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ISBN: 0-8247-0302-2

This book is printed on acid-free paper.

Headquarters
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 To my wonderful staff,
several of whom have been with me for many years.
They make work a pleasure and provide expertise
as well as a warm and caring experience for patients.
 Series Introduction

During the past decade there has been a vast explosion in new information relating
to the art and science of dermatology as well as fundamental cutaneous biology.
Furthermore, this information is no longer of interest only to the small but growing
specialty of dermatology. Scientists from a wide variety of disciplines have come
to recognize both the importance of skin in fundamental biological processes and
the broad implications of understanding the pathogenesis of skin disease. As a re-
sult there is now a multidisciplinary and world-wide interest in the progress of
dermatology.
With these factors in mind, we have undertaken a new series of books specif-
ically oriented to dermatology. The series will be purposely broad in focus and will
range from pure basic science to practical, applied clinical dermatology. Thus, while
there will be something for everyone, all editions in the series should ultimately
prove to be valuable additions to the dermatologist’s library.
Since the inception of this series of books on Basic and Clinical Dermatology,
there has been an expanding interest in the field of dermatological surgery, in general,
and cosmetic surgery in particular. The current volume: Cosmetic Surgery: An In-
terdisciplinary Approach, edited by Dr. Rhoda Narins, fulfills an obvious need for a
broad-based interdisciplinary approach to a subject of great interest and timeliness.
I sincerely believe that this volume will be a valuable edition to the libraries of all
physicians interested in cosmetic surgery.

Alan R. Shalita, M.D.

Distinguished Teaching Professor & Chairman
Department of Dermatology
SUNY Downstate Medical Center

v
 Preface

Very few substantial cosmetic surgery texts integrate the knowledge of dermatolog-
ical, maxillofacial, and plastic surgery procedures. There is a growing demand for
cosmetic enhancement with heightened media attention on the numerous treatments
available. The level of expertise and the number of new treatments have risen dra-
matically. It is necessary to know and understand all the latest technology and in-
novative techniques available in order to choose the optimal proecdure for each
patient. This book includes chapters by dermatological cosmetic surgeons as well as
plastic and oral maxillofacial surgeons from an international faculty, providing a
comprehensive perspective and combined expertise to offer each patient the best
possible surgical treatment. I would like to gratefully acknowledge all the authors
whose hard work has enabled this book to be realized.
This is a how-to manual that will take you step-by-step through surgical pro-
cedures and will thoroughly explain every aspect of the surgical techniques. Con-
tributors have been encouraged to make each chapter readable as an independent
entity. Pre-op information and instruction sheets, consent forms, and post-op instruc-
tions are included. Each chapter discusses the indications and contraindications for
the procedure, techniques, and possible innovative results in the future, along with
the limitations and potential complications.
This book is designed to be comprehensive in scope and to provide information
for the novice as well as the experienced cosmetic surgeon. We hope it will appeal
to cosmetic surgeons of many different specialties worldwide. The topics covered
range from facelifts, filling substances, laser procedures, and liposuction to consul-
tations and office and OR set-ups as well as handling the dissatisfied patient. The
effectiveness of any practicing cosmetic surgeon ultimately depends on making the
right choice of treatment. The extensive experience of the authors enables them to
give invaluable practical tips about each procedure. After reading this book, the
cosmetic surgeon will be able to plan the best combination of treatment and main-
tenance programs for each patient.

