eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Rhinoplasty, Management of Tip Bossing: Treatment

Author: Aaron G Benson, MD, Clinical Adjunct Professor, Division of Neurotology, Department of Otolaryngology Head and Neck Surgery, University of Michigan; Consulting Staff, Toledo Ear, Nose and Throat, Inc
Coauthor(s): Ali Sepehr, MD, Staff Physician, Department of Otolaryngology, Head and Neck Surgery, University of California, Irvine; Hamid R Djalilian, MD, Associate Professor of Otolaryngology, Director of Neurotology and Skull Base Surgery, University of California Irvine Medical Center; Daniel G Danahey, MD, PhD, Consulting Staff, Michiana Eye Center and Facial Plastic Surgery; Peter Hilger, MD, Professor, Department of Otolaryngology, University of Minnesota Medical School
Contributor Information and Disclosures

Updated: Nov 19, 2008

Treatment

Surgical Therapy

Prevention is the best way to avoid nasal bossing. The ideal patient has thick skin, is older than 22 years, and does not have a bifid lobule. The surgeon must also meticulously reduce lateral alar cartilage so that overresection or division does not occur. Finally, Chang and Simons advocate stabilizing the medial and lateral crura with interdomal or medial crural sutures after a vertical dome dissection to prevent bossae.3

Even when every precaution is taken, nasal bossing may still occur. Once formed, the surgeon can augment or camouflage the unaffected side with an overlay of septal or conchal cartilage. More likely, the surgeon will shave or excise the boss while maintaining the curvature of the ala, especially if the boss is associated with increased projection of the dome (see Image 2). However, Kridel et al also advocate nonreductive solutions because shave excisions may further weaken and destabilize the framework, leading to distortion and warping in the future.4

Preoperative Details

Prior to surgery, the surgeon and patient should discuss their expectations. With the help of previous operative reports, if available, determine if the problem is a minor protuberance or a major sign of lower lateral cartilage weakness. Some authors advocate early revision surgery, while others advocate waiting at least one year postoperatively. Photographs are used to document the deformity and highlight the areas that need to be addressed.

Intraoperative Details

Bossing repair is sometimes limited to shaving or excising a protuberance of the nasal tip. When old cartilage incisions are found or when new ones are made, reapproximating cartilage incisions is best. Overlapping the 2 ends to prevent the re-creation of the bossa due to weakness at the anastomosis site is preferred. Daniel cautions the surgeon to be prepared with contingency plans in case small or nonexistent alar components preclude simple shave excision or overlap.5

If overlap is not possible, reinforcement with a cartilage graft helps to reduce the likelihood of the reappearance of a bossa and provides stabilization. Separating the buckled cartilage from the underlying vestibular skin is critical. The cartilage may rebuckle if a scar contracture of the vestibular skin persists. In some cases, weakness in the tip cartilages requires the addition of cartilage grafts to provide structure and support. Tip reconstruction is more complex and may require an external rhinoplasty approach. Ensuring the symmetry of the tip and covering any protuberances with a fascia graft, AlloDerm, or crushed-cartilage graft are vital. This surgery is an outpatient procedure with relatively little risk.

Postoperative Details

Bacitracin ointment applied to incisions combined with a 1-week course of antistaphylococcal antibiotics reduces the risk of postoperative infection. Examine the nasal tip for symmetry and contour during recovery and follow-up appointments.

Complications

Bossing repair typically involves shaving or excision. Postoperative symmetry is the greatest concern to both the patient and surgeon. This procedure requires minimal invasion and should not jeopardize the support of the nasal tip. The most common complications are postoperative tip asymmetry and, rarely, recurrence of bossing.

More on Rhinoplasty, Management of Tip Bossing

Overview: Rhinoplasty, Management of Tip Bossing
Workup: Rhinoplasty, Management of Tip Bossing
Treatment: Rhinoplasty, Management of Tip Bossing
Follow-up: Rhinoplasty, Management of Tip Bossing
Multimedia: Rhinoplasty, Management of Tip Bossing
References
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References

  1. Kamer FM, McQuown SA. Revision rhinoplasty. Analysis and treatment. Arch Otolaryngol Head Neck Surg. Mar 1988;114(3):257-66. [Medline].

  2. Parkes ML, Waller TS. Practical application of nasal asymmetries in rhinoplasty. Am J Cos Surg. 1988;5:37-43.

  3. Chang CW, Simons RL. Hockey-stick vertical dome division technique for overprojected and broad nasal tips. Arch Facial Plast Surg. Mar-Apr 2008;10(2):88-92. [Medline].

  4. Kridel RW, Yoon PJ, Koch RJ. Prevention and correction of nasal tip bossae in rhinoplasty. Arch Facial Plast Surg. Sep-Oct 2003;5(5):416-22. [Medline].

