Docstoc

Cosmetic Facial Surgery

Document Sample
Cosmetic Facial Surgery Powered By Docstoc
					                        I        I                                  m                    I


Peter A. Adamson, MD, CCP
Cosmetic Facial Surgery
SUMMARY                                                            RESUMt
Canadians have committed themselves to a                           Les Canadiens ont developpe des habitudes de vie
healthier lifestyle, and many are seeking to                       plus saines et nombreux sont ceux qui veulent,
                                                                   parallelement, soigner leur apparence. Pour les
look as well as they feel. For patients with                       patients dont les attentes sont realistes, les
realistic expectations, modemr techniques of                       techniques modernes de chirurgie esthetique faciale
cosmetic facial surgery can enhance                                peuvent ameliorer l'apparence et comporter certains
appearance and be of psychological benefit.                        avantages psychologiques. Aujourd'hui, la plupart
Today most procedures can be done under                            des interventions peuvent etre faites sous anesthesie
local anesthesia on an out-patient basis.                          locale en externe. Certains actes techniques tels la
                                                                   rhinoplastie, l'otoplastie et la chirurgie correctrice du
Facial contour defects can be improved by                          menton et des joues peuvent corriger les
means of procedures such as rhinoplasty,                           imperfections au niveau du contour du visage. La
mentoplasty, otoplasty and malarplasty. Facial                     chirurgie de rajeunissement du visage dans le but
rejuvenation surgery to decrease the signs of                      d'attenuer les signes du vieillissement incluent le
aging indudes the forehead lift, eyebrow and                       lifting du front, la correction de la ligne ciliaire et
                                                                   sourciliaire, la rhytidectomie, la liposuccion et la
eyelid lift, rhytidectomy, liposuction and                         dermabrasion chimique. II existe cependant de
chemical peeling. Newer controversial trends                       nouvelles tendances plus controvers6es au niveau de
in cosmetic facial surgery indude collagen                         la chirurgie esthetique du visage soit l'implant de
implantation and fat transfer for contour                          collagene et la reimplantation de graisses pour les
defects, and eyelid tattooing. (Can Fam                            imperfections du contour, et la dernopigmentation
Physcian 1987; 33:2121-2130.)                                      des paupibres.

Key words: cosmetic facial surgery, rhinoplasty, facial rejuvenation surgery

   Dr. Adamson is a cosmetic and              This makes it difficult for the pri-           against surgery. The degree of suc-
reconstructive facial surgeon who             mary-care physician to advise patients         cess that cosmetic facial surgery can
initially practised family medicine           about procedures popularized in the            offer depends not only on the sur-
in Barrie, Ontario. He now is in              mass media.                                    geon's skills, but also on the patient's
private practice at the                          Today, increasing numbers of indi-          age, health, skin texture, bone struc-
Toronto-Dominion Centre and                   viduals are committed to a healthier           ture, and specific needs. Good candi-
holds staff appointments at the               lifestyle, including attention to diet,        dates are persons who are outgoing
Toronto General Hospital and The              regular exercise, and decreasing con-          and have a positive outlook on life.
Hospital for Sick Children. He is an          sumption of cigarettes and alcohol. A          Poor candidates are persons who ex-
assistant professor at the University         natural extension of this lifestyle is         pect absolute perfection or unrealistic
of Toronto and is President of the            the desire to look as well as one feels.       changes in their lifestyle.
Canadian Institute of Facial Plastic          Our society has embraced this con-                The degree of psychological im-
Surgery. He is actively involved in           cept, allowing more individuals to             provement that a patient obtains from
teaching facial plastic surgery               feel free to seek improvement in their         cosmetic facial surgery bears no rela-
throughout the United States and              facial appearance. A 1986 poll                 tionship to the degree of deformity
Canada. Requests for reprints to:             showed that 45% of women and 33%               corrected.' A patient may be deeply
Dr. Peter A. Adamson, P.O. Box                of men would consider cosmetic sur-            concerned about a minor defect such
47, Toronto Dominion Bank Tower,              gery to improve their appearance.'             as a nasal hump that appears to be of
Toronto-Dominion Centre,                      The goal of cosmetic surgery is to im-         no consequence to others and may
Toronto, Ont. MSK 1B7                         prove profile defects or reduce the            achieve significant satisfaction from
                                              signs of aging, thus improving facial          having this slight defect improved.
                                              harmony and enhancing appearance.              Other patients may have significant
  TH IS YEAR thousands of Cana-                  Absolute perfection or a complete           deformities which their physician con-
     dians will have surgery to im-           transformation of the patient's appear-        siders should be corrected, but which
prove their facial appearance. Yet the        ance or lifestyle are unrealistic expec-       they themselves are quite content to
family physician has little exposure to       tations. Patients who express a desire         live with. In the context of facial plas-
this type of surgery during training.         for such results must be advised               tic surgery, more than in any other
CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987                                                                                      2121
branch of medicine, the physician    and make a physical examination of           held so that the patient can make an
must be prepared to listen to the pa-the patient's head and neck. Polaroid        unhurried informed decision about the
                                     films are taken so that the patient can
tient's wishes and take a non-directive                                           surgery.
                                     be shown the defect and the proposed
approach in helping the patient to de-
                                     correction. The patient is also shown
cide about surgery. This can be a dif-                                            Anesthesia
                                     photographs of surgical results
ficult task, as it departs from the more
                                     achieved with other patients with sim-
traditional authoritarian behaviour of                                               Local anesthesia is used for minor
                                     ilar defects. The procedures that the
the physician/surgeon. Neither the pa-                                            procedures such as removal of facial
                                     patient is considering are described in
tient's spouse, family, and friends nor                                           blemishes or scar revisions. For proce-
the surgeon can impose their own aes-detail. Special investigations include       dures lasting up to three hours, local
                                     medical photographs, nasal airflow
thetic standards on the patient seeking                                           anesthesia combined with intravenous
cosmetic facial surgery. Rather, the studies for patients planning rhino-         sedation is usually employed. This
surgeon must decide whether the pa-  plasty, and an ophthalmology assess-         allows almost any given costmetic fa-
                                     ment for patients planning eyelid sur-
tient's expectations are realistic and                                            cial surgical procedure to be done
can be met surgically. Table 1 out-  gery. The patient is given literature to     under local anesthetic if the patient so
lines the various surgical proceduresread and later returns for a second          wishes. General anesthesia is used for
to recontour and rejuvenate the face.consultation to discuss the results of       procedures taking longer than three
                                     the investigations, ask any further          hours, such as complete facial rejuven-
                                     questions, and plan the proposed sur-        ation, for younger patients, and for
Pre-Operative Assessment             gery. For minor procedures only one          those requesting it.
