Aesthetic Laser Resurfacing

70

An anthropometrically and aesthetically appeal- ing face is a summation of the bony foundation as well as the overlying soft tissue. A comprehensive study of the facial form is essential for surgical planning and volumetric restoration of the aesthetics of the face.

Procedures to address the soft-tissue rejuvenation combined with contour enhancement with or without ancillary procedure options have offered appreciable results for a total volumetric profile enhancement.

Presumably, on average, 75% of the facial wrinkles are caused by gravitational, chronological and envi- ronmental factors in varying combinations (Fig. 70.3).

Also, dermatoelastosis (atrophy of the subdermal col- lagen and loss of elasticity), dermatoheliosis (actinic damage i.e. hyperpigmentation, hyperkeratosis) and surface irregularities are not correctable by skin- tightening procedures alone.

70.1 Introduction

“Beauty is only skin deep,” this age-old adage does not hold water any more. There was once a Calvinistic view that one should age gracefully. Not any longer in this jet-age technology-driven generation, where peo- ple pop antiaging pills or receive soft-tissue fillers and neurotoxin injections in their lunch breaks, and opt for body sculpturing over the weekends in order avoid taking time off from their high-profile jobs.

During the mythological period in India (Vedas), restoration of youthfulness dates back to around 3,500 bc, when the “twin Ashwani Devataso broth- ers” used agents like salt, animal oil, alabaster, sulfur, mustard, lime stone and the like for facial rejuvena- tion (Figs. 70.1, 70.2).

Aesthetic Laser Resurfacing

Ashok Gupta, Vinay Jacob

Fig. 70.1. Twin “Ashwani Devataso” brothers from Rig Veda,

the Indian mythological treatise Fig. 70.2. Twin “Ashwani Devataso” brothers from Rig Veda:

surgeons who practiced the art of rejuvenation aside from other surgical skills

For the deep, dynamic and/or gravitational rhytids, such as those on the forehead and around the eyes or the mouth (due to attachments of muscle to the skin) that are not correctable by resurfacing of the skin and the collagen tissue remodeling alone, a combined en- doscopic browlift with soft-tissue fillers offers a more definitive treatment option.

The authors prefer a varying combination of reju- venation procedures, custom-suited for each individ- ual to achieve a volumetric restoration of facial form and aesthetics:

1. Procedures to address the skin and subdermal tis- sue a) Laser-assisted rejuvenation

b) Soft-tissue fillers c) Barbed wires

2. Procedures to address soft-tissue/skeletal contours a) Endoscope-assisted soft-tissue plication and re-

positioning

b) Rhytidoplasty (endoscope-assisted and nonsur- gical)

c) Midface resurfacing and rhytidoplasty d) Facial implant (autogenous/alloplastic) e) Osteotomies/bone lengthening 3. Ancillary procedures – Surgical

a) Auto fat grafting – nasolabial fold b) Auto fat grafting – lip enhancement c) Augmentation rhinoplasty

d) Blepharoplasty

4. Ancillary procedures – nonsurgical a) Botox

b) Skin care and cream program

The preferred combinations for facial rejuvenation are: 1. Surface: laser planing

2. Subsurface: collagen remodeling and soft-tissue repositioning

a) Tightening and plication

b) Suspension of ptotic muscle and fascia

c) Relocation of herniated dystrophic fat deposits d) Subperiosteal lift

3. Profile/regional remodeling a) Micro fat grafting b) Blepharoplasty c) Rhinoplasty

d) Follicular unit hair restoration e) Facial implants for bony enhancement

70.2

Laser Skin Rejuvenation

Lasers/intense pulsed light in aesthetic plastic surgery and dermatosurgery practices have revolutionized the concepts of facial rejuvenation during the last two de- cades. The cutting-edge technology allows predict- able and precise collagen enrichment with resultant skin rejuvenation to produce a fresh and youthful ap- pearance. Newer wavelengths, pulsing techniques and delivery devices have confirmed the resurgence of this technology in aesthetic plastic surgery.

CO

lasers have consistently proved to be the gold standard in skin rejuvenation. They have offered sev- eral advantages over chemical peel/dermabrasion by precisely ablating layers of tissue with minimal ther- mal damage. Additionally, lasers are also being used as a precision cutting tool in procedures like blepha- roplasty, rhytidoplasty and endoscopic forehead lift/

browlift.

