Alar Reduction (Nostril Reduction): Inner, Outer or Combined Incision?

The short answer: is it the nostrils or the width of the alae?

The incision method for alar reduction depends on what needs to be reduced. An inner (internal) incision is used to make the nostrils smaller, an outer (external) incision is used to narrow the side-to-side width of the alae (the nostril wings), and a combined inner and outer incision is used when both are needed.

You can get a rough preview in front of a mirror by gently pressing both nostril wings inward with your fingertips. Notice which change you like: smaller nostrils, or a narrower overall nose width. Your answer points to the incision method that suits you.

Five reasons the nose can look wide at the base

In consultations we often hear, "My nose isn't low, but it looks spread out," or "My nose stands out in every photo." The concern may sound the same, but the cause differs from person to person.

• The alae themselves flare out to the sides
• The nostrils are round and large
• The muscles around the nose make the alae spread further when you smile
• The bridge is fine, but the tip and alae look blunt and heavy
• The skin and soft tissue of the nostril wings are thick

Whether the cause lies only in the alae, or also in the nasal tip or the columella (the column between the nostrils), decides whether alar reduction alone is enough or another procedure should be considered with it.

The three incision methods at a glance

Inner incision: when the nostrils are large

The inner incision removes tissue mainly from the inside of the nostril. The nostril opening becomes smaller by the amount removed, which suits people whose nostrils look large from the front or from below.

Because the incision line sits close to the inside of the nostril, the scar is hard to see. However, since only the inside is reduced, the effect on the overall width of the nose is limited. If the alae are also wide, an inner incision alone may leave you feeling that "my nostrils are smaller, but my nose still looks wide."

Outer incision: when the alae are wide

The outer incision removes skin from the outside of the ala to reduce the side-to-side width. It suits people whose nostril size is fine but whose nostril wings extend out to the sides, making the nose look broad and flat.

How far should the outer incision line go?

With an outer incision, the length and position of the incision line matter most. At RISE Plastic Surgery, we limit the outer incision to the shadowed underside at the base of the ala. If the incision extends higher, onto the side wall of the nostril wing, the scar can be visible from the front, and a scar in that position is difficult to improve even with further surgery.

Combined inner and outer incision: reducing nostril size and width together

If you want both smaller nostrils and a narrower width, a combined incision on the inside and outside is usually the right fit. When the nostrils are reduced from the inside and the outer incision is kept as short as possible, the amount of width that can be reduced is relatively large for the length of the scar.

The incision is designed to end within the line hidden by the natural shadow of the ala, so the scar sits where it is hard to notice from the front.

How is non-incisional alar reduction different?

The non-incisional method does not remove any skin. Instead, a very small puncture is made beside each nostril wing, and a suture is used to pull both alae inward and tie them. There is almost no visible scar and the procedure is short, about 10 to 20 minutes, but the nostrils stay the same size; only the width is drawn in by the tension of the thread.

As the mouth moves, the knot can loosen, or even if it holds, the thread can gradually cut into the tissue so that the pulling force weakens. In many cases the nose returns toward its original width over time. Because the thread pulls the alae inward, the middle of the columella can also become more prominent, making the nose look upturned. For thick or widely flaring alae, rather than choosing the non-incisional method only out of concern about scars, we first recommend an incision that removes only what is needed, within the area where the scar can be hidden.

When alar reduction alone may not be enough

Often the reason the base of the nose looks wide is actually the tip. If the tip cartilage is large and splayed and only the alae are reduced, the proportion between the alae and the tip can look off, and the tip may look even more bulbous. In this case, combining alar reduction with nasal tip cartilage binding, which brings the tip cartilage together, can refine the tip and the alae together without an implant. If the tip also needs more height, we may discuss RISE Dual Nose, which adds your own ear cartilage.

When the nostrils differ in size from side to side, we also look at the cause first. If one ala is simply larger, the larger side can be reduced more to match. But if the columella is bent or the tip cartilage leans to one side, those also need to be corrected. A difference in alar height caused by a height difference between the two sides of the face cannot be fixed with surgery, so the goal is a natural balance rather than perfect symmetry.

What recovery looks like

Our principles for minimizing scars

Skin type plays a role in scarring, but how much tissue is removed and how it is sutured matter more.

• We remove only what is needed, cleanly.
• The muscle and deeper tissue are first sutured in their correct position, which reduces the tension on the skin closure.
• The alae have many sebaceous (oil) glands, and stitches left in too long tend to leave marks, so we remove them on day 3.
• After surgery, sun protection and scar ointment help reduce pigmentation.

What to avoid for two weeks after surgery

Even after the stitches come out, the tissue underneath has not fully healed. For one to two weeks, avoid expressions that strongly stretch the area above the upper lip and the alae, and avoid rubbing or pulling on the nostril wings, as the incision could open. Normal smiling and talking are fine.

What to check during your consultation

• Whether the wide look comes from the nostrils, the alar width, or both
• Whether the outer incision is designed to end within the shadow of the ala
• How much to reduce relative to your face width and the distance between your eyes, and whether there is a risk of over-reduction
• Your skin thickness and the thickness of the nostril wings
• Whether the tip or columella means another procedure, such as cartilage binding, should be considered
• If there is asymmetry, which parts surgery can correct and which it cannot

Once alar tissue is removed, it is difficult to restore. If too much is removed, the nostrils can become narrow slits, or the alae can almost disappear so the tip looks blunter, and these results are hard to correct. That is why it matters to check not only "how much to reduce" but also "whether the reduction is only as much as suits your face."

This column is based on the explanations of alar reduction that Dr. Lim Jungtaek of RISE Plastic Surgery has written on his blog (in Korean).