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Randall et al. Plast Aesthet Res 2024;11:18 https://dx.doi.org/10.20517/2347-9264.2023.115 Page 5 of 13

Cuts that create sharp cartilage edges, especially edges that face the external nasal skin, should be avoided.
These sharp edges on grafts or native cartilage can be smoothed out intraoperatively to help prevent bossae
formation, with care to not over-resect cartilage and sacrifice structural integrity in favor of smoothing out
cartilage edges. Any maneuver that can cause the lower lateral cartilages to weaken and buckle, such as
over-resection, can lead to bossae formation [6,24] .

Surgical approaches that are more invasive, such as delivery via marginal and intercartilaginous incisions,
are typically associated with more disruption of planes and handling of tissue that can increase the risk of
bossae formation. Nondelivery approaches are less disruptive, but also have the disadvantage of not being
able to easily address some deformities such as an increased interdomal width. The external approach allows
for better visualization and may make it easier to ensure symmetry and smooth or covered cartilage edges to
[24]
help prevent bossae formation . During a primary rhinoplasty, the soft cartilage from a conservative
cephalic trim can be used to camouflage potentially visible cartilage edges. Other camouflage materials such
as soft tissue, perichondrium or diced cartilage can also be used.

Correction
Properly addressing bossae surgically necessitates the complete separation of a bossa from the attached soft
tissue via undermining. This releases the scar and fibrous attachment that have helped to form the
deformity and allows the cartilage irregularity to be addressed. Bossae can be carefully trimmed with careful
suture reconstruction of the lower lateral cartilages . Shaving down or complete excision of the bossa has
[21]
been suggested in the past [27,28] , but this has fallen out of favor due to the risk of weakening the underlying
[24]
cartilage, which may lead to further complications or even recurrent bossa formation . However, excision
and reinforcement is a viable alternative. Covering materials used to camouflage the bossae, similar to those
previously discussed regarding tip asymmetries, can be used to help address bossae as well. These materials
can include fascia, perichondrium, or other soft tissue.

Injection of fillers into the nose over the top of bossae can help reduce the noticeability of sharp,
asymmetric edges or irregularities in the nose. However, injection of fillers can lead to further asymmetry of
the shape of the nose and carry the inherent risk of filler injection such as embolization and
[29]
over-injection . Additionally, it does not treat the underlying deformity and with any resorption of filler
injection, the deformity will again become noticeable, providing only a temporary fix. In addition, fillers
[30]
placed in the nose tip have resulted in infection, discoloration, skin necrosis , blindness and granuloma
[31]
formation . The risk of adverse events with nasal filler injections may also increase in post-rhinoplasty
[32]
[33]
patients .
Alar retraction
Excessive resection of the lower lateral cartilages can lead to alar retraction, an abnormal elevation of the
mid-portion of the lower lateral cartilage that can give the appearance of perpetually flared nostrils. When
viewing the profile of the nose, alar retraction also results in excessive columellar show. As many as 28% of
patients undergoing resection of the lateral crus will suffer from unfavorable alar retraction . Alar
[34]
retraction has been documented as the most common complication of rhinoplasty in the Asian nose, so
special consideration for the management of the lower lateral cartilages should be given to patients of Asian
ethnicity .
[35]

Alar retraction can also violate the appropriate function of the external nasal valve, causing dynamic nasal
obstruction. The prevention and treatment of lower lateral cartilage malpositioning can improve aesthetics
as well as nasal breathing . It is possible to improve the patency of the nose without detrimentally affecting
[36]