N a s a l Ba s e S u r g e r y

Behnam Bohluli, DMDa,*, Nima Moharamnejad, DMDb,

Amin Yamani, DMDc

KEYWORDS
 Nasal base  Ethnic variation  Rhinoplasty
 Orthognathic surgery

The nasal base is an important aspect of the nose by divergences or flaring of two medial crura and
with a complex anatomic architecture comprising the amount of connective tissue between them.
a combination of cartilages, skin, connective The area above the nostrils is called the tip lobule,
tissues, and ligaments; it forms the external nasal which comprises one-third to one-half of the
valve and plays an important role in nasal airway height of the nasal base; the alar crease or alar
function. The history of nasal base surgery dates facial groove is the junction between the nose
back to 1892 when Weird introduced his tech- and face, The amount of alar tissue that extends
nique of resection of a small wedge of the alar from the alar crease is called alar flare. The width
skin. For nearly 100 years all the techniques and of the nasal base is usually the distance between
modifications were aimed at finding a way for two alar flares, and this width should ideally fall
resection of a wider volume of skin and conceal- within 2 mm of the lines that are drawn vertically
ing scar lines in normal grooves and creases. from the medial canthus. The nasal sill is an area
However, some recent studies show that all the located between the nasofacial groove and the
nasal base deformities cannot be corrected by columella (Fig. 1).
simple excision and suturing techniques. Alar Regarding the plane of the alar lobule, the axis of
release and medialization would be effective in the alar lobule, as defined by Sheen, is the position
some of these deformities. of the vertical plane of the alar lobule relative to the
This article presents an overview of conven- horizontal plane of the nasal base in frontal view;
tional concepts of alar base surgeries, which this plane is optimally slightly divergent. Excessive
have remained unchanged over many years. Indi- divergence shows that excessive flare exists and
cations and limitations of each technique are dis- that alar medialization should be planed; in some
cussed, followed by a more detailed description patients this plane is oriented vertically, which
of alar release and medialization. shows that alar base resection is contraindicated
and may result in a disproportionally narrow base
(Fig. 2).
ANATOMIC EVALUATION OF NASAL BASE
Ethnic Variations in Nasal Base Anatomy
The nasal base forms an equilateral triangle that
consists of two pear-shaped nostrils. These two Nasal base anatomy in different genders is exten-
nostrils have their long axis 45 to the long axis sively discussed in the literature; Farkas defined
of the columella, and form two-thirds of the length 5 different nostril types in different ethnic nasal
of the nasal base. The columella is located bases that were based on nostril orientation
between the two nostrils and ideally should form (Fig. 3). Standard values are usually defined based
two-thirds of the height of the nasal base, and on anthropometric measurements in the normal
oralmaxsurgery.theclinics.com

should be nearly equal to the length of the upper Caucasian female face. In African Americans
lip. The form of the columella is directly affected the projection of the tip is generally lower. The

a
Department of Oral and Maxillofacial Surgery, Buali Hospital, Azad University, Neyestan #10, Pasdaran
Avenue, Tehran, Iran
b
Craniomaxillofacial Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
c
Department of Oral and Maxillofacial Surgery, Buali Hospital, Azad University, Tehran, Iran
* Corresponding author.
E-mail address: bbohluli@yahoo.com

Oral Maxillofacial Surg Clin N Am 24 (2012) 87–94

doi:10.1016/j.coms.2011.10.009
1042-3699/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
88 Bohluli et al