  During the first consultation the consultation may be necessary, but               Most patients who have local an-
surgeon will take a complete history for others several consultations are         esthesia with sedation are able to


Table 1
Facial Plastic Surgery
Name of           Duration Anesthesia    Office Time Off Light Strenuous Contact Driving Sun       When
Procedure          (Hours)            Out-Patient Work Exercise Exercise Sports         Exposure Performed
                                           or     (Days) (Days) (Weeks) (Weeks) (Days) (Weeks) (Years)
                                       In-Patient
Rhinoplasty          1-3     IV, GA       O,l     10-14     2      3        6       7       6       16+
(Nose)
Mentoplasty             1             IV            0      5-7        2          1         4       1        N.R.      16+
(Chin
Augmentation)
Otoplasty               2             IV            0      5-7        2          2         4       2        N.R.       5+
(Ears)
Malarplasty              1         IV, GA           0      5-7        2          2         4       1        N.R.      16+
(Cheekbones)
ForeheadLife           11/2        IV,GA          O,l      7-10       2          2         4       2        N.R.      30+
Eyebrow Lift           11/2           IV            0      7-10       2          2         4       2          6       30+
Blepharoplasty          2             IV            0      7-10       2          2         4       5          6       30+
(Eyelid Lift)
Rhytidectomy            3          IV, GA         O, l    10-14       2          3         6       10         6       40+
(Face & Neck Lift)
Liposuction              1         IV, GA           0      7-10       2          2         4        5       N.R.      25+
(Fat Suctioning)
Chemical Peel         14 -1        LA, IV          O,l     7-10        1         2         4      1-7         12      40+
Blemish Removal         l/2           LA         OFF, 0     0-7        1         1         3        1         6       16+
ScarRevision          1/2-2        LA,IV            0       0-7        1       1-2         3        1         6       PRN
Dermabrasion          1/2-2        IV, GA          O,l    10-14        1         2         4      1-7         12      16+
(Skin Planning)
Collagen Injection 1/4               NIL          OFF        0       N.R.        1        N.R.    N.R.      N.R.      30+
Legend Anesthesia LA = Local Anesthetic IV              = Intravenous GA = General Anesthetic
             Location OFF = Office 0 = Out-Patient I = In-Patient              NR = No Restriction PRN = As Appropriate
             Exercise Ught Exercise: walking, stretching Strenuous Exercise: jogging, swimming, sexual activity, aerobics,
                       weight lifting, bike riding Contact Sports: squash, tennis, baseball, hockey, football, diving
 2122                                                                             CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987
have their surgery in a day-care facil- and return to work about two weeks       she has a large nose and a retruding
ity and be taken home that evening. after surgery, but they should avoid         chin. Chin augmentation with a pre-
After a general anesthesia lasting less strenuous activities and exercise for    formed Silastic implant can be carried
than two hours, the patient may be three weeks and contact sports for six        out by itself or at the same time as
discharged the same day. Patients un- weeks. The patient can expect signifi-     rhinoplasty (Figure 1). It may be per-
dergoing a longer general anesthesia cant improvement in nasal shape             formed either intra-orally or through a
require admission the day before the within two to three weeks, but the ul-      small submental incision which re-
procedure and spend one night in hos- timate recontouring of the nose may        sults in a virtually invisible scar. The
pital following surgery.                 take up to one year. Rhinoplasty is a   extra-oral approach reduces the
   Most patients have some discom- complex and intricate procedure that          chance for infection and slippage. A
fort, but very little pain, following can generate significant psychological     light Elastoplast dressing is used to
cosmetic facial surgery. Most do not improvement. '                              secure the implant for several days
require analgesics after the first post-                                         before the sutures are removed.
operative day.                           Mentoplasty (chin augmentation)            Chin reduction can be effected
                                           The chin is an important part of a    through a similar submental incision
Facial Contour Surgery                   person's profile, especially if he or   and removal of the surplus bone of
Rhinoplasty
   A significant number of men and Figure 1
women would like to change their Rhinoplasty and Chin At
nasal profile. The most common com-
plaints are that the nose is too large,
crooked, has a bump, or is too bul-
bous at the tip (Figures 1 and 2). Fre-
quently there is a history of nasal
trauma with concomitant obstruction.
Such complications can be improved
by a septoplasty done at the same
time as the cosmetic procedure.
   Usually the tip of the nose is nar-
rowed, set back, or projected further
from the face, and rotated slightly up-
wards to improve a drooping tip. The
nasal hump is removed, and osteoto-
mies of the nasal bones are carried out
to straighten and narrow the nose.
Narrowing of the nasal base is some-
times required to make wide nostrils
smaller.
   The operation can be performed
through a. "closed" approach with all
incisions inside the nose. Many other
noses benefit from an "open" ap-
proach, which requires a small inci-
sion in the columella that heals almost
invisibly. This is a newer approach
and allows much greater exposure and
more accurate sculpting of the nasal
cartilage and bone. A small cast is
placed on the nose and plastic intra-
nasal stents are placed along the sep-
tum. These are removed after one
week. It is no longer necessary to
place large amounts of packing.
Bruising and swelling in the periorbi-
tal and lip *areas recede in approxi-
mately two weeks. Many patients feel
tired for several days after the sur-
gery. Patients commonly have little or
no pain, but do have a dry mouth sec-
ondary to nasal obstruction. This
usually resolves within two weeks. One-year result in a 21-year-old female who had a rhinoplasty and chin
Patients may resume social activities augmentation to improve a large, crooked nose and retruded chin.
CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987                                                                         2123
the chin. If protrusion or retrusion is is performed to re-position the ears        contour. Permanent sutures are placed
the result of a significant deformity ofcloser to the head and to correct other     to maintain the new antihelical fold.
the mandible or maxilla, or if there is deformities and asymmetries (Figure         There is very little, if any, pain asso-
associated dental malocclusion, more    2). The procedure can be performed at       ciated with the surgery, and there are
extensive maxillofacial surgery or      any time after the patient reaches the      no sutures to remove. The thin scars
orthodontia may be necessary. An im-    age of four, as the ear cartilage is then   from the incisions are located behind
proved chin profile enhances the at-    firm and has reached nearly adult size.     the ear and are therefore well hidden.
tractiveness not only of the nose, but  It is best to perform the surgery before    There is some discolouration and
of the entire face as well.             the child begins to attend school in        swelling for up to two weeks, and the
                                        order to avoid classroom teasing. The       ears may be tender for several weeks
                                        procedure can be done at any time in        after surgery. A turban-like bandage
Otoplasty                               adults.                                     is worn for several days. Then an ex-
   Protruding ears are caused by a         The surgeon makes an incision be-        ercise headband is worn for two
Mendelian autosomal dominant trait hind the ear and sculpts the soft tissue         weeks to protect the ears during sleep.
with variable penetrance.2' 3 Otoplasty and cartilage of the ear to improve             As the ears are often not alike,
                                                                                    even in the normal state, perfect sym-
                                                                                     metry of both ears is not a reasonable
                                                                                     expectation. However, patients and
 Figure 2                                                                            surgeons alike are very pleased with
                                                                                     the results of this procedure.
                                                                                    Malarplasty (cheekbone
                                                                                    augmentation)
                                                                                       It is becoming increasingly com-
                                                                                    mon for patients, especially females,
                                                                                    to request augmentation of the malar
                                                                                    bones (Figure 3). This gives more def-
                                                                                    inition to the lateral aspect of the face
                                                                                    and a heightened perception of beauty
                                                                                    for those with flat malar bones. The
                                                                                    procedure is performed intra-orally,
                                                                                    with development of a pocket beneath
                                                                                    the periosteum of the zygoma. Various
                                                                                    shapes and sizes of silicon implants
                                                                                    can be placed and secured with tran-
                                                                                    scutaneous sutures. The resultant
                                                                                    swelling and bruising are minimal.
                                                                                    Most patients can resume normal ac-
                                                                                    tivities within one week.

                                                                                     Facial Rejuvenation Surgery
                                                                                        Facial rejuvenation surgery in-
                                                                                     cludes lifting procedures involving the
                                                                                     forehead, eyelid, eyebrow, and face,
                                                                                     double chin removal, and chemical
                                                                                     peeling. Each individual ages at a dif-
                                                                                     ferent rate and in a unique fashion
                                                                                     because of the numerous factors af-
                                                                                     fecting the aging process. These pro-
                                                                                     cedures can be done at any time dur-
                                                                                     ing adult life, depending on the
                                                                                     person's requirements. The clock can
                                                                                     be turned back, but it will keep tick-
                                                                                     ing; thus a person who has undergone
                                                                                     this type of surgery will always look
                                                                                     better for his or her years, but will
                                                                                     continue to age. The earlier surgery is
                                                                                     done, the more subtle the rejuvenation
                                                                                     will be, and the more years the person
                                                                                     will have to enjoy the results. Secon-
 oIj-IxImIUom resuIL ir             female                                           dary procedures in subsequent years
 protruding ears.                                                                    can provide the patient with a contin-
 2124                                                                               CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987
ued look of youthfulness relative to          facial expression (Figures 4 and 5).       The minimal swelling and bruising are
age throughout life. This youthful ap-           To perform a forehead lift, the sur-    resolved within one week.
pearance tends to complement the ac-          geon makes an incision across the top         Removing the excessive scalp tis-
tive and outgoing lives that most peo-        of the head behind the hairline. The       sue makes the patient's eyes look
ple considering this type of surgery          only hair removed is that on the ex-       larger and more youthful. Forehead
enjoy.                                        cised redundant skin. The muscles          wrinkling and frown lines are re-
                                              causing forehead creases are incised,      duced. The eyebrows are elevated,
Forehead lift                                 the forehead is elevated, and the ex-      and loose skin between eyebrows and
   With aging the eyebrows descend            cess skin is removed. The incision is      temples is smoothed.
over the bony framework of the eyes.          closed with surgical staples. There is
Deep vertical and horizontal lines ap-        little or no pain following surgery, but
pear at the junction of the nose and          there may be some temporary numb-          Blepharoplasty (eyelid lift)
forehead, making a person look angry          ness in parts of the forehead or scalp.       With relaxation of the forehead and
or unpleasant. Horizontal forehead            Central forehead movement will be          temple skin, "hooding" may occur in
wrinkling occurs secondary to constant        decreased after the surgery, thus pre-     the upper eyelids. Thinning and
elevation of the eyebrows and repeated        venting the redevelopment of creases.      stretching of the eyelid skin itself
                                                                                         causes further skin redundancy.
                                                                                         Pseudo-herniation of the periorbital
Figure 3                                                                                 fat pads through the orbital septum
Rhinoplasty and Bilateral Malar Augmentation                                             causes "bags" to occur. Repeated fa-
                                                                                         cial activity and sun exposure causes
                                                                                         wrinkling in the eyelids (Figures 4 and
                                                                                         5).
                                                                                             An ophthalmology exam is com-
                                                                                         pleted pre-operatively to ensure that
                                                                                         there are no ophthalmic contraindica-
                                                                                         tions to surgery. The upper-lid inci-
                                                                                         sion is made just above the tarsal
                                                                                         crease, and the redundant skin and fat
                                                                                         are excised. The lower-lid incision is
                                                                                         made just below the eyelashes in the
                                                                                         natural skin crease, and the redundant
                                                                                         fat is removed. The excess skin is re-
                                                                                         draped and tailored.
                                                                                             There is little or no pain post-opera-
                                                                                          tively, but there is a variable amount
                                                                                          of periorbital bruising and swelling.
                                                                                         The scars gradually blend with the
                                                                                          surrounding skin, and after several
                                                                                          weeks they are barely perceptible
                                                                                         even under close scrutiny. Slight blur-
                                                                                         ring of vision, eye irritation or dry-
                                                                                          ness can occur for up to one month
                                                                                          after surgery. Eyedrops and ointment
                                                                                          may be required during this time.
                                                                                             With the elimination of excessive
                                                                                          skin and sagging around the eyelids,
                                                                                          the patient has a more rested and
                                                                                          youthful appearance. However, a ble-
                                                                                          pharoplasty cannot remove the very
                                                                                          fine wrinkles, or ''crow' s feet",
                                                                                          which give every face character. The
                                                                                          eyelid lift cannot elevate the upper
                                                                                          cheek; a face and neck lift is required
                                                                                          for improvement in this area. The
                                                                                          upper-eyelid lift cannot completely re-
                                                                                          move the skin hooding caused by a
                                                                                          sagging brow; an eyebrow or forehead
                                                                                          lift may be required.