David first reported the use of CO

laser resurfac- ing for correction of facial actinic damage. Fitzpatrick standardized protocols for the treatment of wrinkles and other surface irregularities of the skin (Figs. 70.4, 70.5).

The first author has 14 years of experience in the use of lasers in aesthetic plastic surgery on skin types III, IV and V with a long-term follow-up assessment ranging between 2 and 7 years and confirming lasting results.

Contrary to the popular belief that patients with skin types III, IV and V (darker and olive-complex- ioned skin) are at a greater risk for hyperpigmenta- tion, the author has successfully demonstrated effec- tive repigmentation and color blending in these skin types.

Fig. 70.3. A 48-year-old female patient showing dynamic and gravitational folds

70.2.1

Patient Selection

Caution must be exercised for laser resurfacing, espe- cially in patients who have severe actinic skin damage or has had previous dermabrasion or a deep chemical peel. Fitzpatrick opined that patients with actinic damage greater than grade IV always experience hy- perpigmentation after the procedure and that it could take many months for this pigmentation to resolve. It is mandatory to have a complete clinical and labora- tory evaluation, discussion and informed consent prior to undertaking laser resurfacing.

70.2.2

Contraindications/Precautions

Patients with active herpetic infection, psychoneuro- ses, alcohol and drug abuse, history of hypertrophied or keloid scars, who have been treated with Accutane within the past 6 months, or with unrealistic expecta- tions and those who cannot or will not follow postop- erative instructions should be accepted with a guard- ed prognosis (Fig. 70.6).

70.2.3

Pre-Laser Regimen

For optimum results, all patients scheduled for laser resurfacing are placed on a pre-laser therapeutic pro- gram wherein they are encouraged to avoid factors that might increase hyperpigmentation, such as ex- cessive sun exposure and/or ingestion of high-dose estrogens. A daily application of 0.025% tretinoin

and/or a-hydroxy acid and 4% hydroquinone for a period of at least 3–6 weeks appropriately prepares the patient’s skin for the surgery.

70.2.4 Anesthesia

70.2.4.1 Topical Anesthesia

EMLA (eutectic mixture of lidocaine and prilocaine 1:1 oil/water emulsion) cream anesthetizes the skin

Fig. 70.4. A 55-year-ol male patient with chronological aging and dermatohelosis: plan – full-face laser resurfacing and an- cillary procedures

Fig. 70.5. Four weeks postoperatively: full-face laser resurfac- ing and auto fat grafting – nasolabial folds and upper lip

Fig. 70.6. Patient with keloid in the neck

for laser resurfacing of relatively small areas. To be effective, a thick layer of the cream must be applied on the areas and covered with an occlusive dressing for about 60 min (Fig. 60.7).

70.2.4.2

Regional Nerve Blocks

Regional nerve blocks provide excellent anesthesia of the forehead, nose, chin and middle of the face. All regional blocks are initiated with a skin wheal of the local anesthetic solution and a small dose of a neuro- leptic drug to minimize the pain of the passing of the needle through the skin.

Forehead Nerve Block

The forehead block anesthetizes the supraorbital and supratrochlear nerves. The supraorbital rim should be palpated to feel the foramina of the supraorbital nerve. The supratrochlear nerve is 1 cm medial to the supraorbital nerve. Anesthetic solution (2 ml) is in- jected just superficial to the orbital rim above the fo- ramina and the needle is directed medially.

Nasal Nerve and Medial Cheek, and Upper-Lip Nerve Block (Infratrochlear, Infraorbital, External Nasal, Nasopalatine Blocks)

Anesthetic (1 ml) is injected on each side of the root of the nose between the medial canthus to anesthetize the infratrochlear nerve, and 0.5 ml is injected on each side of the nasal dorsum at the junction of the bony vault and the upper lateral cartilage to anesthe- tize the external nasal nerves. The infraorbital nerve

is anesthetized by injecting 1.0–2.00 ml of anesthetic solution on the maxilla, 1.0 cm below the infraorbital rim, along the middle of the pupillary line. The naso- palatine nerve is blocked by injection of 1.0 ml of an- esthetic solution on either side of the base of the colu- mella at the squamomucosal junction.