Rhoda S. Narins

vii
 Contents

Series Introduction Alan R. Shalita, M.D. v

Preface vii
Contributors xiii

1. Designing the Surgical Suite 1

C. William Hanke and Jenette A. Buening

2. Aesthetic Analysis of the Aging Face 17

Richard G. Glogau

3. Superficial Chemical Peels 27

Seth L. Matarasso and Karyn Grossman

4. Medium and Deep Chemical Peels 37

Gary D. Monheit

5. The Total Body Peel: Peeling the Skin of the Neck, Chest, Hands,
and Other Areas 69
Kim K. Cook

6. Peel Complications and Management 79

Harold J. Brody

7. CO2 Laser Resurfacing 99

Tina S. Alster

8. Erbium Skin Remodeling 123

Cynthia Weinstein

9. The Effective Use of Resurfacing Lasers 163

Stephen O. Kovacs, Arielle N. B. Kauvar, and Roy G. Geronemus

10. Dermabrasion 179

Stephen Mandy
ix
x Contents

11. Filling Substances: Collagen 193

Arnold William Klein

12. Structural Lipoaugmentation 221

Lisa M. Donofrio

13. Fat Transplantation and Autologous Collagen 241

Kevin S. Pinski

14. Human-Derived Filling Materials for Soft-Tissue Augmentation 267

Tina B. West

15. Gortex 289

Naomi Lawrence

16. New Filling Substances on the Horizon 313

Arnold William Klein

17. Botulinum A. Exotoxin 333

Alastair Carruthers and Jean Carruthers

18. Moles, Cysts, and Lipomas: Surgical Treatment of Cutaneous Cysts 355
Vicki J. Levine

19. Flaps and Grafts 379

David A. Davis and Christopher J. Arpey

20. Topical Anesthetics and Local and Regional Blocks 411

Tri H. Nguyen

21. The Pharmacology of Tumescent Liposuction 443

Jeffrey A. Klein

22. Laser Removal of Vascular Lesions, Scars, Warts, and Poikiloderma 455
Robin Ashinoff

23. Laser Treatment of Pigmented Lesions and Tattoos 489

David J. Goldberg

24. Treatment of Varicose and Telangiectatic Veins: Sclerotherapy,

Ambulatory Phlebectomy, and Laser 513
Robert A. Weiss and Margaret A. Weiss

25. Tumescent Liposuction 545

Rhoda S. Narins

26. Liposuction Using General Anesthesia: A Plastic Surgeon’s Viewpoint 573

Mehdi N. Adham, Bahman Teimourian, and Michael Chiaramonte
Contents xi

27. The Cook Weekend Alternative to the Facelift娂 641

William R. Cook, Jr.

28. Abdominal Contouring: Liposuction, Abdominal Rectus Plication,

and Crescent Tuck Abdominoplasty to Contour the Abdomen 661
Edward B. Lack

29. Multivector Face/Neck/Browlift: An Anatomical and

Biomechanical Approach 679
Elliot H. Rose

30. Blepharoplasty 719

Gregg M. Menaker, Ronald L. Moy, and Philina Lamb

31. Cosmetic Upper and Lower Eyelid Blepharoplasty: The

Ophthalmologist’s Perspective 749
Jean Carruthers and Alastair Carruthers

32. Brow Rejuvenation 771

Alan Matarasso, Ivo Pitanguy, Henrique N. Radwanski, and
Giulio Gherardini

33. Combination Cosmetic Procedures 785

William P. Coleman, III

34. Hair Transplantation with Alopecia Reduction 795

Walter P. Unger and Paul C. Cotterill

35. Earlobe Repair, Scar Revision, Actinic Cheilitis, and Other Lip Lesions 847
Nancy Marchell and Yardy Tse

36. Ancillary Aesthetic Dermatologic Treatments and Procedures 871

Zoe Diana Draelos

37. Laser Hair Removal 881

Wendy W. Lou and Arielle N. B. Kauvar

38. Office Photography in Cosmetic Surgery 896

David J. Narins

39. Handling the Dissatisfied or Difficult Patient 911

Timothy Corcoran Flynn and Mark A. Chastain
xii Contents

40. Facial Implants 925

Tracy M. Pfeifer

41. Cosmetic Benefits of Oral and Maxillofacial Surgery 939

Arthur C. Elias

Index 961

About the Editor 987

xiv Contributors

Paul C. Cotterill, M.D. Private Practice, Toronto, Ontario, Canada

David A. Davis, M.D. Department of Dermatology, University of Iowa College

of Medicine, Iowa City, Iowa

Lisa M. Donofrio, M.D. Department of Dermatology, Yale University School of

Medicine, New Haven, Connecticut

Zoe Diana Draelos, M.D. Department of Dermatology, Wake Forest University

School of Medicine, Winston-Salem, North Carolina

Arthur C. Elias, D.M.D. Private Practice, New York, New York

Timothy Corcoran Flynn, M.D. Tulane University School of Medicine, New

Orleans, Louisiana

Roy G. Geronemus, M.D. Laser and Skin Surgery Center of New York, New
York, New York

Giulio Gherardini, M.D., Ph.D. The National Centre for Cosmetic Surgery,
Birmingham, United Kingdom