PREOPERATIVE EVALUATION
Preoperative evaluation usually starts with a
comprehensive interview with rhinoplasty candi-
dates. Any history of massive scar or keloid
formation may affect the treatment plan. The
importance of the external nasal valve should be
emphasized, and overzealous excision of nostrils
must be avoided. The external nasal valve must
be closely observed during deep breathing; partial
or complete valve incompetency demands special
concern in nasal base surgeries. All the ethnical
and cultural characteristics should be borne in
mind, as dogmatic plans for reductive alar base
excisions may result in dissatisfaction. Tissue
Fig. 1. Nasal tip lobule is the area above the nostrils, excisions in nasal base surgery, in contrast to
which makes up one-third to one-half of the height other rhinoplasty maneuvers, are irreversible.
of the nasal base (a); nostrils (b) have an angulation
Life-size photography is an integral part of preop-
of 45 to the long axis of the columella (c); the junc-
tion of nasal skin and cheek is the nasofacial groove
erative evaluations. Photographic analysis should
(d); the amount of tissue that extends from the naso- be done in at least in two directions, frontal and
facial groove is alar flare (e); the area between the na- basal views being the minimum requirement
sofacial groove and columella is the nasal sill (f); and for a thorough photographic evaluation. Deep-
the distance between two alar flares is the nasal breathing photography easily documents most of
width (g). the external nasal valve incompetence and may
be added to the routine preoperative photo series.
columella is short and nostrils round. The interalar
to intercanthal ratio is 1.25:1 in females and 1.3:1
DYNAMIC CHANGES IN NASAL BASE
in males; the nasal base is therefore relatively short
ANATOMY DURING RHINOPLASTY
and excessive alar flaring exists.
In Middle Eastern noses support of lower lateral The width of the nasal base may change consider-
cartilages is weak. Mild alar flaring, nostril asymme- ably in some tip-plasty maneuvers, as during de-
try, large ala, and widened alar base are commonly projecting techniques alar width and alar flare
encountered. Conservative alar base surgery is may increase; conversely, in a projecting nasal
usually indicated in this group of patients. tip the width of nasal base is decreased, and struc-
In Asian noses the interalar distance is generally tural grafting techniques such as alar contouring
wider than the intercanthal distance. Severe grafts and lateral crural strut grafts may potentially
alar flare and horizontally oriented nostrils are increase alar flare (Fig. 4). Some of these potential
commonly seen. changes may be predicted preoperatively and be

Fig. 2. Axis of alar lobule may be vertical (A), divergent (B), and convergent (C).
 Nasal Base Surgery 89

Fig. 3. Ethnic variations in nostril axis. (Data from Farkas LG, Hreczko TA, Deutsch CK. Objective assessment of
standard nostril types—a morphometric study. Ann Plast Surg 1983;11(5):381–9.)

considered in the treatment plan for nasal base NASAL BASE CONSIDERATIONS IN
surgery, though frequent intraoperative judgments SIMULTANEOUS RHINOPLASTY AND
are necessary to obtain the best results; if any ORTHOGNATHIC SURGERY
doubt exists the nasal base surgery may be post-
poned or a second office-based surgery under Simultaneous orthognathic surgery and rhino-
local anesthesia carried out a few weeks or plasty is frequently performed by oral and maxillo-
months after initial surgery. facial surgeons. It is generally accepted that
LeFort I osteotomy widens the nasal base and
increases alar flares. Widening of the alar base
may occur in all types of LeFort I osteotomies,
but is more often seen in LeFort I impactions and
anterior advancements. These changes are bene-
ficial in some patients with narrow noses, but may
attenuate the situation in cases with poor tip
support and wide nasal bases. Many procedures
are performed to overcome these effects; first an
effort is made to form a new wider bed by trimming
the anterior nasal spine and/or pyriform aperture
and lowering the floor of the nose to make enough
space for facial soft tissues in their new skeletal
framework. The effects and stability of alar cinch
suture in reorientation of widened alar walls after
LeFort osteotomies is extremely controversial;
however, in cases of necessity it may be done
through alar base incisions.

OPERATIVE TECHNIQUES IN NASAL BASE

Fig. 4. Nasal width and flare may change during SURGERY
rhinoplasty. If the nose is deprojected, width and flare
increase (a) and when projection increases, width and Alar base surgery is usually the final step in rhino-
flare decrease (b). plasty. A caliper is used to recheck all the
90 Bohluli et al

dimensions. Columellar disharmonies may affect

the nostril size and shape and may affect sill
dimensions, so these are usually adjusted before
any other nasal base procedure. Dimension of
columellar width is sometimes corrected during
fixation of the columellar strut. If further columellar
correction is necessary it is usually done at this
stage. The width of the sill on both sides should
be determined, then the amount of alar flare is re-
assessed. Next, incision designs are planed and
incision lines are marked by surgical pens, then
local anesthetic with vasoconstrictor is injected
in incision lines. After 10 to 15 minutes one of the
following techniques may be applied for alar
base surgery.