Lower Lip and Chin Nerve Block

The mental nerve is located along the same middle pupillary line, 2.0 cm above the inferior mandibular border, at the base of the first mandibular premolar.

Solution (2 ml) can be infiltrated intraorally and ex- traorally.

70.2.4.3

Sedation Analgesia and General Anesthesia

Some patients are best treated with regional nerve blocks and conscious sedation analgesia. Other pa- tients are best treated with general anesthesia.

70.2.4.4 Author’s Experience

In the author’s experience, regional nerve blocks work well for one or two areas such as forehead, cheeks or chin; however, when attempting to do a full face re- surfacing, conscious sedation analgesia is preferred.

In some of the hypersensitive patients, or those un- dergoing other combined procedures, a general anes- thesia is the best option.

Each procedure must be customized according to the wavelength and the type of laser to be used. Most CO

lasers are capable of producing a 500 mJ single pulse with a duration near the thermal relaxation time of skin. The computerized pattern generator (CPG) or scanner enables the user to treat larger areas uniformly as well as repeatedly; however, it requires a higher level of skill and training.

70.3

Surgical Technique

Drape the patient with towels soaked in saline solu- tion. First demarcate the area and wrinkles to be treated with a marking pen. Laser the shoulder or high points of the wrinkles. Try not to overlap the bubbles, although it is believed that an overlap of 10%

is acceptable. When the lased areas are covered com- pletely with gray opalescent bubbles, wipe the area with a saline-soaked sponge to remove all epidermal debris. The skin surface will appear pink, indicating papillary dermis (Fig. 70.8). Next, make a second pass, filling the entire aesthetic unit. This provides uniform coverage of the unit and is also a second pass

Fig. 70.7. Topical anesthesia for full-face resurfacing – after smallpox scarring

for the most wrinkled area. After the pass, the surface is again wiped free of any debris.

The first pass vaporizes the epidermal layer and the gray opalescent bubbles (epidermal debris) are seen.

Pink tissue (the papillary dermis) can be seen on wip- ing off these bubbles.

With the second pass, visible contraction and shrinkage of the skin is appreciated because of desic- cation of tissue and collagen shrinkage. This creates a whitish or grayish appearance, indicating further in- jury to the papillary dermis. The third and subsequent passes create a yellow or tan (chamois cloth) appear- ance, which indicates that the level of the upper re- ticular dermis has been reached. The final pass is made at right angles to the previous passes to create a homogeneous laser effect to the entire area and to eliminate residual wrinkles or irregularity. With this pass, the skin usually shrinks or contracts visibly and the skin is left with a whitish-gray or pale-yellow appearance.

Additional passes may be performed at special areas like ice-pick scars, deep small-pox marks (Fig. 70.9), etc. using an annular pattern, which al- lows us to laser only the shoulders as well as to elevate the unlasered central part owing to shrinkage of the peripheral treated areas.

Significant variations exist in the thickness of skin among the different areas of the face and between in- dividuals of different skin types and also between in- dividuals with varying amounts of actinic damage causing an appreciable thickening of the skin. To im- plement safety norms, the surgeon must be familiar

with the visual signs or feedback of the depth of tissue injury.

The number of passes and depth of treatment may vary within the aesthetic unit; however the entire unit must be feathered and treated with at least one pass for the sake of uniformity of repigmentation. That is to say, if the patient has a small area of wrinkling, the wrinkles need to be treated with multiple passes and the remaining part of the unit with fewer passes. If it is necessary in the course of the laser treatment to cross into an adjacent aesthetic unit, then that unit also should be feathered. Awareness of the varying thickness of the skin in the different facial regions will guide the surgeon in deciding the number of passes permissible within the unit (Fig. 70.10).