One-year result in a 25-year-old female who had a rhinoplasty and                        Eyebrow lift
bilateral malar augmentation to refine her nose and improve her flattened                   Drooping of the eyebrows, espe-
malar bones.                                                                             cially laterally, is one of the first
CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987                                                                                   2125
signs of aging. It is more prominent       forehead crease is the preferred proce-    also has the advantage of allowing
in men (Figure 6). This causes the         dure. It is effectively combined with a    elevation of the glabella, thus reduc-
upper eyelids to bulge and descend         blepharoplasty, imparting maximum          ing skin redundancy between the
until they seem to lie on the eyelashes    improvement.                               eyes. Lifting the eyebrows makes the
themselves. Patients complain that            To perform an eyebrow lift, the         eyes appear larger and more youthful.
their eyes appear to be getting smaller    surgeon removes a wedge of skin            It also lessens ""crow's feet".
or deeper set; women complain that         above the drooping brow. The eye-             Cosmetics can be used to cover
eye makeup usually ends up high on         brow is lifted and secured by deep su-     scars during the healing phase; men
the outer part of the eyelid. The fore-    tures to its new, more youthful posi-      may prefer eyeglasses. In some cases
head lift is often the best procedure to   tion. The top row or two of eyebrow         the scar is dermabraded several
improve this problem. However, in          hairs may be lost. This is not a con-      months later to improve it further.
female patients with very high hair-       cern to women who pluck their brows
lines and in men who have male-pat-        to contour them. Men's brows are           Rhylidectoiny (face and neck lift)
tern baldness, the eyebrow lift or a       usually thick enough to cover the             Over the years the skin of the face
mid-forehead lift through a horizontal     fine-line scar. The mid-forehead lift      and neck loosens, thins, and sags.
Figure 4                                                                              Wrinkling develops, and pouches form
Female Facial Rejuvenation                                                            along the cheek and jaw line, while
                                                                                      cords may form in the anterior neck
                                                                                      because of weakening of the platysma
                                                                                      muscle. Rhytidectomy is designed to
                                                                                      remove the sagging excess skin and
                                                                                      smooth the deeper wrinkles of the
                                                                                      lower face and neck (Figures 5 and 6).
                                                                                      It can be combined with fat suctioning
                                                                                      (liposuction) to reduce jowls and the
                                                                                      submental "wattle" (Figure 5). It does
                                                                                      not reduce the signs of aging about the
                                                                                      eyes, forehead, or mouth, nor does it
                                                                                      remove fine facial wrinkles.
                                                                                         An incision is made from the temple
                                                                                      down in front of the ear, and up behind
                                                                                      the ear down into the neck hair. A
                                                                                      large superficial flap is elevated from
                                                                                      the underlying fascia, and the superfi-
                                                                                      cial musculo-aponeurotic system
                                                                                      (SMAS) fascia is then secured with per-
                                                                                      manent sutures at a higher level. This
                                                                                      is the point at which the true lift
                                                                                      occurs. The redundant skin is re-
                                                                                      draped, tailored, and closed without
                                                                                      tension. This two-layered lift gives a
                                                                                      natural-looking and long-lasting re-
                                                                                      sult.
                                                                                         There is little pain in the post-opera-
                                                                                      tive period, but there is a variable de-
                                                                                      gree of swelling, discolouration, and
                                                                                      tightness of the skin for a week or two.
                                                                                      Some numbness in the face resolves
                                                                                      within several weeks. Patients can re-
                                                                                      sume social activities within two to
                                                                                      three weeks. Hair colouring or perma-
                                                                                      nent-wave solution can be applied in
                                                                                      about three weeks.
                                                                                         The face and neck lift gives the pa-
                                                                                      tient a more refreshed appearance. If
                                                                                      there has been a great deal of sagging,
                                                                                      which is more likely in the older pa-
                                                                                      tient, the result will be more dramatic.
                                                                                      If sagging is less pronounced, the
Two-month result in a 47-year-old female who had a coronal forehead lift              operation will keep the patient looking
and lower blepharoplasty, and face and neck lift with liposuction. Note               young. He or she will always look five
the improvement in her facial ptosis, periorbital fat herniation, jowls, and          to 10 years younger than his or her cur-
facial furrows.                                                                       rent age, but aging will continue. Ap-
2126                                                                                 CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987
proximately 50% of our facelift pa-        piration of the buccal fat pad by way of skin. These are best eliminated by
tients will have a second lift or "tuck    an intraoral approach, but this proce- chemical face peeling. This may be
up" at a later date. This allows further   dure creates some risk of causing a ca- done as an isolated procedure for a re-
tightening of the underlying founda-       daveric appearance in patients who do gional aesthetic unit of the face (for
tion of the face and removal of redun-     not have a cherubic face.4 Further time example, lips, cheeks, and/or fore-
dant skin. In this way, a patient can      will be required to assess accurately head), or it may be done in conjunc-
maintain his or her youthful appear-       the technical merits and long-term re- tion with other facial rejuvenation pro-
ance throughout life.                      sults of these procedures.               cedures. Different peeling compounds
                                                                                    are available, but essentially the tech-
Liposuction (fat suctioning)               Chemical (Face) Peel                     nique causes a second degree burn to
   In some people fat gradually depos-        Fine wrinkles, weatherbeaten skin, the skin, which in turn causes exfolia-
its below the chin until a "double vertical wrinkles of the lips, and tion of the superficial layer of skin.
chin" forms. This deposit obliterates brown sun spots are all marks of aging This process results in a thinner but
the ideal chin-neck line, contributing
to the appearance of aging. Others Figure 5
have a "turkey gobbler" deformity, Male Facial Rejuvenation Surgery
which consists of vertical bands of pla-
tysma muscle, running from the chin
to the base of the neck. Jowls, an ex-
cess of skin and fat, may hang from
the lower jaw. Certain individuals
have a poorly developed cervico-men-
tal angle caused by an anteriorly
placed hyoid cartilage. If they also
have excess submental fat, they can
benefit from fat suctioning of the sub-
mental and submandibular region even
in their twenties (Figure 4).
