How to choose between medial and lateral methods for alar reduction: differences and limitations

The medial and lateral methods for alar reduction are selected based on which area you want to narrow. If the width of the nasal sill is the main concern, the medial approach is a candidate; if the outward flare of the ala is the main concern, the lateral approach is a candidate. However, in practice, both elements and nasal breathing are assessed together[1][2]。

What does the medial method change? — nasal sill width

The medial method primarily adjusts the area around the nasal sill (the floor of the nasal aperture) and brings the left and right nasal sills closer together[1]。It is a candidate when you want to refine the width without removing a large portion of the outer root. However, if the ala itself has a strong outward flare, adjustment by the medial method alone has limitations in achieving the desired change.

What does the lateral method change? — flare and root width

The lateral method adjusts tissue along the alar crease (the boundary between the ala and cheek) and refines the width of the outward-flaring ala and alar base[1][3]。Since the incision extends laterally, the position of the scar and skin characteristics become considerations along with the desired change. Strong quantitative comparative data on scar visibility between surgical methods was not found in the materials reviewed this time.

When is a combination approach used?

When both nasal sill width and alar flare are present, medial and lateral adjustments may be combined. Non-excisional subcutaneous suturing and nasal floor adjustments have also been reported as options, but rather than applying one method to all patients, the choice is made based on harmony between nasal aperture shape and facial width[1][2]。A textbook observation also notes that narrowing only the ala in a wide face may actually emphasize the lateral facial width[2]。

Why avoid over-reduction

An important limitation of alar reduction is that excised tissue cannot easily be restored. Textbooks emphasize preserving natural alar contours and avoiding over-reduction (narrowing too much), especially ignoring the original contour characteristics[4]。To avoid asymmetry, unnatural nasal aperture shape, and excessive narrowing, the contour to be preserved must be determined before determining the amount of tissue to excise.

Is nasal breathing a factor in decision-making?

Since the alar region is part of the external nasal valve, both appearance and alar motion during inspiration are evaluated. There is expert consensus on the diagnosis and management of nasal valve dysfunction, and functional evaluation is particularly important in people with narrowness sensation or those with previous nasal surgery[5]。The choice between medial method, lateral method, and combination is determined by the surgeon after assessing nasal aperture shape, scar position, surgical history, and nasal breathing.