Fig. 70.8. Laser-assisted resurfacing – first pass with epidermal blistering

Fig. 70.9. Deep smallpox marks using an annular pattern for feathering the shoulders

Fig. 70.10. After the third pass, full-face resurfacing and bleph- aroplasty of the upper and lower eyelids (bilateral)

70.4

Elimination of Debris

Generation of char, which is created if the nonvital and desiccated debris is exposed to radiation from a laser, merits a thought when present in the surgical field. A sterile saline-soaked gauze is made use of to remove the epithelial debris and has two beneficial ef- fects. First, it prevents the occurrence of char and, second, it permits an accurate assessment of the vi- sual feedback to evaluate the clinical end point of the laser application, which is the depth of injury to the skin; hence, it is pertinent to remove all epithelial de- bris in-between passes.

Attention should also be given to the evacuation of the laser plume, which is toxic and contains air-borne contaminants, including carbon particles and DNA particles of viruses.

70.5

Wound Management

Wounds are treated in an open method. A profuse exudate is produced, which must be removed gently to avoid the formation of a crust. The patient must use continuous wet compresses for the first day and keep the skin covered with a moisturizing cream subse- quently. In the early postoperative period there may be considerable swelling, some bruising and mild dis- comfort for up to 1 week with a mild burning sensa- tion. From the third to the fifth day onwards, the treated area is soaked with water for 10–15 min, four to five times a day. It is advised not to pick or rub to remove dead skin or scabs, as this may increase the risk of scarring (Fig. 70.11).

Following each soak, a thin layer of a moisturizing ointment is applied to keep the skin moist. Patients who are not vigilant enough to avoid the development of a crust and those who pick the crust off may end up with hypertrophied scarring. A bath or shampooing is permitted, but except for use of the moisturizing ointment, the face must be kept dry. A fluid intake using a drinking straw drawn is preferred should there be any perioral edema. Vigorous or strenuous activity, which would raise the blood pressure or pulse, should be avoided for 2 weeks. The crust or scab on separation leaves the underlying skin smooth and reddish/pink in color and may last for as long as 4–6 weeks prior to blending gradually.

70.6

Post-Laser Care 70.6.1

Skin

Retin-A (0.025%) should be applied when the wound has stabilized, usually by 4–6 weeks after the laser re- surfacing. In some patients whose skin re-epithelial- izes earlier, Retin-A application can be initiated after 3 weeks. Patients who are at a higher risk for hyper- pigmentation after operation (skin types III and IV) or patients with severe actinic damage should also be treated with hydroquinone (4%) starting 4 weeks after the laser resurfacing. Hydroquinone competes with active melanogenesis and thus helps lessen the troublesome and often-persistent hyperpigmentation after resurfacing.

70.6.2

Exposure to UV Rays

Laser resurfacing removes the protective skin barrier provided by the outer layers of the skin. The patient must avoid direct exposure on the treated area at least until normal skin color has returned (up to 3 months).

This dermal injury can be prevented by the use of UV-A and UV-B blocking agents with a sun protec- tion factor of 15 to 30% and shading devices. Patients may be allowed to go outdoors after 2 weeks, provided the treated area is covered with UV-A and UV-B screening agents.

Fig. 70.11. Open wound technique – fourth day after laser treat- ment. The patient is advised not to pick or rub to remove the scabs as this may increase the risk of scarring

70.7

Sequelae/Complications

Complications are rare, if proper technique and selec- tion of laser criteria are followed. Most complications are invariably temporary. Persistent erythema re- solves in about 4–6 weeks, although in some patients it may last up to 6 months. Use of a topical steroid cream can shorten the duration of the erythematous phase. Herpes and milia are other common complica- tions and need antiviral regimens. Acne flare-up and dyschromia are less frequent sequelae (Fig. 70.12).

70.8 Laser Safety

Laser safety standards have been published by the American National Standards Institute (ANSI) for the safe use of lasers in health care facilities (Z136.3).

Laser safety is grouped into five areas, which are de- tailed in the following.

70.8.1

Electrical Safety

There must be adequate amperage and voltage supply as required by the specific laser unit and it is recom- mended that a wall outlet be provided and that exten- sion cords not be used. Liquids should be kept away from the laser to prevent spillage and a short-circuit.

70.8.2 Fire Safety

Flammable materials, including oxygen, anesthetic agents and volatile preparation solutions, drying agents, petroleum ointments or flammable plastic should be kept at bay. Sponges and swabs in the op- erative field as well as drapes must be soaking wet with sterile saline solution. The surgical drapes should be covered with wet sponges and towels. A basin of water or saline and a fire extinguisher should be kept immediately available.