   To perform a liposuction, the sur-
geon makes small incisions under the
patient's chin and behind the earlobe.
Excess fat is removed with a suction
catheter in a cross-hatched fashion to
get a smooth result. A light pressure
dressing is worn for four days, at
which time all sutures are removed.
There is usually very little bruising or
swelling and minimal discomfort.
   In patients who still have good skin
elasticity, liposuction may be the only
procedure required. Over several
months the skin will contract to give a
tighter appearing jaw and neckline. In
older patients who have decreased skin
elasticity, it is necessary to combine li-
posuction with a face and neck lift
in order to redrape the inelastic redun-
dant skin to achieve a more youthful
appearance. Patients with chin retru-
sion will realize an even greater im-
provement with chin augmentation
combined with lipsuction. Small
asymmetries and irregularities may oc-
casionally occur with healing, but
these are usually of little concern and
do not detract from the overall im-
provement.
   Some surgeons have recommended
                                                                                                      Z__. ~J
                                                                                                      .I___._. ...E~._:R..~~~c ~
fat suctioning of the nasolabial folds Three-year result in a 53-year-old male following direct brow lift, upper
and infraorbital regions. This proce- and lower blepharoplasty, and face and neck lift for facial rejuvenation.
dure, however, may result in ridging Because of numerous facial skin cancers, the patient also had a full-face
of the skin, which has been difficult to dermabrasion for therapeutic reasons, but also attained improved
correct. Others have recommended as- cosmesis.
CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987                                                                            2127
                   r~ gi.NXS'1_-
smoother skin. A small patch test is       cleansing of the face. The solution         had been sunburned. Considerable
done several days before peeling the       stings as it is applied, and the amount     swelling may occur, and the patient
desired area in order to ensure that the   of discomfort varies among patients.        needs to be emotionally prepared to
patient has no adverse reaction to the     The stinging is eased with steroids to      accept the temporary distortion of his
peel solution. Chemical peeling will       decrease swelling. Analgesics and           or her appearance. Make-up may be
not improve larger creases and sagging     anxiolytics are prescribed if necessary.    used within seven to 10 days, once all
tissues, but will improve finer wrin-      The patient immediately puts ointment       the crusts are removed. The skin eryth-
kles and changes caused by sun expo-       on the affected area. Loose crusts are      ema fades over about three months,
sure.                                      removed with showering, beginning           during which time the patient should
   Smaller areas may be peeled in the      the first day. This greatly decreases the   avoid prolonged sunlight.
office without sedation of the patient.    discomfort which has been associated           The result of this procedure is a de-
More extensive peeling requires hospi-     with this procedure in the past. The        crease in fine wrinkles and the patchy
tal care. The peeling solution is ap-      underlying skin revealed after shower-      pigmentation seen in older skin. Pa-
plied with cotton swabs after thorough     ing is wrinkle-free and reddened as if it   tients with fair complexions may
                                                                                       achieve more favourable results than
                                                                                       those with darker complexions or
Figure 6                                                                               thicker skin.
Z-plasty, W-plas
                                                                                        Additional Procedures
                                                                                        Growths and blemishes
                                                                                            Small growths and blemishes may
                                                                                        be present from birth or may increase
                                                                                        with aging. Removal of lesions such as
                                                                                        benign nevi and cysts reduces colour
                                                                                        and contour deformities of the face.
                                                                                        Telangiectasia or "spider veins" can
                                                                                        be cauterized in the office. Large
                                                                                        freckles or lentigos can be improved
                                                                                        with a light chemical peel. In each
                                                                                        case the method of treatment is deter-
                                                                                        mined by the type, size, and growth of
                                                                                        the blemish. The degree of improve-
                                                                                        ment depends on the extent of treat-
                                                                                        ment required and the individual's skin
                                                                                        characteristics. With increasing aware-
                                                                                        ness of the risks of ultraviolet irradia-
                                                                                        tion exposure resulting from depletion
                                                                                        of the ozone layer in the atmosphere,
                                                                                         all patients should be advised to avoid
                                                                                        excessive sun exposure or to use sun-
                                                                                        blocking agents.
                                                                                        Scar reilsion
                                                                                           Scars are characterized by location,
                                                                                        colour, line, and contour. Should a
                                                                                        scar be less than ideal with respect to
                                                                                        these characteristics, it can be im-
                                                                                        proved by surgical excision, derma-
                                                                                        brasion, collagen implantation, or
                                                                                        other camouflage techniques. Larger
                                                                                        scars can be excised serially over a
                                                                                        period of time. It is important to re-
                                                                                        member that a scar can never be com-
                                                                                        pletely eliminated, but can only be im-
                                                                                        proved. Furthermore, it may take up to
                                                                                        one year for a scar to mature, at which
                                                                                        time it will have reached its maximal
                                                                                        improvement.
 A 26-year-old male with a severe chin laceration from an MVA. Fifteen                  Dermabrasion (skin planing)
 months following Z-plasty, W-plasty and dermabrasion for scar revision,                  Dermabrasion is most commonly
 the contour, line and colour of the scar are improved.                                 used for acne scarring (Figure 6). To
2128                                                                                   CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987
 achieve ideal results the surgeon must        becomes smoother and often slightly creases about the eyes and mouth are
 surgically plane an entire regional aes-      lighter. Scarring can be reduced, but difficult to correct with collagen.
 thetic unit such as the cheek or fore-        not completely eliminated. Face and
 head, and not just the scarred area it-       neck lifting may further reduce the Fat transter
 self. "Spot" dermabrasion, except for         deeper wrinkles and scars.                  There has recently been renewed in-
 some contour irregularities in straight-                                               terest in transplanting fat from areas
 line scars, leaves a more prominent                                                    such as the abdomen and buttocks in
 contour defect than the initial round        Controversies and Trends                  order to correct contour defects of the
 acne or chicken pox scar. Deep "ice-         in Cosmetic Facial Surgery                face. Investigators are currently study-
 pick" scars are improved by a surgical       Collagen Implantation                     ing the best methods of needle fat ex-
 incision with a punch elevation of the                                                 traction, solutions for fat transfer, and
 depressed area prior to the dermabra-            Collagen, which is the structural re-injection techniques.6 Although the
 sion. Accutane must be discontinued           protein of the skin, is prepared from technique appears relatively simple
 six months prior to dermabrasion, as it      calf hide and purified so that it can be and there have been some encouraging
 may decrease re-epithelialization.            injected into the human dermis to im- early results, long-term results of these
                                               prove contour defects. Three types of newer techniques are yet to be seen.
