See how modified Weir, alar base wedge excisions can be used to narrow excess nostril width and create a more refined nasal tip.

In Part 3 of his bulbous tip rhinoplasty series, Thomas Lamperti, MD, uses a novel, high definition point-of-view camera to narrate an intra-operative video that shows how he is able to narrow overly wide nostrils using an alar base excision using a wedge-based (modified Weir excision) technique. You can watch part 1 and part 2 of the series to see how Dr. Lamperti used cephalic trim and dome binding techniques to further define the nasal tip.

Video Transcript:

"This is Seattle facial plastic surgeon, Dr. Thomas Lamperti. Today I'm going to show you how we can use alar base reduction to narrow wide nostrils during rhinoplasty surgery.

To start I'll use a marking pen to mark out the natural crease where the nostril meets the cheek. I'm now using a caliper to precisely measure the amount of intervening wedge of skin that I want to remove. The amount of skin removed varies among patients but is usually about 3 to 5 millimeters. Base on this measurement I'm now designing the upper portion of the nostril incision. I'll then repeat the process on the left nostril using the same measurements in this case in order to maintain symmetry.I'm tapering the upper limb of the incision line in order to recreate the natural curvature of the ala as it meets the cheek.

Now that I've completed the skin markings I'll go back to the right nostril to begin making the skin incisions. You can see how I very carefully work along the skin markings to make sure that I stay within the natural skin crease. This careful dissection is an important part of ultimately camouflaging the scar. I'll use cautery to seal up oozing blood vessels that we encounter while we make our incisions. I then carefully dissect the tissue down and remove the skin away from the deeper facial muscles. There is no need to actually remove the muscles and so I do pay a lot of attention to avoid disrupting these muscles during the surgery itself.

Once we remove the skin I'll then use my forceps to simulate the improvement that we're going to see once we suture the incision closed. We'll now start the suturing process with a series of deep, dissolvable sutures. These are the sutures that provide the strength to our closure. The sutures themselves will disintegrate on their own after a few months. I like to use a 5-0 vicryl suture.

I'll do a series of several of these deep vicryl sutures. Once I'm happy with the wound apposition I'll move onto the outer skin closure. These sutures are very fine and dissolve after a week or two. I tend to use a 6-0 fast gut suture. Other options would be a nylon suture which would have to be removed. I've been very happy with the healing that the 6-0 fast gut provides and it is much easier on the patient in that I don't have to remove any of these very small sutures in the office as the sutures will just come out on their own.

I'll now move over to the left nostril to repeat the process. In order to maintain symmetry here it is important to perform the alar base excision consistently on both nostrils. This includes paying careful attention to scalpel placement to ensure that the same angle is used on both sides of the nose.

I find that I am using this alar wedge excision technique increasingly more often in my rhinoplasty practice. This is especially the case in patients like this one in which the primary goal is to reduce tip bulbosity. Very often in these situations a modest amount of excessive nostril width is also seen. This conservative alar wedge excision methodology allows for excellent reduction in this excess width in a very safe, consistent manner. In my experience the scar heals very well in patients of all skin colors and thicknesses. Before performing the technique I always offer the option of post-operative scar dermabrasion to smooth the scar via a sanding technique. It is extremely rare that one of my patients ever requests this once they have healed. Occasionally, it is beneficial to inject a small amount of dilute steroid into the scar during the early healing phase to help calm down any scar thickening. Even this minimal treatment is rarely needed in my experience.

Check out the rest of my Youtube channel to see the other steps used in this patient's bulbous nose rhinoplasty. You can read more about all the aspects of rhinoplasty at my rhinoplasty website Rhinoplasty in Seattle.com"