Учебники / Rhinoplasty Dissection Manual Toriumi 1999

10

Alar Base Resection

Follow the accompanying figures and text to perform alar base resections (1,2).

Th e site of incisions and the amount, deg ree , and geometry of alar red uctions depend on a host of an atom ic variations predetermined before and durin g surgery . Alth ough the sur­ geo n's aesthe tic j udgment will ultimately determine the site and degree of resection, a more precise surgical approach may be determined if several anat omic guidelines are asses sed and inte grated . Co nservatis m is mand atory to avoid overreductio n and asy mmetry, condi­ tion s that are difficult to correct satisfactorily.

As the need for reductio n increases, both the incision and exc ision become more ex ten­ sive. Alar redu ction is a co mprom ise operation, in which gre ater reductions exa ct the penalty of a larger scar. The surgeon must balance this compromi se with experienced aes ­ thetic j udgment and prov en scar-camo uflage techniques .

Skin sutures placed acro ss the alar -facial junction often lead to permanent suture marks. Effe ctive camouflage at the alarfacial junction may be facilitated by positioning incisions I mm to 2 mm above the alarfacia l junction . Skin clo sure can be pe rformed with a cyanoa crylate adhes ive (oc tyl-2 -cyanoacrylate , Dermabond ; Ethicon , Somervill e, NJ , U.S.A.).

INTERNAL NOSTRIL FLOOR REDUCTION

In patients requiring minimal alar redu ction, ex cision of a wed ge of epithelium and soft tissue from the nostril flo or only (Fig. I) will slightly reduce the alar flare by reducing the dimension of the internal (medial) border. Althou gh the outward curve of the ala is altered, no medial repo sitioning of the alar-facial junction is effected . The scar is effectively hid­ den within the nostril floor if the nostril sill is not violated. At times , the sha pe of the nos­ tril sill will determine whether this approach is appropriate. Subtle, conservative , but ef­ fective improvements are possible with this approach . Th e dimension of the lateral alar border remains unchanged.

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Figure 1. Internal nostril floor reduction will slightly reduce alar flare.

WEDGE EXCISION OF NOSTRIL FLOOR AND SILL

Furth er reduction of alar flare is accompli shed by carry ing the incision acro ss the sill in the alarfacial jun ction I mm to 2 mm abov e the alar-facial crease. Reduction of flare well as slight reduction of the alar bulk is effected (Fig. 2).

ALAR WEDGE EXCISION

If the alar development is excessive and bulb ous , excision of a wedge of ala at t alar-facial junction 1 mm to 2 mm above the alar-facial crease will reduce the overall bul iness of the alar anatomy (Fig. 3). Som e medi al repo sitioning of the alae may be effect with this maneuv er. Reduction of the overall length of the alar sidewalls occurs when ge erou s wedges are excised, ideal in the reduction of the alar flare created when corr ecti the overprojecting tip.

SLIDING ALAR FLAP

More substantial alar reduction with medi al repositioning is effected with a generous i cision abov e the alarfac ial jun ction with variou s degree s of alar excision (Fig. 4). Redu tion of th e volume, curve, and flare of both the internal and external alar margins will r sult from this procedure, the extent of each dependent on the angulation of the alar incisio A backcut placed 2 mm above the alar-facial j unction allows the alar flap to slide mediall narr owing the alar base signifi cantly .

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Figure 2. Wedge excision of nostril floor and sill conservatively reduces flare as well as al bulk.