Aesthetic surgery: coming of age.

lation has resulted in a growing demand for such interventions to ameliorate the visible signs of ageing. Particular concerns are imperfections in the appearance of the skin, including unevenness in colour and texture, raised or depressed scars, wrinkles, sagging accumulations of subcutaneous fat, and hair loss. Fine wrinkling, photodamage caused by lifelong sun exposure, and scars caused by acne, chickenpox, surgery, or trauma can now be treated by laser resurfacing. High-energy shortpulsed or scanned carbondioxide lasers and pulsed erbium yttrium-aluminiumgarnet (YAG) lasers precisely remove skin tissue of uniform depth with little bleeding, while limiting the heat-related damage to surrounding tissues and so minimising the risk of scars and pigmentary changes. With proper selection of patients and wound care, the results of laser resurfacing are dramatic. Wrinkles round the eyes and mouth, typically unresponsive to face-lifting, can be successfully treated. Vascular lesions, such as superficial blood vessels, %elangiectasias, port-wine stains, haemangiomas, and leg veins, as well as scars, striae, and diffuse skin redness, can be treated quickly and effectively with several lasers, including the potassium-titanylphosphate laser and the newestgeneration pulsed-dye lasers, which can eliminate vascular patches with little or no bruising. Pigmented lesions, including tattoos and dark brown birthmarks, can be lightened with lasers that selectively destroy the pigment while sparing the adjacent tissue by emitting very short intense bursts of laser energy called Q-switched pulses. Qswitched lasers of specific wavelengths (Q-switched ruby, alexandrite, or neodymium YAG lasers) are best suited for removing tattoos of particular colours. Unwanted hair can also be treated quickly with lasers adapted for this purpose. Best results are seen in dark-haired, light-skinned patients, in whom a few treatments can result in a sharp permanent reduction in hair growth. Injectable or implantable filler substances are available for correction of soft-tissue losses from ageing, scarring, or skin disease. These materials can help reduce grooves between the cheeks and the nose as well as wrinkles, improve the contour of thinning lips, and fill deep acne scars. Bovine dermal collagen implants were approved in the USA by the Food and Drug Administration (FDA) in the early 1980s. Since then, autologous collagen products that may offer longer duration of correction and lower risk of allergic reactions have been developed, as have various Lower face before (top) and I month after C02 laser resurfacing other injectable substances, none of which are yet approved for use in the USA. Alternatively, fat can be taken from a non-facial site and implanted into facial sites in the same individual, thus eliminating the risk of immune reaction. Synthetic implantable agents--eg, expanded polytetrafluoroethylene--are available in various shapes and sizes and offer a permanent filling effect while being immunologically inert. Frown lines of the forehead and around the eyes respond well to treatment with botulinum A exotoxin. This substance, which is not yet approved for this indication by the FDA, is injected into the relevant muscle groups to provide relaxation of dynamic skin creases for 3-6 months. Age-related fat redistribution can occur in the cheeks and below the chin and jaw. Cervicofacial liposuction effectively removes fat from these regions and improves the contour of the neck and face. Liposuction also removes larger volumes of fat from other body areas that are resistant to diet and exercise, such as the upper arms, abdomen, hips, and thighs. Liposuction is safest and most effective with the tumescent anaesthetic technique--ie, injection of several litres of dilute lidocaine, epinephrine, and sodium bicarbonate into the subcutaneous fat before liposuction. The effects of fluid compression and epinephrine on the subcutaneous compartment allow use of high concentrations of lidocaine and decrease the need for sedation. Liposuction can now be done with little blood loss and with mild postoperative pain, swelling, and bruising. Improved techniques for hair transplantation have enabled a more natural appearance. Dermatological surgeons have learned to transplant hair singly or in groups of two or three into the balding scalp in the same configurations as on normal scalps. The technology is available to transplant even large bald patches within only one or two sessions. Given the demand for aesthetic procedures and the improvements that are increasing their efficacy, cosmetic dermatological surgery can be expected to remain a growing area within dermatology.