Richard G. Glogau, M.D. Department of Dermatology, University of California

at San Francisco, San Francisco, California

David J. Goldberg, M.D. New Jersey Medical School, Newark, New Jersey

Karyn Grossman, M.D. Private Practice, Santa Monica, California

C. William Hanke, M.D. Laser and Skin Surgery Center of Indiana, Carmel,
and Indiana University School of Medicine, Indianapolis, Indiana

Arielle N. B. Kauvar, M.D. Laser and Skin Surgery Center of New York, and
New York University School of Medicine, New York, New York

Arnold William Klein, M.D. University of California at Los Angeles School of

Medicine, Los Angeles, California

Jeffrey A. Klein, M.D. Department of Dermatology, University of California at

Irvine, Irvine, California

Stephen O. Kovacs, M.D. Laser and Skin Surgery Center of New York, New
York, New York

Edward B. Lack, M.D. The Center for Liposculpture and Cosmetic Surgery,
Ltd., Des Plaines, Illinois

Philina Lamb, M.D. Division of Dermatology, VA–West Los Angeles Medical

Center, University of California at Los Angeles, Los Angeles, California
 Contributors

Mehdi N. Adham, M.D. University of Oklahoma Health Sciences Center,

Oklahoma City, Oklahoma

Tina S. Alster, M.D. Washington Institute of Dermatologic Laser Surgery, and

Department of Medicine, Georgetown University, Washington, D.C.

Christopher J. Arpey, M.D. Department of Dermatology, University of Iowa

College of Medicine, Iowa City, Iowa

Robin Ashinoff, M.D. Department of Dermatology, New York University, New

York, New York

Harold J. Brody, M.D. Department of Dermatology, Emory University School

of Medicine, Atlanta, Georgia

Jenette A. Buening, M.D. Laser and Skin Surgery Center of Indiana, Carmel,
Indiana

Alastair Carruthers, M.D. University of British Columbia, Vancouver, British

Columbia, Canada

Jean Carruthers, M.D. University of British Columbia, Vancouver, British

Columbia, Canada

Mark A. Chastain, M.D. Tulane University School of Medicine, New Orleans,

Louisiana

Michael Chiaramonte, M.D. University of Maryland, Baltimore, Maryland

William P. Coleman, III, M.D. Department of Dermatology, Tulane University

School of Medicine, New Orleans, Louisiana

Kim K. Cook, M.D. Coronado Skin Medical Center, Inc., Coronado, California

William R. Cook, Jr., M.D. Coronado Skin Medical Center, Inc., Coronado,
California
xiii
Contributors xv

Naomi Lawrence, M.D. Department of Dermatologic Surgery, Cooper Health

System, Marlton, New Jersey

Vicki J. Levine, M.D. Department of Dermatology, New York University School

of Medicine, New York, New York

Wendy W. Lou, M.D. Laser and Skin Surgery Center of New York, New York,
New York

Stephen Mandy, M.D. Department of Dermatology, University of Miami,

Miami, Florida

Nancy Marchell, M.D. Laguna Hills Dermatology, Inc., Laguna Hills, California

Alan Matarasso, M.D. Albert Einstein College of Medicine, New York, New
York

Seth L. Matarasso, M.D. University of California School of Medicine, San

Francisco, California

Gregg M. Menaker, M.D. Departmen of Dermatology, Harvard Medical School,

Boston, Massachusetts

Gary D. Monheit, M.D. University of Alabama at Birmingham, Birmingham,

Alabama

Ronald L. Moy, M.D. Division of Dermatology, VA–West Los Angeles Medical

Center, University of California at Los Angeles, Los Angeles, California

David J. Narins, M.D. New York University School of Medicine, New York,
New York

Rhoda S. Narins, M.D. Dermatology Surgery and Laser Center, New York and
White Plains, and Department of Dermatology, New York University Medical
Center, New York, New York

Tri H. Nguyen, M.D. Department of Dermatology, Mayo Clinic Foundation,

Rochester, Minnesota

Tracy M. Pfeifer, M.D. Department of Plastic Surgery, Manhattan Eye, Ear and
Throat Hospital, New York, New York

Kevin S. Pinski, M.D. Department of Dermatology, Northwestern University

Medical School, Chicago, Illinois

Ivo Pitanguy, M.D. Pontifical Catholic University of Rio de Janeiro and Carlos
Chagas Institute of Post-Graduate Medical Studies, Rio de Janeiro, Brazil
xvi Contributors

