Pinched tip and bossae
A pinched tip is a nose narrowed too far at the point, so the tip looks squeezed, the sidewall above the nostril falls in, and in thin skin the cut ends of the cartilage show through as two hard points called bossae. It is the classic consequence of taking too much from the lower lateral cartilages, and the modern correction is to rebuild those cartilages rather than trim anything further.
What repeats
Four findings that hold across the literature.
It is an over-resection deformity
The review of what goes wrong in reductive rhinoplasty lists the pinched tip and bossae with the deep radix, saddle nose, inverted-V, polly-beak, alar retraction, deep alar grooves and external valve collapse, all consequences of removing too much, all answered by grafting rather than by further reduction.
Rests on: Moritz et al., when reductive rhinoplasty goes wrong · and complications and their management.
The lateral crus is the structure at fault
A lateral crus that is weak, over-narrowed, concave or malpositioned gives a pinched tip, a collapsed sidewall and an incompetent external valve at once. The lateral crural strut graft, a strip of cartilage set under the crus and carried out toward the rim, was developed for exactly that list, and a cadaveric study set out to test the anatomical claim behind it rather than take it on experience.
Rests on: Silva Filho et al., cadaveric study of the lateral crural strut graft.
One graft family answers most of it
In a secondary series in Asian patients, the same lateral crural strut graft was applied across notching, pinching, alar retraction, an incompetent external valve, a deviated tip, cephalic rotation and lateral crus malposition, deformities produced by implants, tip plasty and capsular contracture. The extended alar contour graft is the evolution of the same idea, carrying support further out along the rim.
Rests on: Kook et al., secondary rhinoplasty in Asians · Cochran, extended alar contour grafts.
Reshaping can replace resection
Where the lateral crus is long and concave rather than missing, folding it rather than cutting it is described: vertical alar folding modifies the crus and rotates the tip without removing the cartilage that would later be missed. It is a technique series, not a comparison.
Rests on: Şeneldir et al., vertical alar folding.
By what has been lost
The correction follows what is left of the cartilage.
Cartilage weakened but present
Support is added under it, a lateral crural strut graft, and the crus is repositioned rather than replaced.
Rests on: Silva Filho et al. · Kook et al..
Cartilage over-resected or missing
The crus is rebuilt, usually from septum, ear or rib, and the rim supported out to the soft triangle with an extended alar contour graft or an alar rim graft.
Rests on: Cochran · and rib cartilage grafts.
Bossae in thin skin
The visible points are the cut ends of cartilage tenting the skin. Correction means taking the edges down and camouflaging them (fascia, perichondrium or diced cartilage) because in thin skin anything with an edge shows.
Rests on: Moritz et al..
Sidewall collapse with a breathing complaint
A pinched tip and external valve collapse are the same failure seen from two sides. Where breathing is the complaint, the graft is doing functional work and the outcome should be measured that way.
Rests on: Kook et al. · and the septum and the airway.
What to ask about a pinched tip
Questions the evidence supports asking.
Is this shape, support, or skin?
A tip can look pinched because the cartilage is narrow, because it has no support and is falling in, or because thin skin is showing what is underneath. The three need different operations, and surgeons surveyed on the examination rank the tip, the nostrils and the skin among the regions they most want to assess for this deformity.
Rests on: Longino et al., what experienced surgeons examine.
Am I having trouble breathing through that side?
Sidewall collapse travels with the pinched appearance. If one nostril closes on inspiration, the operation is functional as well as aesthetic.
Rests on: Kook et al..
What is being added, and where does it come from?
The named answers are a lateral crural strut graft, an alar rim graft or an extended alar contour graft. All of them need cartilage; ask which source.
Rests on: Cochran · Silva Filho et al..
Will the graft show?
In thin skin it can. Ask what camouflage is planned over it.
Rests on: Moritz et al..
The terms, defined
The words used about this deformity.
- Pinched tip: a tip narrowed too far, with the sidewall falling in above the nostril. [40199493]
- Bossae: visible or palpable knuckles at the tip where cut cartilage edges tent thin skin. [40199493]
- Lateral crus: the outer arm of the lower lateral cartilage, running from the dome toward the cheek; the structure whose loss produces this deformity. [27277274]
- Lateral crural strut graft: cartilage set under the lateral crus to support and reposition it. [27277274]
- Extended alar contour graft: support carried further out along the nostril rim; an evolution of the strut graft. [28953723]
- Alar rim graft: a strip along the rim itself, for a retracted or collapsing margin.
- External nasal valve: the nostril and its rim; it collapses when the lateral crus cannot hold it open. [40920505]
- Vertical alar folding: folding a long, concave lateral crus rather than resecting it. [31346711]
Where else this is documented
Sources outside the journals, each one free to read.
The national guideline
The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should record about the tip and the external valve before operating, and what counts as an outcome afterwards.
Rests on: the clinical practice guideline · the plain language summary.
The surgeons' own textbook chapters
Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries four chapters on tip support and the grafts used to rebuild it. They are written for surgeons and go further into technique than a patient page should.
The reference summary
Rhinoplasty Tip-Shaping Surgery in StatPearls, on the National Library of Medicine's Bookshelf, sets out tip anatomy, the suture and graft options and the complication list in full text at no charge. The general Rhinoplasty chapter sits beside it.
The societies
- American Society of Plastic Surgeons, patient information.
- American Academy of Facial Plastic and Reconstructive Surgery, patient information.
- The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.
The trials in progress
One registered trial covers tip cartilage handling in primary rhinoplasty. No registered trial tests the correction of a pinched tip.
- Lateral Crural Steal With Columellar Strut Graft in Primary Open Rhinoplasty, recruiting, 22 participants.
What is not settled
- Incidence is unreported. The pinched tip is described as common after aggressive cephalic trimming, and nobody has counted it.
- The graft literature is technique series and one cadaveric study; there is no comparison of lateral crural strut against alar rim against extended alar contour at matched deformity. [27277274, 28953723, 40920505]
- Whether reshaping techniques such as vertical alar folding prevent the deformity that resection causes is untested against resection. [31346711]
- The archive holds little on bossae specifically; most of what is written about them sits inside broader over-resection reviews. [40199493]
Written by rhinoplasty.cc from the sources linked above, 2026-09-09.
Who publishes on revision and secondary rhinoplasty
Ranked surgeons with papers under this topic in the archive, most first.
Rod J. Rohrich (8) · Dean M. Toriumi (7) · Samuel Lin (5) · Richard E. Davis (4) · Sam P. Most (4) · Michael Lee (3) · Paul Nassif (2) · Angela Sturm (1) · Anil Shah (1) · Anita Patel (1)
The literature: Revision and secondary rhinoplasty, 181 papers. Video: Revision and secondary, 322 videos. Every technique.