    Surgical planing of the skin is car-      collagen are currently available: Zy-
ried out with a high-speed diamond            derm 1, Zyderm ii, and Zyplast. Zy- Eyelid Tattooing
fraize or wire brush, which removes           plast is the latest and most commonly
the epidermis and superficial layers of                                                    Over the past few years, tattooing of
                                               used form of collagen, as it is thicker the eyelids has been popularized. It
the dermis. The normal skin is taken          and appears to last longer.               has been recommended for busy
down to the level of the pitted scar,
thus diminishing the high-low junc-               Before treatment begins, a test in- women who do not wish to take time
tions which cast shadows on the skin          jection is made in the forearm. The pa- to apply makeup, for athletes, and for
when light strikes the face. The deeper       tient is checked at 28 days after the more senior patients with visual,
dermis contains the epidermal appen-          procedure for signs of adverse reac- arthritic or tremour problems that pre-
dages, which form new skin, and               tions. About 3% of the general popula- vent the application of eyelid cosmet-
therefore the depth of dermabrasion is        tion will react and should not be given ics. The patient chooses a pigment
limited. Before the procedure is              collagen.5 Those at particular risk are which is then injected in a dot fashion
begun, the skin is frozen with Frigid-        highly allergic persons and persons just above the upper, or below the
erm. This eliminates pain and allows          with collagen-vascular diseases. Treat- lower, lash line. The effect will de-
the surgeon to sculpt the skin. Bleed-        ment procedures are performed at least pend on the colour of pigment used,
ing is reduced so that the capillary          two weeks apart, and most patients re- the width of the line placed, and the
loops in the dermis can be seen, which        quire two to four sessions initially. In- density of the tattoo dots.
allows a more accurate assessment of          jections are relatively painless, as Xy-     There has been some concern about
the depth of dermabrasion. The patient        locaine is placed in the syringe. After the irreversibility of this technique,
washes his or her face with cool water        the implantations there is some swell- especially for younger women who
and applies medicated ointment. This          ing, redness, and, rarely, mild sore- may wish to change their eyelid ap-
decreases crust formation, which re-          ness. This reaction lasts only a few pearance later on. There have been
sults in more rapid healing and less          hours. Some minor bruising occasion- rare reports of eyelash loss, infection,
                                              ally occurs.                              and "bleeding" of the pigment.7 Pa-
discomfort.                                                                             tients must be made aware of these po-
                                                 Touch-up injections are needed to
    Most of the crusts fall off within 10     maintain maximum correction, as col- tential problems when they are consid-
days, leaving very erythematous skin.         lagen is naturally metabolized by the ering this procedure.
Make-up may then be applied. The              body. Most patients choose to receive
erythema subsides slowly over three           touch-ups between six and 18 months Conclusions
months, leaving a smoother skin. Sun          after initial treatment.
exposure must be avoided during this                                                       The great majority of patients un-
stage to prevent development of hyper-           The most common use of collagen is dergoing cosmetic facial surgery are
pigmentation. Fair complexions are            to fill in the deep facial creases of the very pleased with the results.' Nearly
less prone to pigmentation problems           nasolabial folds, glabella and forehead all would have the procedure done
than are darker complexions.                  that are associated with aging. This again, and many do return for further
                                              procedure may be carried out before facial rejuvenation surgery when other
   It is generally thought that derma-        facial rejuvenation surgery, or as a signs of aging appear. Patients increas-
brasion cannot be performed unless ac-        touch-up to maximize results follow- ingly present for surgery at a relatively
tive acne has settled completely. It is       ing such surgery. Collagen can be used early stage of life because they wish to
ideal to wait until acne is under con-        to reduce certain acne scars, tissue loss maintain their youthful appearance and
trol, but absolute resolution is not nec-     from disease or injury, or other depres- to enjoy the results of their surgery for
essary. Acne may flare for several            sions. However, since collagen im- a longer period of time. Increasing
months following dermabrasion be-             plantation does not yield a permanent numbers of men are requesting cos-
cause of the inflammatory response of         result, the surgeon and the patient metic facial surgery.
healing. Following this response,             must weigh the benefits of repeated in-      There are, however, certain risks as-
however, most acne patients see their         jections against more definitive surgi- sociated with any surgical procedure.
acne become less active than it was.          cal management. Firm scars, or those In addition to hematoma and infection,
    As a result of dermabrasion the skin      with distinct margins, and very tiny more serious complications could in-
CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987                                                                                 2129
XNIZORAIq
  K E T 0 C 0 N A Z 0 L E
ANTIFUNGAL AGENT
INDICATIONS
Serious or lite threatening systemic tuoigal intections in normal, predisposed or
                                                                                       interferes with steroid synthesis, the potential tor a deleterious ettect on
                                                                                       puberty andlor fertility must be carefully considered when long-term therapy is
                                                                                       contemplated. Calcium and phosphorus serum levels should be monitored in
                                                                                       long-term treatment since NIZORAL interteres with vitamin D metabolism:
                                                                                       hypoparathyroidism developed in a 6 year old during long-term therapy.
                                                                                       DRUG INTERACTIONS
                                                                                       NIZORAL + cyclosporin = Increases plasma concentrations of
                                                                                       cyclosporin.
                                                                                       Since the occurrence of nephrotoxicity as a side effect of cyclosporin is
                                                                                                                                                                            clude visual loss associated with ble-
                                                                                                                                                                            pharoplasty, and sensory or motor-
                                                                                                                                                                            nerve injuries associated with facial
                                                                                                                                                                            surgical procedures. Abnormal wound
                                                                                                                                                                            healing may be a problem. Fortu-
immunocompromised patients where alternate therapy is considered inappro-              correlated with high plasma trough levels, additional care is required when
priate or has been unsuccessful: systemic candidiasis, chronic mucocuta-               they are used concomitantly.                                                         nately, none of these complications are
neous candidiasis, coccidioidomycosis and paracoccidioidomycosis,                      NIZORAL + warfarin = potantliation of the action of warfarin.                        common, and this is one of the reasons
histoplasmosis and chromomycosis. Severe recalcitrant dermatophytoses                  A sharp drop in the prothombin level may occur during concomitant therapy
unresponsive to other torms ot therapy.                                                with antivitamin K type oral anticoagulants. More careful monitoring of antico-      why these procedures are increasing in
When clinically warranted, therapy may be initiated prior to identitication of the     agulant ehlect is necessary, with appropriate adjustment of the warfarin dose.       popularity.
causative organismL                                                                    NIZORAL + insulin = decreases insulin needs in diabetic patients.
