Dr. Kridel in Vogue Magazine, where he was
the only facial plastic surgeon noted for Texas.
Dr. Kridel voted top doc for women by H Texas Magazine.
Dr. Kridel named as a Super Doctor in Texas Monthly Magazine.
Many of the best articles in the rhinoplasty literature are the result f an experienced surgeon taking an in-depth look at a specific clinical problem. Kridel and colleagues1 has provided us with a gem of an article dealing with the definition, etiology, prevention, and tratment of nasal bossae. Their contribution in superb, and there is a very little that a discussant cand disagree with.
Therefore,my only option is to offer a personal perpective.
Many of the insights of Kridel and coauthors are new, and one of themost important is distinguishing between early and late presentation.
Their observation that bossae can occur early and be the result of preexisting deformities that have been accentuated by dastabilizing surgery, often from a closed delivery approach that divides the interdomal ligaments, is noteworthy. Equally, the causal effect of aggresive open suture techniqyes must be included.2,3 However, their suggested method of treatment-"repair as sonn as posible after discovery once postoperative swelling and firmness that I support. Early reoperation following primary rhinoplasty, as proposed by Gruber4 and now by Kridel et al,1 is probably fine fior the welltrained rhinoplasty suregeon with extensive secondary rhinoplasty experience. Unfortunately, most early bossae will probably occur as part of the younger surgeon's learning curve, and the opportunity to commpound the problem, leading to a tertiary reapir with fewer options, is all too real.
Which brings us to the crux of the article: Is a bossa just a ssurface bump, or is the tip of an iceberg?
Classically, a bossa was considered an isolated entity that could be shaved off under local anesthesia as a simple office revision-a concept supported by the quoted references from Parkes and Bassilios,5 Simons and Gallo,6 Tardy et al,7 and Thomas and Tardy.8 In contrast, Kridel et al1 state the following: "We stringly opose one technique that has long been recomended: simple shaving or excision of the knob." Their reasoning is that this removal leads to further weakening and distortion of the nasal tip framework. What is one to do instead?
Based on my own experience, I agree with both opinions. This stance makes preoperative analysis, palpation, and extensive discussion with the patient a critical necesity. The surgeon and the patient must answer one important question: Is the problem an isolated bossa as in Figure1A, or is it a total tip problem as in Figure 2C The treatment will cary enormously with a compound leap in complexity. In late-onset and isolated bossa, I am comfortable shaving it down judiciously through a limited rim incision and essentialy performing a small revision similar to thet suggested by Parkes. As the problem becomes more intermediary and the skin thinner, it is at this point that I wish that I were talented, closed-multilayer graft without opening the nose.
Figure 1. A 47-year-old woman had undergone rhinoplasty at age 18 years. A and C, Her primary complaint was the "points" on the end of her nose and "nose job" look. B and D, Result following a major secondary reconstruction including tip grafts.
Figure 2. Intraoperative findings of patient from a Figure 1. A, The bossae are visible prior to elevation of the skin, and following its elevation (B-D) it is obvious that there are no alar remmants beyond the middle crura. Since there were no alar remmants to be sutured or supported, the tip was reconstructed with a tip graft and a rigid struct acting asa a cap graft.
Unfortunately, I have found myself on too many occasions in the same situation as Kridel at al1 in having to fix major tip deformities. Once the tip is opened, it becomes your dilemma to solve irrespective of the status remaining alar cartilages. You may have planned to repair a divided dome or to insert a batten support only to find miniscule alar remnants, wich defy your expected treatment. Therefore, the surgeon must have a progressive approach to the remaining alar remnants. When the alar rim strips can be repaired and sutured, I am a strong advocate of the sophisticated methods used by Neu,10 which can be achieve both repair and domal definition. However, one is often stuck with a mini-rim strip and the need for major alar rim support as seen in Figure 2A. The technique that I have found that works exceptionally well is the alar extender graft used by Gunter,11 wich provides rigid rim support. On occasion, one finds virtually no remaining alar remnants, and then one is forced to turn the structure tip graft12 or isolated tip repplacement as advocated by Juri.13 Eventually, the question becomes even more complex as to whether domal definition is all that is required or whether it is necessary to provide alar rim suppert or, on certain occasions, anatomical lateral crura replacement.14 All of these problems can be compounded by a thin-scarred skin envelope with minimal septal donor material. One simply cannot open these tips expecting to find suturable or repairable alar rim strips. Thus, there is little wonder that in the middles of these total tip cases, one wishes that beveling off the bossa had been possible. The individual in Figure 1 is a classic example of a patient whose primary complaint was the little "point on the end of my nose". As seen in Figure 2, she had no significant alar remants beyond the middle crura; there was nothing to suture or to support with a batten.15 The tip was reconstructed with an open structure tip graft, and the alar rims were lowered with composite grafts.
In closing, I would urge the reader to realiza that this article is advocating an open approach to bossae correction that relies on suture repairs and batten support. It is a significantly more complez treaatment than presented in prior publications on this subject. In addition, there is no guarantee that these techniques will work in certain secondary cases with minimal or no alar remnants remaining. If one eschews shaving the bossa,one must be prepared for total tip reconstruction using innumerable sophisticated secondary techniques or risk a titanic crash as the surface bossae submerge into an iceberg requiring total tip reconstruction. The final caveat is to answer this question with the patient before the operation: Is this a minor bump, or is it a major tip deformity?
REFERENCES
Kridel RWH, Yoon PJ, Koch RJ. Prevention and correction of nasal tip bossae in rhinoplasty. Arch Facial Plast Surg. 2003;5:416-422.
The nasal tip. In: Daniel RK, ed. Aesthetic Plactic Surgery: Rhinoplasty.Boston, Mass: Little Brown; 1993:215-280.
Daniel RK. Rhinoplasty: An Atlas of Surgical Techniques. New York, NY: Springer; 2002:279-349.
Gruber R. Early surgical intervention after rhinoplasty. Aesthetic Plas Surg. 2001;21:549-551.
