The principles behind both the prevention and tratment of nasal tip bossae are reconstitute domes, reforce weak cartilages, and avoid sharp edges and irreularities. With existing bossae, mobilization and freeing of the twisted cartilage are performed first. Of key importance here is the undermining of the vestibular skin cartilage and the scarred, distorted configuration. Once the cartilage is freed from its vestibular skin, it often relaxes and is amenable to suture correction (Figure 8). There are many techniques that may be used, and the one selected is based on the physical and intraoperative findings. We strongly oppose one technique that has long been recommended: simple shaving or excision of the knob.3,5,10,12 While this may temporarily solve the problem, this removal of cartilage ultimately contributes to further weakening and distortion of the nasal tip framework. Additionally, long.term follow.up shows that disrupted lower lateral cartilages will lead to further bossae, as we have noted in patients with vertical dome division (Figure 9). Cut cartilage ends must be resutured.
The first major principle is that any weak areas that may be subject to contracture forces must be reinforced to prevent unpredictable healing. There a several options available for the repair of overresected cephalic margins. When the bossa creates a prominence, it may simply be cut laterally and an overlap suture repair of the free edges may be performed (Figure 10A). In contrast, direct anastomosis of the free edges is a less stable repair and will be subject to posoperative healing forces that may distort the repair and cause abnormal sharpness. The overlap suture technique stregthens and better contours the region. When the cartilage is flimsy and weak, alternatively a batten support graft can be added under that cartilage to give it strenght, support and normal contour (Figure 10B). Extremely fragmented or weakened alar cartilages may require total replacement with either septal or auricular cartilage interposition grafts. These should be securred according to the principle mentioned herein, in an overlapping fashion (Figure 11). A condition frequently associated with bossae is alar notching or retraction secondary to the void created by the overressexted lower lateral cartilage and the subsequent scar contracture that raises the alar margin. This condition may require composite grfting of sking and cartilage for correction.
The second major principle is that with any interrupted strip or vertical dome division procedure, continuity of the alar cartilage must be restored. When the lateral crural cartilages are interrupted, reconstitution should be acomplished with an averlap suture repair or batten graft technique. However, a previously stated, the domes must also be secured to each other should be accomplished with an overlap suture repair or batten graft technique. However, a previously stated, the domes must also be secured to each other to prevent lateral pull. To address the free cartilage edges that arise from a vertical dome division, domal continuity may be restored by sewing the cut ends together in an overlapping fashion as advocated by Adamson et al11 or with a curved interposition graft. a domal truncation technique with transdomal suturing may be used for projecting bossae13 (Figure 12).
The third major principle is to avoid sharp edges, irregularities and asymmetries. All cut cartilage edges should be smoothed. Residual asymmetries may require camouflage, preferably with crushed cartilage or with other materials such perichondrium, fascia, or acellular dermis.3,7 Parkes et al8 reviewed 1000 rhinoplasties, of wich 3% developed bossae that were attributed to cartilage adherence or thin overlying skin. The risk factors of thin skin, string cartilages, and intralobular bifidity must be recognized. In patients with strong lateralized domes, bifidity should be obliteterated by suturing the domes together. The surgeon should be observant and recognize preoperative and intraoperative asymmetries so that appropiate corrections may be made. Bossae are usually the result of an "overreductive" nasal defect, so setting reasonable goals, being conservative, and avoiding overzealous excisions are important.
Some controversy exists aver when bossae should by repaired, with some authors recommending waiting 1 to 3 years postoperatively, with the reasoning that trip changes may occur over many years.14 However, we believe that there is no reason to wait for any specified amount of time, as bossae will not disappear without intervention and are likely only to worsen with time. We therefore advocate repair as soom as possible after discovery once postoperative swelling and firmness have resolved.