N.B. NIZORAL is not recommended for lungal inlections ol the CNS.                       Due to a possible insulin-sparing effect, insulin needs should be assessed             Patients considering such surgery
                                                                                        more frequently when NIZORAL is used concomitantly.
CONTRAINDICATIONS
                                                                                        NIZORAL + ritampicin and/or isoniazid = reduces NIZORAL levels.                     should first discuss their concerns with
Known hypersensitivity, hepatic dystunction, ini women of childbearing poten
tial unless etlective forms of contraception are employed.                              These drugs should not be used concomiantly.                                        their family physician. He or she
                                                                                        NIZORAL + phenytoin = Increases or decreases plasma levels of
WARNINGS                                                                                either drug. (Mediated via cytochrome P,50 enzymes).                                should be able to refer the patient to a
Idiosyncratic hepatocellular dysfunction has been reported and can be fatal
unless properly recognized and managed Liver function tests (SGGT. alkaline             ADVERSE REACTIONS                                                                   surgeon known to have expertise in the
                                                                                        Some deaths occurred in clinical trials which may or may not be drug related.
phosphatase, SGPT. SGOT. bilirubin) should be pertormed before, and at
periodic (monthly or more frequently) intervals during treatment, particularly in       Gastrointestinal: nausea and/or vomiting (3%), G.I hemorrhage (<1%),                area of the patient's concern. There are
patients with a history ol significant alcohol consumption, those expected to           abdominal pain (1.2%), diarrhea (<1%).
                                                                                        Dermatological: pruritis (1.5%), alopecia, purpur, rash, dermatitis (<1% in
                                                                                                                                                                            currently several specialties whose
be on prolonged therapy and those receiving other potentially hepatotoxic                                                                                                   members exhibit expertise in facial
drugs, concurrently Minor elevations of liver enzymes usually normalize                 all capes).
during therapy and do not necessitate discontinuation of therapy, however,              Central Nervous System: headache, dizziness, somnolence, tremors, ner
                                                                                        vousness, paresthesias (<1% in all cases).
                                                                                                                                                                            cosmetic surgery. These specialties in-
symptomatic manilestation ol hepatotoxicity is an indication lor termination of
therapy Deaths have been reported following therapeutic doses of ketocona-              Endocrinological: gynecomastia (<1%), dose-dependent decrease in tes                clude otolaryngology-head and neck
zole associated with evidence of hepatotoxicity.                                        tosterone serum levels, decrease in basal and ACTH-induced cortisol levels,         surgery, general plastic surgery, ocu-
In man, single doses of 200. 400 or 600mg NIZORAL cause a dose-related                  increased serum levels of 17 OH progesterone and decreased urinary levels of
decrease in serum testosterone level,, which returns to baseline values 8 to 24         17-ketosteroids, hypoparathyroidism                                                 loplastic surgery, dermatologic sur-
                                                                                       Genitourinary: oligospermia and azoospermia, impotence, loss of libido,
hours later. During chronic administration of 200 mg daily, testosterone levels
were not signilicantly suppressed, Doses ol 1200mg/day have resulted in                menstrual irregularities.                                                            gery, maxillofacial surgery, and den-
reduction ot serum testosterone to the castrate level within 24 hours This was         Hematological: thrombcytopenia, ecsinophilia, decreased hemocrit, ane
                                                                                       mia, leuokopenia, neutropenia (<10%).
                                                                                                                                                                            tistry. Patients should be confident that
maintained for the duration ot therapy. Oligospermia and azoospermia have                                                                                                   they have identified their specific ex-
been reported at therapeutic doses and above.                                          Hepatic: idiosyncratic hepatocellular dysfunction (<0 01%, see WARN-
In 6 healthy temales receiving 400mg once in the late tollicular phase and             INGS), transient increases in liver enzymes. Three patirnts have died in
                                                                                       hepatic coma, two when ketoconazole therapy was continued despite icteric
                                                                                                                                                                            pectations for surgery and have dis-
once in the luteal phase, NIZORAL produced a 380/0 drop in 17t -estradiol
along with a 500/o increase in progesterone during the lollicular phase as well        symptoms and the third despite discontinuation ov therapy                            cussed these fully with their surgeon,
as a 610/n drop in 17(5-estradiol and a 940/o increase in progesterone during          Miscellaneous: fever and chills, photophobia, idiosyncratic allergic re              and they must be prepared to undergo
the luteal phase The potential for a deleterious eoIect on puberty andlor fertility    actions, anaphylactic shock, pronounced dyspnea, arthralgia, sensation of
must be caretully considered when long-term NIZORAL therapy is contem                  detachment, corneal deposits, cataract enlargement (<1%/n)                           a surgical procedure with its attendant
plated in children                                                                     DOSAGE AND ADMINISTRATION                                                            risks in order to achieve their desired
A single dose ot 200 mg ot NIZORAL had no efoect on human cortisol levels.             The infecting organism should be identified although when clinically warranted
however. 400 or 600mg caused a slight non-signiticant tall in basal cortisol           therapy may be initiated prior to obtaining these results                            goals. The burgeoning increase in pa-
levels and a signiticant but reversible blunting of cortisol response to ACTH                                                                                               tients desiring facial plastic surgery re-
Chronic administration of 800 or 1200mg NIZORAL impaired the ability ot the             GENERAL GUIDELINES N.B. Refer to WARNINGS AND PRECAUTIONS
adrenals to produce cortisol although evidence ot frank adrenal insufficiency                                       RECOMMENDED RESPONSE                                    flects positively on the success of these
was not observed Cortisol levels should be monitored regularly in patients
predisposed to adrenal insutticiency, those with marginal adrenal fLinction. or
                                                                                         CONDITION                  TREATMENr        TIMEb                                  procedures.
