LAUSR

It is most gratifying that this paper has drawn so much interest from colleagues who look to the journal for direction in the way they care for their patients. This could not be considered a ‘hot’ topic, after all, being an occasional subject in Plastic surgery journals. Even then such papers tend to be focused on a small aspect of the topic, usually of technique. This level of interest may be that a Review article on this topic was timely in filling an overdue need. Moreover, it was most readable in providing a logical presentation of relevant information that summarizes the findings from many sources into a coherent analysis of the basics of skeletal aging of the face. Specifically, the changes from the aging process form the foundation for logical correction. I give thanks to Dr Chin Ho Wong for this paper. It was conceived of and thoroughly researched by him, with a focus on raising surgeon’s awareness of the overlooked importance of correcting aging changes of the facial skeleton. This being fundamental, not only to obtaining a natural appearing rejuvenation of the aging face but maybe as important, in the prevention of many of the aging changes. During his fellowship time with me, Dr Wong was impressed that nearly every patient undergoing facial rejuvenation surgery had hydroxyapatite granules placed, usually on several locations on their facial skeleton. Given that facial rejuvenation has traditionally been considered surgery of the soft tissues he had not been expecting this focus on the skeleton. He had not seen this performed previously in his previous fellowship experience, nor had he heard this added dimension discussed at scientific meetings. For those readers who have been positively influenced by the paper, and others reading for the first time, I am pleased to report that, even with the benefit of hindsight, there is nothing we would change in the paper. This is despite a further 10 years of experience, now numbering over 1500 cases. The message is clearly conveyed, aided significantly by the clarity of the illustrations, by Levent Efe, whose work and style has become widely appreciated. Readers will be interested to know that these illustrations, especially Figures 5 and 6, have been widely reproduced elsewhere, in many chapters and articles, and not just in plastic surgery publications. You may well ask then, why has there not been a wider use of hydroxyapatite onlay augmentation in facial rejuvenation. For this added perspective, please read on. With the advent of a non surgical option, specifically, injectable commercial fillers out of a package, and the ready availability of cosmetic ‘filler’ practitioners, the simplicity, convenience and the usually good initial results, naturally attracts most potential candidates. However, it is important to appreciate that the filler results are not comparable to those provided by hydroxyapatite. The latter obtains a permanent correction with the one treatment, and properly done, the outcome is not the slightest surgical in appearance. The key difference is the anatomical depth of the implanted volume. Hydroxyapatite is placed, not in the soft tissues as are fillers and fat, but subperiosteally, directly on the bone. As a consequence of the subperiosteal dissection, the overlying structures are lifted with the periosteum and then maintained in that position by the placement of the & Bryan C. Mendelson [email protected]