Narrowing Wide Columella

The width of columella is directly affected by
distance and divergence of medial crural foot
plates and the amount of connective tissue
between them. To shape the columellar base
Fig. 6. Two stab incisions are made on both sides of
a stab incision is made on both lateral sides of
the columella, and a mattress suture is done using
columellar base. A horizontal mattress suture is a straight needle.
performed through two stab incisions; the suture
is tightened gradually and tied when a suitable
Wedge Resection
width of columella is achieved, then the stab inci-
sions are closed with 6-0 nylon suture. This In this technique a small wedge of skin is resected
maneuver will affect the surface and orientation from lateral aspect of alar skin. The inferior border
of nostrils (Figs. 5–7). of incision must be located in the nasofacial

Fig. 5. Columellar deformities may affect nostril Fig. 7. Postoperative view of the same patient in basal
shape and orientation. view.
 Nasal Base Surgery 91

groove, and the superior border may be placed A normal flaring nostril is much more pleasing in
up to 3 mm over inferior to the incision line. appearance than a visible scar and distorted nasal
Incisions are usually started with a no. 11 blade base, therefore the amount of excised tissue
then continued with a no. 15 blade. Care should should be minimal and closure should be done
be taken not to enter vestibular linings. Incision meticulously without any tension.
lines are sutured with 6-0 nylon sutures. In wedge
resection all efforts are made to hide the incisions Nostril Sill Resection
in normal creases and shadows of the nose. Care
If the nasal base is too wide or the circumference
must be taken during the procedure to ensure
of nostrils is large, sill resection is indicated. In
a minimal amount of skin should be excised,
this technique two parallel markings are made in
bearing in mind the possibility of visible scarring
the nostril sill, then this small part of sill is resected.
(Fig. 8).
The incision lines are precisely sutured with 6-0
nylon sutures (Fig. 9).
Indications for wedge resection
Important points in nostril sill resection
1. To reduce excessive alar flare. Alar flare is the In most cases incision lines do not enter the nasal
amount of alar tissue that extends from the na- vestibule; vestibular incisions are rarely indicated
sofacial groove; excessive alar tissue is some- when there is a plan to reduce the size of nostrils.
times diagnosed in preoperative analysis or Sill resection does not diminish excessive flare,
occurs in deprojecting procedures. and this problem should be solved by wedge
2. To refine thick bulky alar tissue. In bulky nasal resection or alar medialization.
walls the nostrils are usually small, so refining Incisions should not enter medially to the colu-
procedures are usually planned to reduce the mellar base, otherwise notching or distortion may
tissues without entering the nasal sill and vesti- occur. Asymmetric alar bases may be corrected
bule. In this technique the lateral nasal wall is by unequal excision of alar base tissue on two
refined without the size and shape of nostrils sides.
being affected.
3. To reduce the height of the lateral nasal wall. Combination of Wedge and Sill Resection
This technique reduces the height of lateral
In some patients both excessive flare and wide
nasal walls, but should not be replaced by
nasal base are seen. In these cases a combination
known standard deprojecting methods.
of wedge and sill excision may be used (Fig. 10).

Important points in wedge resection Lateral Wall Debulking (Rim Excision)

Incision lines are usually hidden in the nasofacial When lateral nasal walls of the nose are thick and
groove, although in a modification that was bulky, debulking procedures are indicated. To
defined by Sheen, the inferior incision line is perform this technique an elliptical surface of
placed 1 mm superior to the nasofacial groove to
conceal the scar in normal nasal shadows and
make a curved, agreeable alar wall.

Fig. 8. Wedge resection. Two parallel incisions are Fig. 9. For sill resection, two parallel incisions are
made in the lateral nasal wall. Incision line may be made in the nostril sill; a small part of the sill is re-
placed in nasofacial groove or up to 1 mm above it. sected and meticulously sutured.
92 Bohluli et al

Fig. 10. When both excessive alar flare and sill exist,
wedge and sill excisions are combined.

medial alar wall is marked and excised with a

wedge-type incision. Incision lines usually are
based on normal rim incisions and are easily
closed with 6-0 nylon sutures.