In surgery of the upper airway and face, endo- tracheal tubes or plastic tubes used for delivery of oxygen should be made of nonflammable, laser-im- permeable material or should be wrapped with laser- impermeable material, such as wrinkled, duff-side- out tin foil covered with wet towels. The cuff should be inflated with saline solution instead of air and pro- tected with moist sponges. When lasering an awake patient, the author prefers to turn off the flow of the oxygen during the process of lasering. A helpful tech- nique is delivery of oxygen deep into the pharynx by insertion of a pediatric feeding tube after topically anesthetizing the throat; but again, the tube must be protected from the laser using tin foil.

70.8.3

Respiratory Safety

A mechanical smoke evacuator is essential and should have an inline suction filter to remove viral particles and reduce the risks. Special surgical laser masks can filter particles as small as 0.3 µm.

70.8.4 Eye Safety

Strict guidelines are available that define the nominal hazard zone (NHZ) for each laser wavelength. Per- sonnel must wear protective eyewear as specified for the laser being used. For the CO

laser, regular indus- trial safety glasses with polycarbonate lenses are best.

When procedures are performed near the eye or di- rectly on the eye with the laser, stainless steel or im- permeable eye shields should be used to cover the cor- nea of the patient (Fig. 70.13).

Fig. 70.12. Two months after laser treatment, acne flare-up and dyschromia

70.8.5 Avoid Char

Char is carbon. If char accumulates on tissue, it is a sign that temperatures have reached 300 °C. Contin- ued lasering of char can produce temperatures of 600 °C (the temperature of red-hot coal). If char is seen, thermal injury has occurred.

70.9

Facial Implants

Silhouette enrichment along with the laser resurfac- ing can be better achieved with a minimal procedure such as an augmentation. The preferred implants that can be safely inserted as combination therapy with laser resurfacing are the malar, the dorsal nasal, and chin and angle mandible implants (Figs. 70.14, 70.15).

The access route for implant placement is decided on the basis of the area to be augmented and the type of laser being used. Extensive undermining of the tissue should be avoided, with staying on the subperiosteal plane at all times so that the implant capsule is less obvious or palpable. Antibiotic solution should be used to frequently impregnate the implant and to irrigate the surgical field.

70.10

Laser-Assisted Blepharoplasty

Additional regional procedures that are executed along with laser resurfacing include laser-assisted blepharoplasty, wherein the laser is used in cutting mode to excise the upper-eyelid skin fold and in the resurfacing mode for the lower eyelid and periorbita.

Fig. 70.13. Stainless steel eye shield in place (rough on the out-

side and smooth on the corneal surface) Fig. 70.14. Preoperative view: dorsal nasal implant for profile enhancement along with laser resurfacing

Fig. 70.15. Postoperative view: dorsal nasal implant for profile enhancement along with laser resurfacing

70.11 Mini-Facelift

A limited undermining facelift can be combined with laser resurfacing at the same sitting, taking care not to laser the undermined skin.

70.12

Endoscopic Procedures

The endoscopic forehead and browlift with the flexi- guide laser probe allows shrinkage of the procerus muscles and subperiosteal lift without damage to the supraorbital/supratrochlear nerves.

70.13 Soft-Tissue Fillers

Soft-tissue fillers/substitutes are most commonly used for immediate correction of natural or acquired de- pressions caused by aging or building up of volume for nasolabial creases, the lip rolls and sunken cheek- bones. Options for soft-tissue fillers are as follows:

1. Alloplastic

a) Semibioresorbable: acrylic hydrogel and hyal- uronic acid contain nonanimal stabilized hyal- uronic acid in various proportions.

b) Bioresorbable: collagen is derived from a bovine source. The disadvantage is allergy and the ef- fects are temporary, lasting for only about 12 months.

2. Autogenous

Micro auto fat injection or lipofilling is the pre- ferred option of the author to achieve stable aes- thetic results. The microglobules of the fat are har- vested using a 2.00 mm super Luer-Lock cannula (malleable) attached to syringes ranging from 2.00 to 20.00 ml. This fine cannula allows harvesting of a core of fat globules without distorting the fat cell architecture to enable viable micro fat transplant.

