What gets smaller with alar reduction? How the incision is made changes depending on flare and width

Alar reduction (nasal wing reduction) is a surgery where a portion of skin at the base of the alar (small wing of the nose) is removed to reduce the width of the nose, the flare of the alar, and the size of the nostrils[1]. What can be changed is the area around the base of the alar; the shape of the nasal tip and the height of the nose are handled by separate procedures[2]. Where the incision is made depends on whether your concern is "flare to the sides" or "the width of the nose itself"[3].

What can be changed with alar reduction?

What can be changed includes the width at the base of the alar, the lateral flare, the size of the nostrils, and asymmetry between the left and right sides. In a review article summarizing procedures on the nasal base, four representative concerns for which this surgery is needed are listed: a wide nasal base, lateral flare of the alar, large nostrils, and asymmetry in the nostrils or alar[1].

Even with the same complaint of "large alar," the type of deviation is not singular. Deformities at the base of the alar are categorized into: excess or deficiency in the horizontal direction, excess or deficiency in the vertical direction, the base being positioned too high or too low, the nasal sill (alar base) being too wide or narrow, and issues at the base of the nasal columella[1]. The design of where and how much to cut changes based on which axis the deviation is on[1].

What are the 3 cutting methods and how do they differ?

There are 3 basic cutting methods: a crescent-shaped incision following the groove at the base of the alar (external method), an incision at the base of the nostril (internal method), and a combination of both methods[1].

The crescent-shaped external excision is used to reduce the bulge of the alar, shorten the vertical length, and reduce the lateral flare as seen from the front[1]. According to textbooks, if only flare is a concern, external excision alone is sufficient; if you want to narrow the width between the left and right alars themselves, the incision at the base of the nostril should be combined[3].

A method of narrowing the base symmetrically through subcutaneous suturing without making an external incision has also been reported[4]. There is also a method of incorporating the external incision line into the incision line of the lip lift procedure (a surgery to shorten the philtrum)[4].

What type of nose is not adequately addressed by alar reduction alone?

A nose type with short nostrils and a wide base tends to be unsatisfying with alar reduction alone. In Asian rhinoplasty textbooks, it is stated that unless a procedure to increase the length of the nostrils is performed simultaneously, a beautiful shape is difficult to achieve[5].

If there is distortion at the base of the nasal septum (the wall dividing the left and right nostrils), the basic protocol is to correct it before cutting the alar[1]. Correcting the base of the nasal septum is important not only for appearance but also for maintaining the function of the nasal inlet (external nasal valve)[1].

When considering the nose as a whole, alar reduction is generally not performed in isolation but is combined with nasal tip surgery to balance the base and tip[2]. Whether a design that makes only the alar smaller while leaving the nasal tip unchanged is suitable depends on the proportions with the nasal tip[2].

What happens if you remove too much? Why it's hard to reverse

The alar is a difficult area to correct if too much is removed. Excessive removal of the alar or nostril in past rhinoplasty procedures is cited as one cause of an overly narrow base[5]. After a procedure to augment the nasal tip, the base may appear narrower[5].

When too much is filed or removed in nasal surgery, known problems include deepening of the groove at the base of the alar, the alar being pulled upward (alar retraction), and the nasal inlet becoming pinched making breathing difficult (external nasal valve collapse)[6]. The author of the review states that the best strategy is to avoid removing too much, and when correction is needed, grafting of cartilage or other materials is required[6].

Narrowing the nasal width affects not only appearance but also the airway. The reduction procedure carries the risk of narrowing the nasal cavity and making breathing difficult, so the review emphasizes the need to carefully balance appearance and breathing[4].

If your face is wide, could making the alar too small be counterproductive?

In people with a wide face, making the alar too small can sometimes make the lateral width of the face appear more prominent instead[5]. The textbook cautions that surgical decisions should prioritize harmony with the overall face rather than specific measurements[5]. The determining axis becomes "what width suits this face" rather than "narrowing by X millimeters"[5].

What to confirm at your consultation

What you want to clarify is whether your concern is "flare," "width," "nostril size," or "asymmetry," and which cutting method suits it[1]. Since the excision design is determined individually based on horizontal, vertical, superior-inferior, and nasal sill width axes, the location and amount of tissue removed varies from person to person even for the same procedure name[1].

The condition of the base of the nasal septum, the length of the nostrils, and the balance with facial width cannot be determined from an article alone[1][5]. At your consultation, have the base of the nostrils and nasal septum position examined, and confirm with your doctor whether alar reduction alone will address your concerns or whether additional procedures should be combined.