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Tip Grafts in Closed Rhinoplasty: Insertion andFixation Made Easy
Sir:f the closed technique is to be used, after preparing
the tip graft, the next step is to place it into a subcutaneous pocket made from one rim incision in theright or left vestibule. Sometimes this procedure may bequite difficult and troublesome and can result in graft
malposition, especially if graft fixation is to be achieved
with sutures through the skin. Such drawbacks makesome surgeons elect to use the open technique when
dealing with tip grafts.
A simple method of inserting the cartilage graft (toproject the nasal tip) is through one rim incision in oneof the vestibules. After the tip pocket is created, a section lifter (with its concave surface toward the skin)(Fig. 1) is used to guide the 6-0 nylon needle safely fromthe tip skin to the vestibule. After the needle has passed
through the cartilage graft(s) (Fig. 1), the same section
lifter is used to guide needle on its safe return route

I

Copyright ©2008 by the American Society of Plastic Surgeons126eFig. 1. (Above) Section lifter passing through one rim incision. Its
concave surface safely guides the needle from the nasal skin tothe nasal vestibule. (Below) The suture is passed through the cartilage graft.

from the vestibule to the tip skin. Pulling both suture
extremities through the tip skin will orient the graft tothe correct position in the tip subcutaneous pocket.
The suture is tied loosely over a small piece of cottonand left in place for only 24 hours.
DOI: 10.1097/01.prs.0000300221.07515.d2

João Cabas Neto, M.D.
Dario Ernesto Rodriguez Fernandez, M.D.
George da Silva Carvalho, M.D.
Clinica Aleixo Neto
Vitória, Espı́rito Santo, Brazil
Correspondence to Dr. Cabas Neto
Rua Aleixo Neto 1666
Praia do Canto 29057-200
Vitória, Espı́rito Santo, Brazil
cabas@uol.com.br

A New and Simple Marker for theTranscartilaginous Incision: The Cabas-Coffler
MarkerSir:

www.PRSJournal.com

Volume 121, Number 3 • ViewpointsW

hen performing a closed rhinoplasty using Peck’smarking technique,1 one designs the transcartilaginous incision to resemble a gull’s wing. As part ofthe technique, the initial local infiltration of anesthesia
should not distort the tip. Next, the suction tip is placedintranasally in the dome area to imprint the initial siteof the transcartilaginous incision.1 For some time, thismaneuver has proved quite difficult to perform withaccuracy, because the suction tip will only provide around and limited imprint of the externally designed
incision.
We have designed a simple marker that is able toimprint a dotted line in the vestibular skin that reflects
exactly the line that has been drawn on the externalskin. Known as the Cabas-Coffler marker (Fig. 1), it was
created from a standard Allis forceps by rasping one
side to make it smooth in order not to damage the nasal
tip skin; the opposite side (i.e., the side that will imprint
the dotted line in the nasal vestibular skin) was madesharper.
At first we used methylene blue dye to print thetranscartilaginous incision in the vestibule. Today wefind that totally unnecessary. By using the marker without any dye, a dotted line can still be obtained without
blurring the vestibular skin (Fig. 2).

Fig. 2. The marker transfers the “gull’s wing” line to the vestibular skin, thus making the incision more precise.

DOI: 10.1097/01.prs.0000300187.44113.f0

João Cabas Neto, M.D.
Hélio José Coffler, Jr., M.D.
Clinica Aleixo Neto, Vitória, Espı́rito Santo, Brazil
Correspondence to Dr. Neto
Rua Aleixo Neto 1666
Praia do Canto 29055-200
Vitória, Espı́rito Santo, Brazil
cabas@uol.com.br

REFERENCE
1. Peck, G. C. Techniques in Aesthetic Rhinoplasty, 2nd Ed. Philadelphia: J. B. Lippincott, 1990.

Fig. 1. (Left) The Allis forceps. (Right) Removing the teeth fromone side of the Allis forceps and deepening those on the opposite
side will create the Cabas-Coffler marker.

