- Reduction of flaring rim:
First Incision: The incision follows the natural creases with the alar insertion. It is generally 1.5cm or less, the incision starts laterally and ends with the rim meeting the floor. (Fig. 10 – 1 and Fig. 17 – 25)
Second Incision: Made superior to the first incision, judging the amount of flare of the rim, but it should not be more than 0.4cm above the first incision. It joins the first incision in a triangle laterally. (Fig. 10 – 3)
- Reduction of wide floor:
Wide floor with or without flaring rim:
- The first incision. Laterally follows the alar insertions natural crease, but medially ends on the floor two to three mm medial to the rim insertion. The incised length is about 1.5cm. (Fig. 10 – 2 and Figs. 17 – 25,26)
- The second incision. If there is no flare, it starts with rim insertion to the floor and joins the first incision in a triangle laterally. If there is flaring of the rim, then a few millimeters of the rim are included in the triangular wedge. In the case of a bulky alar facial junction with normal sized nostrils, the incision is modified in a way that the skin and subcutaneous tissue are excised as an ellipse instead of as a triangular wedge to avoid nares narrowing. The first incision as of flaring rim or wide floor, the second starts at the first incision laterally, and curves in an ellipse to meet the lower incision at the edge of the rim. This will preserve the size of the nostrils and avoid compromising the airways. (Fig. 10 – 5)
- Scarring: If the incision lies at the natural crease and the wound edge accurately approximated, this is a very rare complication.
- Notching: This becomes evident if vestibular skin is not preserved.
- Asymmetry: Minor asymmetry of the nostrils is always expected and usually does not bother the patient. An obvious asymmetry should be revised.
- Airway compromise: If excessive excisions are performed, a wedge of more than 0.5cm may compromise the airways. Repair is accomplished by special flaps technique.
|Fig. 10 – 6. (A,B,C) The patient with wide nares, alar wedge resection was performed.|
|Fig. 10 – 8. (A) Alar wedge resection: The technique of new dome creation, suture fixation, columellar strut and tip graft have reduced the need for nares narrowing down to 20% of cases, because new dome creation stretches the alar sidewalls and flared nares. (B) A case of bulky alar facial junction with normal sized nostrils. The nasion is modified in a way that the skin and subcutaneous tissues are excised as an ellipsed instead of as a triangular wedge to avoid compromising the airways.|
Alar Wedge Excision