Yiqing QIU,Qingfang ZHAO,Zhixiong CHEN,Yichen SHEN,Mengmeng LUO,Qiaoyun QIU,Jinghong XU

ABSTRACT Background Nasal alarplasty is an important component of esthetic rhinoplasty in Asians.The two main surgical techniques that correct alar hypertrophy by reducing the height or length often leave external scars and are associated with a high relapse rate.Methods We developed a new technique,called three-dimensional (3D) M-shaped resection,which corrects both the nasal alar height and length and simultaneously minimizes external scarring.We performed this procedure from January 2013 to September 2016 in 49 consecutive female patients diagnosed with saddle nose and nasal alar hypertrophy.Their mean age was 28.6 (range,18-40) years.All patients had previously undergone simple rhinoplasty.Nasal alar length and height,nostril length and width,and maximal nose width were analyzed preoperatively and postoperatively from photographs.Results After a mean of 9 (range,3-24) months of follow-up,surgery was considered successful in 46 women (94%) with good cosmetic effects.In three patients,nasal alar hypertrophy recurred (6 months postoperatively).There were no early complications such as hematomas,infections,skin or mucosal necrosis,or wound dehiscence.The mean reductions postoperatively were 1.7 mm and 0.9 mm for nasal alar length and height,respectively,1.6 mm for both nostril length and width,and 3.5 mm for nose width.Conclusion The 3D M-shaped resection for nasal alar hypertrophy effectively reduced hypertrophy in 94% of patients for up to 24 months,producing minimal external scars and good cosmetic effects.It is a simple and convenient technique that is an effective and safe option for nasal alarplasty.

KEY WORDS Nasal alar hypertrophy;Three-dimensional M-shaped resection;Invisible external scars

INTRODUCTION

The nose has important esthetic and functional roles[1-2].Currently,a large number of Asians,especially women,are unsatisfied with the shape of their noses and require esthetic rhinoplasty to correct irregularities such as a saddle nose or hypertrophy of the nasal alae or nasal tip.Nasal alarplasty,also commonly known as nasal alar reduction,is effective for treating nasal alar hypertrophy and narrowing the nostrils[3].The two main surgical techniques for alarplasty,reducing the length or height of the nasal alae,often leave external scars and are associated with a high relapse rate[4-6].We describe a new technique,called 3D M-shaped resection,which decreases both the length and height of the nasal alae and minimizes or eliminates external scars.

PATIENTS AND METHODS

From January 2013 to September 2016,3D M-shaped resection was used to correct nasal alar hypertrophy in 49 consecutive female patients with a diagnosis of both saddle nose and nasal alar hypertrophy.Their mean age was 28.6 (range,18-40) years.All patients underwent previous simple rhinoplasty before nasal alarplasty with 3D M-shaped resection.The patients were followed up for 3-24 months after the M-shaped resection surgery.The nasal alar length and height,nostril length and width,and nose width (at the widest point) were analyzed using photographs taken preoperatively and postoperatively (at a mean of 9 months after the operation).

Surgical Procedure

Before initiating the procedure,we drew two 3D“M”lines on the nasal floor (Fig.1A).We then resected only the skin in these marked areas within the“M”lines(Fig.1B).A small scalpel was subsequently used to cut away the excess external part of the incision along the alar groove.We used curved scissors to facilitate undermining and separation of the nasal ala from the underlying muscle and then sutured both limbs with 6-0 nylon thread (Fig.1C),submerging the knot.The skin incisions (3D“M”lines) were subsequently sutured with non-absorbable threads,achieving linear and positional alignment (Fig.1D).The non-absorbable threads were removed 7-9 days later.

RESULTS

The nasal alarplasty with 3D M-shaped resection decreased both the length and height of the nasal alae and produced external scars that were difficult to detect at the last follow-up.Figs.2 and 3 illustrate typical results in two patients.

The mean length and height of the nasal alae decreased,respectively,from 20.1 mm and 13.1 mm before surgery to 18.4 mm and 12.2 mm after surgery.Similarly,the mean length and width of the nostrils decreased,respectively,from 12.3 mm and 6.8 mm before surgery to 10.7 mm and 5.2 mm after surgery.The mean width of the nose also decreased from 39.2 mm preoperatively to 35.7 mm postoperatively.After 3-24 months of follow-up,46 (94%) of the 49 women were considered to have a successful surgery,which was consistent with the cosmetic results.Three women experienced a recurrence of nasal alar hypertrophy (6 months postoperatively).No patient developed early complications,such as infection,skin or mucosal necrosis,asymmetry,or wound dehiscence.

Fig.1 (A) Preoperative view of a classic Asian female nose,with the two 3D“M”lines on the nasal floor,marked by points.(B) Skin resection within the“M”areas.(C) Scissors were used to undermine the area through the incision,and the limbs were sutured with a 6-0 nylon thread.(D) Final results,showing skin sutures with a non-absorbable thread,which were removed 7-9 days later.

Case 1

A 22-year-old woman presented with hypertrophic nasal alae resulting in a wide nose (Fig.2A).Excess skin and soft tissues were removed from the two designated 3D“M”lines under local anesthesia.At the 8-day follow-up after surgery,both the length and height of the nasal alae and the length and width of the nostrils decreased notably(Fig.2D).The width of the nose (at the widest point),therefore,decreased remarkably.Moreover,the flaps survived without obvious scarring.