  5. Daniel R. Nasal bossae. Arch Facial Plast Surg. Sep-Oct 2003;5(5):424-6. [Medline].

  6. Adamson PA. Refinement of the nasal tip. Facial Plast Surg. Winter 1988;5(2):115-34. [Medline].

  7. Allen BC, Rhee JS. Complications associated with isotretinoin use after rhinoplasty. Aesthetic Plast Surg. Mar-Apr 2005;29(2):102-6. [Medline].

  8. Cohen S. Complications following rhinoplasty. Plast Reconstr Surg. 1956;18:213-227.

  9. Gillman GS, Simons RL, Lee DJ. Nasal tip bossae in rhinoplasty. Etiology, predisposing factors, and management techniques. Arch Facial Plast Surg. Apr-Jun 1999;1(2):83-9. [Medline].

  10. Goodwin WJ Jr, Schmidt JF. Iatrogenic nasal tip bossae. Etiology, prevention, and treatment. Arch Otolaryngol Head Neck Surg. Jul 1987;113(7):737-9. [Medline].

  11. Holt GR, Garner ET, McLarey D. Postoperative sequelae and complications of rhinoplasty. Otolaryngol Clin North Am. Nov 1987;20(4):853-76. [Medline].

  12. Kamer FM, Churukian MM, Hansen L. The nasal bossa: a complication of rhinoplasty. Laryngoscope. Mar 1986;96(3):303-7. [Medline].

  13. Klabunde EH, Falces E. Incidence of complications in cosmetic rhinoplasties. Plast Reconstr Surg. Aug 1964;34:192-6. [Medline].

  14. McCollough EG. Surgery of the nasal tip. Otolaryngol Clin North Am. Nov 1987;20(4):769-84. [Medline].

  15. Rees TD. Postoperative considerations and complications. In: Aesthetic Plastic Surgery. Rees TD, ed. Philadelphia, Pa: WB Saunders Co; 1980:337-386.

  16. Steiss CF. Errors in rhinoplasty and their prevention. Plast Reconstr Surg Transplant Bull. Sep 1961;28:276-8. [Medline].

  17. Thomas JR, Tardy ME. Complications of rhinoplasty. In: Johns ME, ed. Complications of Head and Neck Surgery. Philadelphia, Pa: BC Decker; 1986:269-270.

  18. Wise JB, Becker SS, Sparano A, et al. Intermediate crural overlay in rhinoplasty: a deprojection technique that shortens the medial leg of the tripod without lengthening the nose. Arch Facial Plast Surg. Jul-Aug 2006;8(4):240-4. [Medline].

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Further Reading

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Keywords

tip bossing, rhinoplasty, management of tip bossing, nasal tip asymmetry, bossae, septorhinoplasty, nasal bossing, nasal protuberance, nasal projection, nose job, plastic surgery, rhinoplasty, nasal tip boss, nasal tip bossing, nasal flap

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Contributor Information and Disclosures

Author

Aaron G Benson, MD, Clinical Adjunct Professor, Division of Neurotology, Department of Otolaryngology Head and Neck Surgery, University of Michigan; Consulting Staff, Toledo Ear, Nose and Throat, Inc
Aaron G Benson, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Ali Sepehr, MD, Staff Physician, Department of Otolaryngology, Head and Neck Surgery, University of California, Irvine
Ali Sepehr, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Medical Association, California Medical Association, and Triological Society
Disclosure: Nothing to disclose.

Hamid R Djalilian, MD, Associate Professor of Otolaryngology, Director of Neurotology and Skull Base Surgery, University of California Irvine Medical Center
Hamid R Djalilian, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Neurotology Society, American Society of Gene Therapy, Association for Research in Otolaryngology, Chicago Medical Society, and Illinois State Medical Society
Disclosure: Mind:Set Technologies Ownership interest Other

Daniel G Danahey, MD, PhD, Consulting Staff, Michiana Eye Center and Facial Plastic Surgery
Daniel G Danahey, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, Sigma Xi, and Triological Society
Disclosure: Nothing to disclose.

Peter Hilger, MD, Professor, Department of Otolaryngology, University of Minnesota Medical School
Peter Hilger, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and Minnesota Medical Association
Disclosure: Nothing to disclose.

Medical Editor

S Valentine Fernandes, MBBS, MB, BS, BSc(Hons), MCPS, FRCSEd, FRACS, FACS, Conjoint Senior Clinical Lecturer, Department of Otorhinolaryngology, Newcastle University; Senior Consultant Surgeon, Department of Otorhinolaryngology-Head and Neck Surgery, John Hunter, Toronto Private and Kurri Hospitals, Australia
S Valentine Fernandes, MBBS, MB, BS, BSc(Hons), MCPS, FRCSEd, FRACS, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American College of Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Dean Toriumi, MD, Department of Otolaryngology, Associate Professor, University of Illinois Medical Center
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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