Arterial Embolization and Skin Necrosis of theNasal Ala following Injection of Dermal Fillers
Sir:T

he most common adverse effects of injection ofbiodegradable dermal fillers are bruising and erythema in the acute phase and allergic changes, abscessformation, and granulomatous change in the chronic
phase.1–3 The most serious side effect is localized tissue
necrosis, which is induced by mechanical interruptionof local vascularity, though it occurs very rarely (ninein 10,000 patients who underwent collagen
implantation).2 The only reported case of arterial embolization induced by hyaluronic acid injection involved the glabellar region.4
A 50-year-old Japanese woman with no previous history of cosmetic surgery underwent injection of hyaluronic acid gel (Restylane; Q-Med, Uppsala, Sweden)
to shape the nasal tip contour and of human tissue–
derived, reconstituted collagen matrix (Sheba; Hans
Biomed, Daejeon, South Korea) for wrinkle correctionof the upper white lip and nasolabial fold and augmentation of the upper vermilion. Immediately after
the injection, the patient had a striking pain on the left
side of her face. A few hours later she noticed reddish
discoloration from the left side of the nose and upper
lip to the glabellar region, which corresponded to thearea nourished by the angular branch of the facial
artery. By the third day of onset, blisters had appearedat the left nasal ala. When the patient consulted ourhospital on the sixth day, a gangrenous skin necrosis
measuring 1 ⫻ 1.5 cm was present on the left nasal ala(Fig. 1). Three-dimensional computed tomographic
angiography performed on the ninth day demon-127ePlastic and Reconstructive Surgery • March 2008

Fig. 2. Debridement sample. Photomicrograph of subcutaneous tissue shows intra-arterial foreign bodies (*) and thickeningof the intima (hematoxylin and eosin stain; scale bar ⫽ 300 ␮m).

Fig. 1. View of the patient on her first visit (6 days after injection).
Gangrenous skin necrosis is seen on the left nasal ala. Erythema
was seen on the whole area nourished by the angular branch of
the facial artery (i.e., the glabellar region, the left side of the nose,and the left upper lip).

strated local occlusion of the angular branch of thefacial artery and compensatory dilation of collateral
vessels such as the infraorbital artery and its daughter
branches. Intravenous administration of alprostadil(Prostandin; 120 ␮g/day) was then started, and thesurrounding erythema decreased with time. The necrosis extended to the surrounding skin and subcutaneous tissue, and was surgically removed on the twelfthday. A full-thickness skin graft taken from the postauricular area was grafted to the residual skin defect on
the day 43 and was successfully accepted.
In the present case, the alar skin resulted in massive
necrosis, despite the absence of filler injection into theala. Histopathological examination of the biopsy specimen from the nasal ala indicated intra-arterial andsubdermal deposition of foreign bodies (Fig. 2), although we could not identify whether they were Restylane or Sheba. Sharp pain and the erythema in theearly phase suggest acute and widespread embolizationof the artery. Together with the results of the threedimensional computed tomographic angiography, wediagnosed the patient as having arterial embolizationsof the angular branch and its daughter branches.
Like the glabellar region, the nasal ala may be aparticular region in which blood supply depends
strongly on a single arterial branch. Otherwise, collateral blood supply was blocked by the concurrent filler
injection to the nasal tip, which may have been a criticalfactor in this case. Although accidental intra-arterial
injection of dermal fillers is apparently rare, the po-128e

tential risk of vascular embolization should be noted,
especially when injecting into the subcutis of theglabellar region, the nasal ala, and the nasolabial
folds.
DOI: 10.1097/01.prs.0000300188.82515.7f

Keita Inoue, M.D.
Katsujiro Sato, M.D.
Daisuke Matsumoto, M.D.
Koichi Gonda, M.D.
Kotaro Yoshimura, M.D.
Department of Plastic Surgery
University of Tokyo School of Medicine
Tokyo, Japan
Correspondence to Dr. Yoshimura
Department of Plastic Surgery
University of Tokyo School of Medicine
7-3-1 Hongo, Bunkyo-Ku
Tokyo 113-8655, Japan
yoshimura-pla@h.u-tokyo.ac.jp

REFERENCES
1. Bowman, P. H., and Narins, R. S. Hylans and soft tissue augmentation. In J. Carruther and A. Carruther, Procedures inCosmetic Dermatology Series: Soft Tissue Augmentation, 1st Ed. Philadelphia: Saunders, 2005. Pp 33-54.
2. Hanke, C. W., Higley, H. R., Jolivette, D. M., et al. Abscessformation and local necrosis after treatment with Zyderm orZyplast collagen implant. J. Am. Acad. Dermatol. 25: 319, 1991.
3. Lupton, J. R., and Alster, T. S. Cutaneous hypersensitivity
reaction to injectable hyaluronic acid gel. Dermatol. Surg. 26:135, 2000.
4. Schanz, S., Schippert, W., Ulmer, A., et al. Arterial embolization caused by injection of hyaluronic acid (Restylane). Br. J.
Dermatol. 146: 928, 2002.