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Page 4 of 13 Randall et al. Plast Aesthet Res 2024;11:18 https://dx.doi.org/10.20517/2347-9264.2023.115

[12]
another tissue to create a moldable graft . Erol has termed his specific technique as “Turkish Delight”, in
which he wraps his thinly diced cartilage in Surgicel, so that the mold can better adapt to adjacent and
[13]
[14]
enveloping tissues . More recently, Tasman described using diced cartilage in tissue glue . It is important
to recognize that some common cartilage softening techniques are destructive to chondrocytes and can
diminish the long-term viability of the grafts . Crushing and shaving are most likely to damage the cellular
[15]
[15]
structure of the cartilage .
Bracaglia et al. were able to correct nasal tip asymmetry in 18/20 revision rhinoplasty patients via the use of
[16]
a rainbow graft . This graft is explained in more detail as a method of correction of alar retraction.
Often, the nasal tip can appear asymmetric due to weak or unsupported lower lateral cartilages. A
columellar strut graft, while frequently used for tip projection, can also be used as an anchoring point for
weakened lower lateral cartilages. This can help to strengthen and support the structure of the nasal tip and
correct the asymmetry of the lower lateral cartilages [3,17,18] . The septal extension graft is another graft typically
used for tip support that can also help strengthen weak lower lateral cartilages and correct asymmetry by
creating a more solid foundation [19,20] . Both the columellar strut graft and the septal extension graft, if not
placed or shaped appropriately or covered with further grafting or other material, can cause nasal tip
asymmetry.

Nasal bossae
Bossa is a Latin synonym of massa for “lump” or “bump”, with bossae being the plural form. True to their
nomenclature, nasal bossae are sharp “knob-like” bumps of the lower lateral cartilage that can alter the
external appearance of the nose. Bossae can occur as natural asymmetries of the lower lateral cartilages,
though they are most frequently seen in the setting of previously performed surgery. Previous reviews have
demonstrated that bossae may be present in as many as 3%-5% of patients who have undergone primary
rhinoplasty [5,21,22] . As a surgical complication, bossae are thought to form from sharp, irregular cartilage
edges that undergo scar contracture and form a pointed bump .
[23]
The timing of bossae determines size, structure, and difficulty in treating. Earlier bossae are usually simple
irregularities in the cartilage that are appreciable through thin skin. Late bossae can form because of fibrosis
or scar contracture of sharp cartilage and adjacent tissues. There have been some suggestions in the past of
delaying bossae treatment until the irregularity is “fully declared”. However, bossae are unlikely to improve
with time, and leaving them to develop typically leads to more scar formation, resulting in a more difficult
correction, so it is suggested that these be addressed without any unnecessary delay .
[24]
Prevention
Bossae can be more noticeable in patients with thin skin over the nasal tip and thick lower lateral cartilages.
Surgical technique that minimizes trauma and unnecessary manipulation, while always worth practicing, is
especially important to use in these patients given their propensity to develop noticeable bossae.

Intralobular bifidity, defined as a widened interdomal distance, has been suggested as a significant risk
factor for bossae formation because of the possibility of the domes becoming “knuckled”, which can lead to
bossa formation . Some authors suggest that vertical dome division techniques may present the risk of
[25]
[21]
bossae formation , though this is controversial . Many surgeons advocate for the reapproximation of the
[26]
lower lateral cartilages with sutures to help prevent the widening of the domes to prevent bossa
formation [6,24] .