and the amount of tissue to be resected was determined according to the degree of flaring. A second line was drawn outside and parallel to the reference line, and a third line was extended backward along the alar groove at the end of the reference line. If the third line was long, more tissue had to be resected to achieve an alar volume reduction, which might have resulted in visible scarring. A wedge-shaped mucosal resection was then performed in the nose by extending the reference and second lines inward to create a tapered effect.

In patients with a wide alar base, the resection amount was determined according to the width of the alar base. The second line was drawn inside and parallel to the reference line and tapered toward the outer side to meet the reference line. A wedge-shaped mucosal resection was performed in the nose by extending the reference and second lines inward to create a tapered effect.

Of the 41 patients who underwent alar base reduction, 25 (61.0%) had type 1 (alar flaring) and 16 (39.0%) had type 2 (wide alar base). The degree of visible scarring was unnoticeable in 31 patients (75.6%), noticeable but acceptable in 9 (22.0%), and noticeable and unacceptable in 1 (2.4%; Table 3; Fig. 1). The degree of scarring measured using the modified Stony Book Scar Evaluation Scale scores was 5.32±0.690 for type 1 and 5.25±0.775 for type 2. In addition, asymmetry was observed in 32 patients (78.0%) in which 19 and 13 patients had type 1 and type 2 asymmetry, respectively. Notching of the nasal sill was observed in one patient (2.4%) and blunting of the alar crease was observed in two (4.9%). No patient required revision surgery (Table 3, Fig. 2).

Figure 1. A 20-year-old male patient, noticeable but acceptable scar finding was observed during a 6-month postoperative follow-up.

Figure 2. A 23-year-old female patient, notching of the nasal sill was observed during a 6-month postoperative follow-up.

Table 3 . The complications of alar base surgery.

	Type 1 (n=25)	Type 2 (n=16)	Number (%)	p-value
Asymmetry	19	13	32 (78.0)
Notching	0	1	1 (2.4)
Alar crease blunting	2	0	2 (4.9)
Visible scar				0.173
Unnoticeable	17	14	31 (75.6)
Noticeable but acceptable	7	2	9 (22.0)
Noticeable and unacceptable	1	0	1 (2.4)

The scar severity did not differ significantly between type 1 (alar flaring) and type 2 (wide alar base).

Achieving optimal results with alar base reduction requires careful consideration of potential complications, such as scarring and asymmetry, as well as the overall benefits for the patient. Surgeons must carefully evaluate factors, such as alar flaring, nostril width, and lateral alar length, to ensure that modifications are appropriate and effective. While most patients report high satisfaction with their alar base reduction, complications such as scarring, notching, and asymmetry can occur and step-off deformities may require further treatment [1]. Alar resection along the alar-facial groove ensures better scar outcomes and hides the scar within the groove, especially in patients with a deep facial groove [4]. The alar incision is made along the alar-facial groove and then sutured using intracutaneous suture techniques. This method results in an unnoticeable scar that effectively gets concealed within the natural alar crease [5].

In our study, asymmetry was observed in 32 patients (78.0%) with 19 and 13 patients having types 1 and 2, respectively. Among them, 30 patients (93.8%) showed asymmetry in preoperative photographs. Of these, 26 patients (86.7%) had similar or improved asymmetry compared to their preoperative symmetry, while 4 (13.3%) had worsened asymmetry. It is crucial to assess asymmetry during preoperative evaluation and explain the potential occurrence of asymmetry in patients after surgery. To ensure symmetry, precise measurements and caliper use are crucial, although pre-existing nostril asymmetry may pose a challenge.

When designing alar base surgery, excessive removal of the inner nasal sill compared with the outer alar base can result in alar base notching or teardrop deformity. However, excessive removal of the inner nasal sill compared with the outer alar base can cause blunting of the alar crease, resulting in an unnatural appearance of the alar base. Therefore, careful attention is required [6,7].

Alar base surgery should be approached conservatively, because once it is performed, it cannot be easily reversed. If the amount of reduction is insufficient, an additional excision should be performed in future [8].

In conclusion, alar base reduction can yield satisfactory outcomes, but some surgeons may worry about potential complications, such as scar formation, nostril asymmetry, notching, and loss of the alar crease. Therefore, it is important to take precautions and employ meticulous techniques to minimize the risk of such complications.

This study was supported by a research fund from the Chosun University in 2020.

The author has nothing to disclose.