ALAR WEDGE EXCISION
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History:
Robert F. Weir first described alar reduction in 1892. He used an incision along the alar insertion curve. Then, Jack Joseph described his incision that transverses the nasal wall leaving a visible scar. Gustave Aufricht (a student of Joseph) in 1943, described what we use today, as a modified Weir excision. Aufricht stated that ‘nothing causes such an obvious discrepancy in harmony after rhinoplasty as oversized nostrils’.

Indications:

  1. To reduce flare of the rim.
  2. To reduce a wide nostril floor.
  3. To reduce both flaring and wide floor.

Aetiologies:

  1. Alar rim flare is seen in Blacks, Asians, Indians and even white races. It may be associated with wide tip. (Figs. 10 – 6 to 9)
  2. The flaring of the rim may result during operations due to loss of tip support, particularly when the simple technique of transcartilagenous cephalic trimming of the alar rim is applied without alar delivery and without the use of columellar and tip grafts. Some authors reported performing alar reduction in 75% or 90% of their primary rhinoplasties (Millard, Beck). The author of this book only performs the modified Weir incision in 20% of his rhinoplasties, because he routinely uses the technique of new dome creation, suture fixation, scoring, columellar strut and tip grafts unit. These manoeuvres provide excellent tip projection and support and stretch the nostril walls, preventing alar flaring. They not only prevent alar flaring intraoperatively, but also stretch and narrow the nares in patients with preoperative flaring, as the nostrils become more vertical, so a planned preoperative nares narrowing may not be needed by the end of the operation.

Surgical Techniques :

  1. Principles:
    1. Modified Weir excision should be the last step of the septorhinoplasty procedure.
    2. Modified Weir excision should be made in natural creases.
    3. Vestibular skin should be preserved to avoid notching.
    4. The ideal alar floor width is aimed to be approximately equal to the intercanthal distance.

blankFig. 10 – 1. Reduction of alar flare.

blankFig. 10 – 2. Reduction of the floor width.

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Fig. 10 – 3. The first and second incisions extend laterally into the nasolabial groove.
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Fig. 10 – 4. The infratip lobule base is about 75% of the nasal base (N.B.) width (Powell and Humphrey’s).
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Fig. 10 – 5. An elliptical excision used for reduction of bulky nasolabial junction in the presence of normal size nostrils.
  1. The infratip lobule base is about 75% of the nasal base width and its length is one third of the columella (Powell and Humphrey’s). (Fig. 10 – 4)

 

ALAR WEDGE EXCISION: Techniques

    1. 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)
    2. Reduction of wide floor:
      Wide floor with or without flaring rim:

      1. 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)
      2. 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)

Complications:

    1. Scarring: If the incision lies at the natural crease and the wound edge accurately approximated, this is a very rare complication.
    2. Notching: This becomes evident if vestibular skin is not preserved.
    3. Asymmetry: Minor asymmetry of the nostrils is always expected and usually does not bother the patient. An obvious asymmetry should be revised.
    4. 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.
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Fig. 10 – 6. (A,B,C) The patient with wide nares, alar wedge resection was performed.
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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.

Refrences
Alar Wedge Excision
 

1. Aufricht G: A few hints and surgical details in rhinoplasty. Laryngoscope 57:335, 1943.
2. Aufricht G: Joseph’s rhinoplasty with some modifications. Surg Clin Norht Am. 51:299, 1971.
3. Cinelli JA: Calibrated Weir operation. Arch Otolaryngol 74:81-83, 1961.
4. Converse JM: Reconstructive Plastic Surgery, 2nd ed. Philadelphia: W.B. Saunders, 1977. Pp. 1091-1093.
5. ellenbogen, R. Alar rim lowering. Plast. Reconstr. Surg. 79:50, 1987.
6. Gunter, J.P. the importance of the alar-columellar relationship in rhinoplasty. Presented at the American Society of Plastic and Reconstructive Surgery Annual Meeting, 1988.
7. Joseph J: Nasenplastik und sonstige gesichtsplastik nebst einem anbang uber mamaplastik. Leipzig: Curt Kabitzsch, 1931, pp 110-113.
8. Milliard R: External excisions in rhinoplasty. Brit J Plastic Surg. 12:340-348, 1959.
9. Milliard DR Jr.: Corrective rhinoplasty and augmentation mentoplasty. In Grabb WC, Smith JW, editors: Plastic surgery, ed 2, Boston, 1973, Little Brown.
10. Milliard, D.R. the alar cinch in the flat, flaring nose. Plast. Reconstr. Surg. 65:669, 1980.
11. Milstein S. editor: Joseph’shinoplasty and facial plastic surgery: Mammaplasty, Phoenix, 1987, Columella.
12. Peck GC: Techniques in aesthetic rhinoplasty, ed 2, Philadelphia, 1990, Lippincott.
13. Rees TD: Nasal plastic surgery in the Negro. Plastic Reconstr Surg 43:13-18, 1969.
14. Webster, R.C., Smith, R.C., and Kazda, G. Columella-labial changes in solution of rhinoplastic problems. Laryngoscope 95:629, 1985.
15. Weir RF: On restoring sunken noses without scarring the face. NY MED 56:449-454, 1892.

 

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