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. [6]
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 (see image below) while maintaining the curvature of the ala, especially if the boss is associated with increased projection of the dome. 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. [7]
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. [8]
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.
Outcome and Prognosis
As previously stated, 2.1% of rhinoplasties require bossing repair. Excision and shaving or grafting usually corrects the problem, after which no further treatment is necessary. On rare occasions, bossing recurs.
Future and Controversies
A better understanding of the etiology of bossing can lead to better methods of prevention.
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Unilateral nasal tip bossing.
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An open excision of a nasal boss.