Case 2

A 32-year-old woman presented with prominent nostrils and hypertrophic nasal alae (Fig.3A-C).This patient had undergone rhinoplasty with a silicone prosthesis on the nasal dorsum 11 days previously.At the 9-day follow-up after surgery (Fig.3D-F),both the length and width of the nostrils and the width of the nose significantly decreased.No conspicuous scars or other serious complications were observed.

Case 3

Fig.2 (A-C) Preoperative views of a 22-year-old female patient.Note the prominent nasal alae.(D-F) Postoperative views 8 days after 3D M-shaped resection.

Fig.3 (A-C) Preoperative views of a 32-year-old female patient.Note the enlarged and prominent nasal alae.(D-F) Views at 9 days postoperatively.A silicone prosthesis was present on the nasal dorsum before surgery.

A 29-year-old female patient presented with hypertrophic nasal alae and a thick nasal tip (Fig.4A-C).She underwent 3D M-shaped resection to reduce the hypertrophic nasal alar base.At the 3-month follow-up after surgery (Fig.4D-F),the length and width of the nostrils decreased without obvious scarring,which means that the alar base was reduced without serious complications.The patient expressed a high level of satisfaction.

DISCUSSION

Fig.4 (A-C) Preoperative views of a 29-year-old female patient.The nasal alar base was wide and the nasal tip was hypertrophic.(D-F) Views at 3 months after 3D M-shaped resection.

Since 1892,when Robert Weir performed the first alar base reduction surgery to correct nasal flaring[7],many approaches have been developed to reduce the inter-alar distance and achieve an esthetically balanced alar base.These approaches can be divided into two types according to the location of the excision:external excision around the alar crease and internal excision from the nostrils[8].

Usually,external excision is performed to correct nasal flaring and reduce the distance between the lateral-most point on each ala,whereas internal excision is performed to preserve nostril morphology and reduce the nasal base.Complications of the existing methods include obvious scarring,tissue necrosis,asymmetry of the nasal alar base,and caudal septum deformities.

Sometimes,surgeons need to use both types of excision to achieve ideal results.However,more excisions result in more harm and a higher incidence of complications.In this study,we used an M-shaped excision to correct nasal flaring and preserve nostril morphology using one excision.Thus,we could create an esthetically balanced alar base with fewer complications such as scars and a lower incidence of nostril asymmetry.This technique requires surgeons to design an M region along the alar rim and the footplates of the crura and resect the soft tissue in this area.In view of the stereoscopic appearance of the excised tissue,we call this technique a 3D M-shaped resection.

After surgery,all measurements were decreased relative to preoperative values.The mean reductions were 1.7 mm and 0.9 mm for nasal ala length and height,respectively,1.6 mm for both nostril length and width,and 3.5 mm for nose width.Based on these data and the study by Sun et al.[9],the long-term effectiveness in reducing nasal alar hypertrophy was obvious.Only 3 (6%) of our patients experienced a recurrence of hypertrophy,which was likely due to the structure and texture of abundant sebaceous glands in the area[10].For these relapse cases,surgery appeared to produce little benefit.

In the new technique described in this study,the decision on where to draw the 3D“M”lines embodied the cosmetic surgeon’s geometric spatial perceptions and esthetic judgment.The marked lines directly determined the amount of removed tissue and removing too much or too little tissue would produce an unsatisfactory cosmetic effect.During the procedure,it was important to pay particular attention to the symmetrical characteristics and size of the nostrils.When suturing the skin incisions(the 3D“M”lines) with non-absorbable threads,it was important to achieve both linear and positional alignment to ensure an esthetically pleasing shape and avoid scar hyperplasia.

Compared with existing surgical techniques,the 3D M-shaped resection technique has three main advantages.First,this technique can decrease both the length and height of the nasal ala simultaneously,avoiding repeated operations and simultaneously minimizing external scarring.Furthermore,by adjusting the length and width of the nostrils,the nostril asymmetry can be rectified.Additionally,external scars can be hidden along the alar groove,which is esthetically appealing.Most of our patients considered their external scars inconspicuous and easily covered by normal cosmetics.One main disadvantage of the 3D M-shaped resection technique is the unnatural curve of the alar rim,which may result from inappropriate resections of the lateral alar wall.To decrease the incidence of this complication,surgeons should avoid excising excess lateral nasal alar tissue.

CONCLUSIONS

The 3D M-shaped resection for nasal alar hypertrophy is a simple and convenient technique with a high success rate(94%) for up to 24 months.It produces minimal external scars and good cosmetic effects and is a good choice for patients with nasal alar hypertrophy.

ETHICS DECLARATIONS

Ethics Approval and Consent to Participate

This study was approved by the Ethics Committee of the First Affiliated Hospital of the Zhejiang University School of Medicine.All participants provided written informed consent before study enrollment.

Consent for Publication

All the authors have consented to the publication of this article.

Competing Interests

The authors declare no conflicts of interest.The authors state that the views expressed in the article are their own and not the official position of the institution or funder.