This 2.00 mm super Luer-Lock cannula is also used for lipodissection and lipocontouring in areas of fat excess. Alternatively, a small-bore cannula is attached to a sterile mucus extractor and with low-power suc- tion the aspirated fat is collected in a closed system that maintains the sterility of the tissue. This aspirat- ed fat is not centrifuged and is allowed to form two supernatant layers over the fluid, i.e., the fat globules at the top, the oil-based suspension in the middle and the plasmatic fluid at the bottom. These fat globules are subsequently transplanted using a no. 16 gauge needle (Figs. 70.16, 70.17).

Fig. 70.16. Long-term follow-up results: full-face laser resurfac- ing plus micro auto fat grafting of nasolabial folds and upper lip plus augmentation rhinoplasty

Fig. 70.17. Long-term follow-up results: full-face laser resurfac- ing plus micro auto fat grafting of nasolabial folds and upper lip plus blepharoplasty

70.14 Botulinum Toxin

Though temporary, the effect of botulinum toxin as an agent for smoothing dynamic wrinkles is well ac- cepted. The conditions that can be addressed with this toxin simultaneously along with laser resurfacing are the horizontal forehead lines, the glabellar frown lines, the lateral canthal lines or crow’s-feet, discrete chin lines, platysmal bands, and the horizontal and vertical neck lines.

70.15 Barbed Wires

Suspension barbed wire sutures for the sagging tem- ples, cheek, jowls and neck in management of the tissue ptosis are achieving great popularity as office procedures. They are of additive benefit with laser resurfacing.

70.16

Ancillary Treatment

Numerous skin-toning lotions and antiaging creams available across the counter for texture and color en- hancement allow further enhancement of the final result. These include cleansers containing chamomile, toners containing hydroquinone, sunscreens contain- ing ZnO, and agents like lactic acid and tretinoic acid, anti-inflammatory medications, natural antipigments such as licorice roots, Triticum vulgare, and antioxi- dants like lupine oil.

70.17

Aesthetic Laser Resurfacing:

What I Have learned over the Past 14 Years

Though the laser is a remarkable surgical tool in the hands of the aesthetic surgeon, it is not a panacea for all needs. It has a high learning curve and requires expertise to avoid complications. Most of the unfa- vorable or unacceptable results tend to arise from an inappropriate selection of technology, equipment and patient. The other detrimental factors are poor or no, pre- and post-laser treatment, an associated history of keloid formation and inadequate patient compliance.

In the author’s experience, whenever there is a safety issue, it is essential to perform a test on a small- er and hidden area before beginning the full-face re- surfacing. While treating patients with skin types III and IV, it is best to treat the entire face by feathering the wrinkle-free or scar-free areas with either a lower-

power setting or fewer passes. These yield the same results with less chance for complications and the darker skin tones can be treated safely and effectively when the treatment is superficial.

Progressive improvement in elastosis in the deep dermis continues for an average follow-up period of 5 years and has been conclusively proved, and physi- cian, patient and histological evaluations have con- firmed that clinical benefits persist even longer. An effective and harmonious repigmentation with volu- metric rejuvenation of the face can be safely achieved by a combination of multiple aesthetic surgical proce- dures along with laser resurfacing simultaneously.

References

1. Abergel RP, David LM: (1989) Aging Hands: A Technique Of Hand Rejuvenation By Laser Resurfacing And Autolo- gous Fat Transfer. J Dermatol Surg Oncol 15:725–728 2. Agban MG: (1989) Augmentation And Corrective Malar-

plasty. In Lewis J (Ed): The Art Of Plastic Surgery. Boston, Little, Brown, p 543

3. American National Standard Institute: Safe Use Of La- sers In Health Care Environment, Z136 Draft, New York.

ANSI, 1987

4. Apfelberg DB: (1995) The Ultra Pulse Carbon Dioxide La- ser In Plastic Surgery/Dermatology. American Society For Laser Medicine And Surgery Abstracts (Abstract 237), San Diego, CA, April 2–4, 1995. New York, Wiley-Liss, p 51 5. Barrent A, Whitaker LA: (1986) Facial Form Analysis Of

