Treatment of Alar Flaring
Alar flaring is a structural nasal deformity requiring surgical correction through alar base reduction techniques, not medical management. This is a cosmetic and anatomic issue involving the width and shape of the nasal base, not an inflammatory or allergic condition 1, 2.
Understanding Alar Flaring
Alar flaring represents excessive lateral displacement of the alar lobules, contributing to widening of the lower third of the nose 1. A quantitative definition has been established: an alar flare angle less than 130 degrees (measured between the line connecting the alar to the alar root point and the line connecting the alar to the pronasale) constitutes pathologic alar flaring 2. The ideal alar flare angle ranges between 130-140 degrees 2.
Surgical Treatment Options
Primary Surgical Techniques
Three basic excision patterns are available for alar base reduction 3:
Alar wedge excision: An elliptical excision placed in the alar crease that reduces the size and shortens the vertical length of the alar lobule, correcting excessive flaring on frontal view 3
Nostril sill excision: Decreases interalar distance and nostril sill length while reducing nostril size 3
Combined alar wedge and nostril sill excision: Used when both wide alar base and excessive flaring with large alar lobule are present 3
Tailoring the Approach
The excision pattern should be designed based on specific flare type according to alar rim shape on basal view analysis 1. This classification-based approach narrows the lower third of the nose without creating an operated appearance 1.
Columellar base deformities and positioning of medial crural footplates must be addressed before alar base resections 3. This is the primary step of nasal base surgery to attain aesthetic ideals and improve external nasal valve function 3.
Technical Considerations
The dynamic relationship between flare and changes in tip projection must be considered during surgical planning 1. Tip elevation procedures may be performed concurrently with alar base reduction 2. In one surgical series, all 33 patients underwent tip elevation, with 12 requiring external alar wedge excision alone and 5 requiring combined external alar wedge excision and alar base excision 2.
Expected Outcomes
External alar wedge excision can completely correct alar flares, with postoperative alar flare angles exceeding 130 degrees 2. In a series with 12-27 months follow-up (mean 16 months), all patients achieved satisfactory results with minimal complications 2. Only one patient reported an acceptable scar, with no infections or alar deformities observed 2.
Common Pitfalls to Avoid
Overzealous correction is difficult to revise and should be avoided 1. Potential complications include 4:
- Poor scarring
- Notching
- Nostril asymmetry or stenosis (external valve obstruction)
- Alar deformities ("parenthesis" or "bowling pin" deformities)
Comprehensive nasofacial analysis and systematic treatment planning are essential 4. The implications of treating columellar deformities, tip positioning, and alar-columellar discrepancies on overall lower third nasal aesthetics must be considered 4.
Non-Surgical Considerations
In cases of alar flaring following maxillary advancement or impaction surgery (Le Fort I osteotomies), an alar base suture can reduce alar flaring but will also increase the nasolabial angle 5. This suture technique does not significantly influence nasal tip projection 5.