Henrique N. Radwanski, M.D. Pontifical Catholic University of Rio de Janeiro

and Carlos Chagas Institute of Post-Graduate Medical Studies, Rio de Janeiro,
Brazil

Elliot H. Rose, M.D. Division of Plastic Surgery, The Mount Sinai/NYU

Medical Center, and The Aesthetic Surgery Center, New York, New York

Bahman Teimourian, M.D. Georgetown University Medical Center, Bethesda,

Maryland

Edward O. Terino, M.D. Plastic Surgery Institute of Southern California,

Thousand Oaks, California

Yardy Tse, M.D. Division of Dermatology, Department of Medicine, University

of California at San Diego, San Diego, California

Walter P. Unger, M.D. University of Toronto, Toronto, Ontario, Canada

Cynthia Weinstein, M.D. Laser House, Laser Surgery Institute of Melbourne

and Freemason’s Hospital, East Melbourne, Victoria, Australia

Margaret A. Weiss, M.D. Johns Hopkins University School of Medicine,

Baltimore, Maryland

Robert A. Weiss, M.D. Johns Hopkins University School of Medicine,

Baltimore, Maryland

Tina B. West, M.D. Department of Dermatology, The Washington Hospital

Center, Washington, D.C.
 1
Designing the Surgical Suite

C. William Hanke
Laser and Skin Surgery Center of Indiana, Carmel, Indiana, and Indiana
University School of Medicine, Indianapolis, Indiana

Jenette A. Buening
Laser and Skin Surgery Center of Indiana, Carmel, Indiana

FACILITY TYPE
The number of outpatient surgery procedures has surpassed the number of inpatient
procedures, and currently makes up 60 to 80% of the surgery market. States have
established regulations and accrediting organizations have developed standards in an
attempt to assure quality care in the outpatient setting. The California Assembly
passed AB 595, which requires regulatory oversight of outpatient surgery facilities
that use general anesthesia or intravenous sedation. This California Statute mandates
accreditation of office surgical facilities by the Accreditation Association for Am-
bulatory Health Care (AAAHC), the Joint Commission on Accreditation of Health-
care Organizations (JCAHO), Institute for Medical Quality (IMQ), or the American
Accreditation Association for Ambulatory Surgical Facilities (AAAASC); state li-
censure of an outpatient surgical facility; and Medicare certification of an ambulatory
surgery center. Other states have adopted similar policies or are considering them.
Consequently, three key questions must be answered to determine what type
of facility to design and develop:
1. What types of surgical procedures do you perform?
2. What types of anesthesia do you require?
3. What regulations regarding office surgery have been implemented in your
state?

Ambulatory Surgery Centers

Some physicians prefer to do procedures under local anesthesia in the office, and
will use an ambulatory surgery center or hospital operating room when intravenous
sedation or general anesthesia is necessary. Many free-standing or hospital-based
ambulatory surgery centers will grant privileges to dermatologic surgeons who can
document proper training and experience. A minority of dermatologic surgeons have
1
2 Hanke and Buening

developed their own ambulatory surgery centers as an extension of the office. The
cost to develop an office ambulatory surgery center is much higher than that for an
office alone. Therefore, a high volume of insurance-reimbursable ambulatory surgery
center procedures is required to support the facility. In dermatologic surgery, this
usually necessitates a large case load of flaps, grafts, and complex repairs.
Ambulatory surgery centers are highly regulated. Some states require a Certif-
icate of Need (CON) before a new ambulatory surgery center can be built. Some
states have a state licensure requirement for ambulatory surgery centers that is dis-
tinct from Medicare certification. Currently, AAAHC and other accrediting bodies
have ‘‘deemed status’’ which allows them to survey for AAAHC accreditation and
Medicare Healthcare Financing Administration (HCFA) certification during a single
survey. However, the Medicare survey does not satisfy state licensure requirements
and the state will schedule a separate survey for state licensure. As was stated earlier,
ambulatory surgery centers are highly regulated.
A Medicare-certified, state-licensed ambulatory surgery center will have a num-
ber of very specific design requirements depending on the particular state. A typical
list of requirements includes operating rooms as large as 400 sq ft, recovery room(s),
soiled utility room, clean utility room, separate waiting room for the ambulatory
surgery center, 8-ft wide corridor access to operating rooms, special air filtration
requirements, emergency power, emergency cart, special fire protection, and special
ceiling and wall coverings. One or more registered nurses are required for staffing.
The exact requirements for a particular state can be obtained from the ambulatory
care division of the state department of health.