Cinch Suture (Alar Release and Medialization)

Fig. 11. The boundaries of the pyriform ligament
In 1981 Millard first described this method for show the superior border at the nasal bone and the
correcting wide flat nostrils in normal rhinoplasty inferior border at the anterior nasal spine. Dotted
patients. He used a circumferential nonresorbable line displays the limits of this fascial network. (Data
suture through alar base incisions to medialize from Rohrich RJ, Hoxworth RE, Thornton JF, et al. The
flared alar walls. The main drawback of this pyriform ligament. Plast Reconstr Surg 2008;121(1):
technique was recurrence and scar formation. 277–81.)
Re-advent of this technique goes back to 2008,
when Rohrich performed a comprehensive that starts from the dermis of the alar incision,
anatomic study on the pyriform area and explained goes though the nasal base and columella, and
the role of pyriform ligament in translating shape enters the other sill incision site before turning
and position of alar walls. This study was the basis back to the original site. The same steps are
for more laboratory and clinical research. done for the other alar wall, then sutures are grad-
ually tightened and the alar walls medialized by
Alar Release and Medialization Techniques these sutures (Fig. 12).
Pyriform ligament Indications for alar release and medialization
This ligament originates from nasal bones, covers
the lower lateral and upper lateral cartilages, 1. Extremely wide nasal base. Alar release could
extends toward the pyriform aperture, and rea- reduce the amount of resected tissue, therefore
ches the other side at the nasal spine. It is thought the possibility of scar formation and distortion
that this ligament plays the main role in spatial will be decreased.
positioning of alar walls, and should be released 2. Vertically oriented alar lobule. In these cases
when massive medialization is required (Fig. 11). routine procedures may make a convergent
lobule and distort the nasal base.
Surgical technique and indications This technique
is usually performed through sill incisions. After Wound care of alar base incisions
performing incisions in the nasal sill, dissection is Wound care closely resembles that of other inci-
done to gain access to the pyriform aperture, sion lines in facial aesthetic surgery. Incision lines
then a periosteal elevator is inserted to detach should be closed without any tension. The wound
the pyriform ligament both inside and outside of may be continuously rinsed during suturing time;
the pyriform aperture and anterior maxilla. Each this maneuver removes any possible fibrin clots
alar wall is medialized by a circumferential suture and may help scar-free healing. The wounds are
 Nasal Base Surgery 93

Overresection of Nasal Base Tissue

A tendency to make a smaller nose may lead to
overresection of nasal tissue. It should be remem-
bered that overresection of soft tissue is extremely
difficult to undo, and if any mistake is to happen in
the treatment plan it is generally recommended
that it be on the side of underresection rather
than overresection.

Fig. 12. In alar release and medialization, classic sill SUMMARY

incisions are made with resection of a small part of
tissue, or without resection two circumferential Nasal base surgery is an extremely sensitive part
sutures are done to medialize alar walls after of rhinoplasty. Diagnosis of nasal base pathology
releasing pyriform ligament and perialar soft tissue. is usually done by clinical examination of the
The first suture picks up dermis tissue of alar wall
patient and a comprehensive assessment of life-
and passes through the nasal base and columella until
it appears in the second sill incision area, then it re-
size photographs. Alar flare excess, wide nasal
turns back to its original site. Exactly the same proce- base, and bulky alar tissues are the main problems
dure is done for the second side. Two sutures are that are confronted in nasal base surgery. Opera-
gradually tightened to medialize the two side walls tive technique is usually designed by preoperative
in a symmetric position. (Data from Gruber RP, evaluations and intraoperative judgments. If any
Freeman MB, Hsu C, et al. Nasal base reduction by doubt exists in surgical technique or amount of
alar release: a laboratory evaluation. Plast Reconstr tissue excision, it is usually recommended that
Surg 2009;123(2):709–15; and Gruber RP, Freeman nasal base surgery be postponed for a few weeks
MB, Hsu C, et al. Nasal base reduction: a treatment to months to allow better evaluation. Visible scar
algorithm including alar release with medialization.
and overresection are the main complications,
Plast Reconstr Surg 2009;123(2):716–25.)
which may be prevented by a thorough treatment
plan and a conservative surgical technique.
usually covered with an antibiotic ointment. Clear
ointments such as ophthalmic gentamicin provide
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