The Lower And Middle Face. Plast Reconstr Surg 78:158 6. Di Bernardo BE, et al: (2000) Laser Hair Removal. In CPS,

Vol 27. Number 2. April 2000, p 99–211

7. Di Bernardo BE, et al: (199) Laser Hair Removal. Where Are We Now? Plast Reconstr Surg 104:247–257

8. Dover JS, et al: (1990) Illustrated Cutaneous Surgery: A Practitioner’s Guide. Norwalk, Appelton & Lange 9. Fitzpatrick RE: (1995) Use Of The Ultra Pulse CO2 Laser

For Dermatology Including Facial Resurfacing. American Society For Laser Medicine And Surgery Abstracts (Ab- stract 234), San Diego, CA, April 2-4, 1995. New York, Wiley-Liss, p 50

10. Fitzpatrick TB, et al: (1997) Dermat. In Gen. Medicine, Ed 2, New York, McGraw Hill

11. Flowers RS: (1988) Implants For Correction Of Soft Tissue And Bony Facial Deformities. Presented At The Congress Of The Pan Pacific Surgical Association, Honolulu 12. Flowers RS: (1988) Aesthetic Surgery In The Oriental:

Current Trends. In Marsh J (Ed): Current Therapy In Plas- tic And Reconstructive Surgery. New York, Decker, p 483 13. Futrel JW, Edgerton MT: (1979) Use Of Methylmethacry-

late In Reconstructive Craniofacial Surgery. In Converse JH, Mccarthy JG, Wood Smith D (Eds): Symposium On Diagnosis And Treatment Of Craniofacial Anomalies. St.

Louis, Mosby

14. Goldberg DJ, et al: (1997) Topical Suspension Assisted Q-Switched Nd:Yag Laser Hair Removal. Dermatol Surg 23:741–745

15. Gonzalez-Ulloa M: (1974) Building Out The Malar Promi- nances As An Addition To Rhytidectomy. Plast Reconstr Surg 53:293

16. Groner R, et al: (1997) Endoscopic Harvesting Of The La- tissimus Dorsi Muscle Flap. Eur J Plast Surg 20: 4 17. Grossman MC, et al: (1995) Laser Targeted At Hair Fol-

licles. Laser Surg Med 5:47

18. Hinderar U: (1975) Malar Implants For Improvement Of The Facial Appearance. Plast Reconstr Surg 56:157 19. Jobe, Iverson R, Vistnes L, et al: (1972) Bone Deformation

Beneath Alloplastic Implants. Plast Reconstr Surg 51:169–

20. Letterman G, Schurter M: (1983) Maxillary Implants: An 175 Adjunct To Facial Surgery, Postgrad Instructional Course.

ISAPS, Uppsala

21. Miller MJ: (1994) Minimally Invasive Technique Of Tis- sue Harvest In Head And Neck Reconstruction. Clin Plast Surg 21: 149

22. Ousterhout DK, Baker S, Zlotolow J: (1980) Methylmeth- acrylate Onlay Implants In The Treatment Of Forehead Deformities Secondary To Craniosynostosis. J Maxillofac Surg 8:228

23. Ousterhout DK: (2000) Mandibular Angle Augmentation.

In Ousterhout DK (Ed): Aesthetic Contouring Of The Craniofacial Skeleton. Boston, Little, Brown

24. Prendergast M, Schoenrock LD: (1989) Malar Augmenta- tion. Arch Otolaryngol Head Neck Surg 115:964

25. Whitaker LA, Barlette SP: (1988) Aesthetic Surgery Of The Facial Skeleton. Perspect Plast Surg 2:23

26. Whitaker LA, Pertchuk M: (1982) Facial Skeletal Contour- ing For Aesthetic Purposes. Plast Reconstr Surg 69:245 27. Whitaker LA: (1987) Aesthetic Augmentation Of The Ma-

lar Midface Structures. Plast Reconstr Surg 80:337 28. Whitaker LA: (1989) Biological Boundaries: A Concept In

Facial Skeletal Grafting. Clin Plast Surg 16:1

29. Wilkinson T: (1983) Complications In Aesthetic Malar Augmentation. Plast Reconstr Surg 7:643