Office Surgical Facilities

It is possible to develop a high-quality office surgical facility (OSF) without the
expense of an ambulatory surgical center. Many physicians would use only local
anesthesia or light oral or intramuscular sedation in a facility of this type. Other
physicians would contract with a Certified Registered Nurse Anesthetist (CRNA) or
anesthesiologist to deliver intravenous sedation or general anesthesia. An appropri-
ately sized procedure room for an OSF would be 144 to 256 sq ft. If general anes-
thesia or intravenous sedation is used, a recovery area should be available. However,
we have surveyed OSFs and ambulatory surgery centers where patients were recov-
ered in the operating rooms after the procedure. Full emergency preparedness is
necessary, and includes emergency cart and emergency power.

ACCREDITATION BY AAAHC
The AAAHC currently has 1000 ambulatory health care facilities under accreditation.
The American Society for Dermatologic Surgery (ASDS) is one of 12 sponsoring
healthcare organizations for AAAHC, and has two seats on the AAAHC Board of
Directors (Table 1). The ASDS and the other sponsoring healthcare organizations
have input into the AAAHC accreditation standards. The standards are under con-
tinuous review and revision by the AAAHC Board of Directors. The purpose of
AAAHC is delineated in Table 2.
AAAHC accredits many different types of ambulatory healthcare organizations
(Table 3). AAAHC Core Standards must be satisfied by all organizations, but Adjunct
Standards are applied only when appropriate (Tables 4, 5).
Designing the Surgical Suite 3

TABLE 1 AAAHC Sponsoring Organizations and Initial Year of Sponsorship

Year of
Sponsoring organization sponsorship

American Academy of Cosmetic Surgery (AACS) 1989

American Academy of Dental Group Practice (AADGP) 1987
American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) 1983
American Association of Oral and Maxillofacial Surgeons (AAOMS) 1989
American College Health Association (ACHA) 1979
American College of Occupational and Environmental Medicine (ACOEM) 1987
American Society for Dermatologic Surgery (ASDS) 1993
Association of Freestanding Radiation Oncology Centers (AFROC) 1989
Federated Ambulatory Surgery Association (FASA) 1979
Medical Group Management Association (MGMA) 1979
National Association of Community Health Centers (NACHC) 1979
Outpatient Ophthalmic Surgery Society (OOSS) 1982

TABLE 2 Purpose of AAAHC

Conduct a survey and accreditation program that will promote and identify high-quality,
cost-effective ambulatory health care programs and services
Establish standards for accreditation of ambulatory health care organizations and services
Recognize compliance with standards by issuance of certificates of accreditation
Conduct programs of education and research that will further the other purposes of the
corporation; to publish the results thereof; and to accept grants, gifts, bequests, and
devices in support of the purposes of the corporation
Provide programs that will facilitate communication, sharing of expertise, and consultation
among ambulatory health care organizations and services
Assume such other responsibilities and conduct such other activities as are compatible with
such survey, standard-setting, accreditation, and communication programs