during periods of prolonged stress, such as in the intensive care unit                   DERMAL AND CUTANEOUS
In males. 1200mg/day NiIZORAL produced a rapid and signiticant decline in                  MYCOSES
                                                                                         Derrnaromycoses                            4 6 weeks              4 weeks
adrenal androgens (androstenedione and dehydroepiandrosterone), Since the
eftects on hormonal pathways are incompletely understood, tudicious consid               Hair or scalp mycoses                      4-8 weeks              4 weeks           References
eration is recommended before prescribing NIZORAL on a long-term basis                   Pityriasis versicolor                      3-6 weeks              3 weeks
 Studies in rats indicate that ketoconazole leads to increased bone tragility in         Oral thrush                                1-2 weeks              1 week            1. Cash TF, Winstead BA, Janda CH. The
females. therefore, doses above 400 mg/day should not be used in susceptible             Chronic mucoculaneous                                                               great american shape up. Psychol Today
 patients (post-menopausal women and the elderly) Because ot ketoconazole's                candidiasis                              6-12 months            4 months          1986; 20:30-4.
ability to interfere with steroid synthesis and vitamin D metabolism, careful            Onychomycosis                              612 months             3 months
consideration should be given to use in children Calcium and phosphorus                  DEEP MYCOSES'                                                                       2. Goin JM, Goin MK. Changing the
 levels should be monitored during long-term therapy
 Animal studies indicate that NIZORAL crosses the placental barrier and is only          Systemic candidiasis                       24    weeks            4 weeks           body: psychological effects of plastic sur-
 eliminated very slowly from tetal membranes. This must be carelully consid
                                                                                         Paracoccidroidomycosis                     2-4   months           2 months          gery. Baltimore, MD: Williams and Wil-
ered in pregnant patients
                                                                                         Coccidioidomycosis                         >6    months           6 months          kins, 1981; pp. 135; 127-9; 154-7.
                                                                                         Histoplasmosis                             2-4   months           2 months
 PRECAUTIONS                                                                             Chromomycosis                              >6    months           3 months          3. Potter EL. A hereditary ear malforma-
 Patients should report any signs and symptoms (unusual tatigue, anorexia,
 nausea andlor vomiting. jaundice, dark urine or pale stools) suggesting liver          a Base the duration of therapy on individual clinical and mycological                tion transmitted through five generations. J
 dystunction so that appropriate biochemical testing can be done. Liver func              response
                                                                                        b If no response is seen, dosage can be increased up to maximum recomi
                                                                                                                                                                             Heredity 1937; 28:255-8.
 tion tests should be performed before and during the initial days of treatment
 and at monthly or more frequent intervals during treatment in patients with a            mended,                                                                            4. Rogers BD. Microtic, lop, cup and pro-
 history of significant alcohol intake or suspicion of liver disorder, those treated    c Continue treatment Ior at least 1 week alter apparent eradication of the           truding ears: four directly inheritable defor-
 concurrently with other potentially hepatoxic drugs, and those destined tor              infecting oungus
 long-term therapy (see WARNINGS)                                                                                                                                            mities. Plastic Reconstruct Surgery 1968;
 NIZORAL requires acidity tor dissolution and absorption Antacids. anticholin           ADULTS                                                                               41:208-31.
                                                                                        200 mg once a day Dose may be increased to 400 mg in patients who do not
 ergics or H,-blockers should he given at least 2 hours after NIZORAL For               respond (see Table) Daily maximum dose of 400 mg should not be exceeded
 achlorhydric patients dissolve each NIZORAL tablet in 4 mL aqueous                                                                                                          5. Keen M, Arena S. The surgical anatomy
 0 2 N HCI, drink with a straw to avoid contact with the teeth and tollow with a        CHILDREN                                                                             and plastic surgical significance of the buc-
 cup ot water                                                                           <20 kg: 50 mg, 20 40 kg 100 mg, over 40 kg 200 mg Daily maximum dose
 Anaphylactic reactions to NIZORAL with severe angiodema have been re-                  ol 100 400 mg should not be exceeded.                                                cal fat pad. Presented at The American
 ported in 2 cases Use NIZORAL cauliously in patienis with a known sensitivity          NIZORAL should be taken once daily with a meal Since NIZORAL requires                Academy of Facial Plastic and Reconstruc-
 to micoiiazole as cross sensitivity may exist                                          adequate gastric acidity lor dissolution, avoid concomitant use of antacids,         tive Surgery, Spring Meeting, May 2,
 Use in Women of Child-Bearing Age                                                      anticholinergics and H,-blockers or administer them at least 2 hours alter
 An effective aorm of contraception must be used during NIZORAL theoapy                 NIZORAL. In achlorhydric patients dissolve each tablet in 4 mL 0 2 N HCI.             1987, Denver, Colarado.
 Use in Pregnancy                                                                       drink with a straw to avoid contact with the teeth and follow with a cup of water
 In rats, NIZORAL is leratogenic. crosses the placental barrier and is eliirvinated     AVAILABILITY
                                                                                                                                                                             6. Zyderm collagen implantation: a sum-
 very slowly trom tetal membranes, evidence oa malernal toxicity and embry-             Tablets of 200mg ketoconazole, botlles of 100                                        mary of clinical investigation. Information
 otoxicity was seen at doses of 10 mg/kg. Very careful consideration should be          Frill Product Monograph available on request                                         piece. Palo Alto, Calif: Collagen Corpora-
 given to the implications tor mother and letus before using NIZORAL in                                                                                                      tion, 1982.
 pregnancy                                                                              'Trademark            JANSSEN 1987                                           %-H]
 Use During Lactation                                                                                                                                                        7. Agris J. Autologous fat transplantation:
 Nursing should be stopped before starting therapy since animal studios                                                                                                      a 3-year study. Am J Cosmetic Surgery
 indicate that NIZORAL is excreted in1 milk                                                J ANSSEN JANSSEN Pharmaceucica Inc
 Use in Children                                                                        EZ PHRMCUTC       6535 Mill Creek Drive                                               1987; 4(2):95- 102.
 Limited data dictates that caution be exorcised when NIZORAL Is given to                3 H R A ETC       Mississauga, Ontario
 children Carelul hepatic and hematotogicat monitoring is indicated NIZORAL                                            L5N 2M2                                               8. Anderson RL. Eyelid tatooing: a sign of
                                                                                                                                                                             the times. Arch Opthalmol 1985; 103
                                                                                                                                                                             (10): 1469-71.
         2130                                                                                                                                                               CAN. FAM. PHYSICIAN Vol. 33: SEPTEMBER 1987