TABLE 3 Types of Ambulatory Health Care Organizations Accredited by AAAHC

Ambulatory health care clinics Hospital-sponsored ambulatory care clinics

Ambulatory surgery centers and surgery centers
Birthing centers Occupational health services
College and university health services Office surgery centers and practices
Community health centers Oral and maxillofacial surgeons’ offices
Dental group practices Radiation oncology centers
Diagnostic imaging centers Single-specialty group practices
Endoscopy centers Surgical recovery centers
Health maintenance organizations (HMOs) Urgent or immediate care centers
Another random document with
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 ils reviennent à leur première querelle. Le roi d’Afrique
laisse à Doralice le choix entre Mandricard et
Rodomont. Ce dernier est repoussé, et part plein de
dépit, dans l’intention de s’en retourner en Afrique. Il
loge un soir dans une hôtellerie sur les bords de la
Saône.
Chant XXVIII. — L’hôtelier conte à Rodomont l’histoire de
Joconde. Rodomont, ayant changé son premier
dessein d’aller en Afrique, s’arrête dans une petite
chapelle abandonnée où arrive Isabelle avec l’ermite,
conduisant les restes mortels de Zerbin. Le païen veut
détourner Isabelle de la résolution qu’elle a prise de se
retirer du monde, et s’impatiente des remontrances de
l’ermite. 71
Chant XXIX. — Triste fin de l’ermite. Isabelle, pour
conserver sa chasteté, amène par une pieuse ruse
Rodomont à lui trancher la tête. Le païen construit un
pont étroit sur le fleuve voisin, et fait prisonniers les
chevaliers qui y arrivent, ou les tue ; il place leurs
armes comme un trophée sur la tombe d’Isabelle.
Arrive en cet endroit Roland qui se prend de querelle
avec Rodomont, le jette dans le fleuve, et donne de
nombreuses preuves de sa folie. 98
Chant XXX. — Étranges preuves de folie de Roland. —
Mandricard et Roger combattent l’un contre l’autre
pour l’écu d’Hector et l’épée de Roland. Roger est
blessé et Mandricard est tué. — Bradamante reçoit
des mains d’Hippalque la lettre de Roger et se plaint
de lui. — Renaud vient à Montauban, et emmène avec
lui ses frères et ses cousins au secours de Charles. 117
Chant XXXI. — Funestes effets de la jalousie. — Combat 141
de Renaud et de Guidon le Sauvage. Ce dernier est
reconnu, et se joint à la troupe des guerriers de
Montauban qui, réunis aux forces dont dispose
Charles, fait un grand carnage des Maures. —
Brandimart va avec Fleur-de-Lys sur les traces de
 Roland, et arrive au petit pont construit par Rodomont
dont il devient prisonnier. — L’armée des Sarrasins se
retire à Arles.
Chant XXXII. — Mesures prises par Agramant pour
renforcer son armée. — Bradamante, jalouse de Roger
à cause de Marphise, quitte son château et arrive à la
Roche-Tristan. Là, elle est obligée de combattre contre
trois princes, et leur fait vider les arçons. 169
Chant XXXIII. — Dans une salle de la Roche-Tristan,
Bradamante voit peintes sur les murailles les guerres
futures des Français en Italie. Défiée de nouveau par
les trois princes qu’elle avait déjà battus, elle les
enlève une seconde fois de selle. — Renaud et
Gradasse en viennent aux mains pour la possession
de Bayard. Celui-ci, épouvanté par un monstrueux
oiseau, s’enfuit dans un bois, et le combat se trouve
suspendu. — Astolphe va en Éthiopie sur l’Hippogriffe.
Là, par le son de son cor, il chasse dans l’enfer les
Harpies qui infectaient les tables du roi Sénapes. 197
Chant XXXIV. — Astolphe, étant entré dans la grotte par
où l’on descend dans l’enfer, apprend d’une âme
quelle peine est infligée à ceux qui méconnaissent
l’amour d’autrui. De là il va dans le Paradis terrestre ;
puis il passe dans la Lune, où on lui donne le moyen
de rendre la raison à Roland. Description du palais des
Parques. 230
Chant XXXV. — Éloge du cardinal d’Este. Le poète
montre comment le temps efface les noms des
hommes obscurs et voue à une immortelle renommée
ceux des hommes illustres. — Bradamante défie
Rodomont, le jette dans le fleuve, et suspend son
armure à la tombe d’Isabelle. Elle combat contre
Serpentin, Grandonio et Ferragus, qu’elle jette tour à
tour hors de selle. Elle appelle Roger au combat. 253
Chant XXXVI. — Bradamante persistant à défier Roger, 274
Marphise qui a prévenu ce dernier, est renversée
 plusieurs fois par la lance enchantée ; alors s’élève
une mêlée générale entre les chevaliers de l’un et
l’autre camp, qui étaient restés jusque-là spectateurs
de la lutte. Bradamante, qui parmi eux a reconnu
Roger, s’acharne contre lui ; mais, ne pouvant se
résoudre à lui faire outrage, elle se jette sur les Maures
et les disperse. S’étant ensuite retirée avec Roger en
un endroit écarté, où s’élève un mausolée, survient
Marphise, à laquelle Bradamante s’attaque de
nouveau. Roger s’efforce en vain de séparer les deux
adversaires ; pendant qu’il est lui-même aux prises
avec l’obstinée Marphise, une voix sortant du
mausolée leur apprend qu’ils sont frère et sœur.
Notes 297

F I N D E L A TA B L E D E S M AT I È R E S D U TO M E T R O I S I È M E .
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