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The binding of avidine is monitored by the conversion of the substrate (S) to a colored product (P) generic valsartan 80mg arteria retinae. Explain the effects of excess of antigen Immunoelectron Microscopic Test and antibody on precipitation reaction generic valsartan 80mg fast delivery hypertension nos 4019. When viral particles mixed with specific an- Discuss the agglutination reactions with tisera are observed under the electron mi- their applications order valsartan online pills blood pressure kids. In the example shown buy generic valsartan 80mg online blood pressure chart 16 year old, a mixed cell population is stained with two antibodies, one specific for surface antigen A and the other specific for surface antigen B. The anti-A antibodies are labeled with fluorescein (blue) and the anti-B antibodies with rhodamine (brown). The cells are expelled, one at a time, from a small vibrating nozzle that generates microdroplets, each containing not more than a single cell. As it leaves the nozzle, each droplet receives a small electrical charge and the computer that controls the flow cytometer can detect exactly, when a drop generated by the nozzle passes through the beam of laser light that excites the fluorochrome. The intensity of the fluorescence emitted by each droplet that contains a cell is monitored by a detector and displayed on a computer screen. Because the computer tracks the position of cache droplet, it is possible to determine when a particular droplet will arrive between the deflection plates. By applying a momentary charge to the deflection plates when a droplet is passing between them, it is possible to deflect the path of a particular droplet into one or another collecting vessel. This allows the sorting of a population of cells into subpopulations having differ- ent profiles of surface markers. Complement System 7 The complement system includes serum and activate or inhibit reactions in the cascade. Up to C5, activation involves prote- The term ‘complement’ refers to the ability of olytic cleavage, liberating smaller fragments these proteins, to complement (augment) the from C2 through C5 except for C2, where for effects of other components of the immune historical reasons the larger fragment that re- system (e. Complement has sev- mains bound to the complex is termed C2a, eral main effects: the smaller fragments are by the letter ‘a’ 1. Production of peptide fragments that system can be initiated, either by antigen- participate in inflammation and attract antibody complexes or by a variety of non- phagocytes. Opsonization of organisms and immune vation of complement components occurs complexes for clearance by phagocyto- via three main pathways. Further more the complement goes to work, as soon Only, immunoglobulin M (IgM) and immu- as an invading microbe is detected; the noglobulin G (IgG) (IgG1, IgG2, IgG3 not system makes up an effective host im- IgG4) activate or fix complement via the clas- mune defense long before specific host sical pathway. C1 in A cascade is a set of reactions that amplify serum is a macromolecular complex consist- some effects, i. One molecule 2 so far identified in the complement system, of IgM or two molecules of IgG can initiate 13 participate in the cascade itself, seven the process. C1q binding in the presence 78 Textbook of Immunology of Escherichia coli, Salmonella of low viru- lence), viruses (parainfluenza virus, human immunodeficiency virus) and even apoptotic cells interact with C1q directly, causing C1 activation and there by classical pathway. Alternative pathway (properdin pathway) The alternative pathway does not involve im- mune complex. Many unrelated substances such as bacterial endotoxin, IgA and IgD an- tibodies, cobra venom factor, nephritic factor (protein present in the serum of glomerulo- nephritis) initiate alternative pathway. The additional C3b binds of calcium ions, leads to sequential activation to the C3 convertase to form C3bBbC3b, of C1r and C1s. C3b forms complex with C4bC2a pro- mannan-binding lectin pathway ducing a new enzyme called C5 convertase Lectins are proteins that bind to specific car- (C4bC2aC3b). C5a is an anaphylatoxin or mannan-binding lectin is an acute phase and chemotactic factor. The C5b component protein, which binds sugar residues like man- is extremely labile and becomes inactive nose, found on microbial surface (e. Listeria within 2 minutes, unless C6 binds to it and species, Salmonella species, Candida albi- stabilizes its activity. Loss of membrane integrity Regulation of the results in the unregulated flow of electrolytes Complement System and causes lysis and death of cell. Following the activation of the complement, Non-immunological classical pathway acti- its components and split products are capa- vators: Certain bacteria (e. Factor ‘P’ (properdin) protects C3b and stabilizes this C3 convertases of the al- ternative pathway. Anaphylatoxin inactivator is an alpha globulin that enzymatically degrades C3a, C4a and C5a, which are anaphyla- Fig. The Complement Activation activation of complement system is regulated at different stages. Complement plays an important role in hu- moral immunity by amplifying the response Regulation Before Assembly and converting into an effective defense of Convertase Activity mechanism to destroy invading pathogens. Inhibitor-bound 4b is cleaved by factor I of the interactions of complement fragments to form bound 4d and soluble 4c. Inhibitor-bound C3b is cleaved by fac- ity by binding, biologically active comple- tor I to form iC3b and soluble C3f frag- ment components and degrading them into ment. The complement receptors I releases C3c and leaves C3dg bound and their primary ligands, which include to the membrane. Increased capillary permeability: C2 kinins are vasoactive amines, which in- creases capillary permeability. Virus neutralization: May require par- ticipation of ‘C’ for neutralization of herpes virus by IgM antibody. Immune adherence: ‘C’ bound to im- mune complex adhere to erythrocytes or to non-primate platelets. The immune adherence (C3 and C4) contributes to defense against pathogenic microorgan- isms, since such adherent particles are rapidly phagocytosed. Opsonization: Cells, immune complex- Deficiency in the complement system affects es are easily phagocytosed much more both innate and acquired immunity. A num- efficiently in the presence of C3b recep- ber of gene defects involving complement tors in most of the cells. Chemotaxis: C3a and C5a stimulate the to susceptibility to infections or risk to auto- movement of neutrophils. Although the two pathways are initiated in different ways, they combine to activate the complement system; B. The action of C3b is critical for opsonization and along with C5b for formation of membrane attack complexes. Synthesis of Complement C3 deficiency results in serious problems Complements are synthesized by liver, with recurrent infections and with immune spleen and phagocytic cells. Explain in detail nents (C5, C6, C7, C8 and C9) involved in about complement pathway. Cells and Tissues of the Immune System 8 The cells, which take part in immune reac- ing separated by connective tissue trabecu- tions are organized into tissue and organs in lae. Lymphocytes (thymocytes) are placed order to perform their functions most effec- more densely towards the periphery of each tively.
We assume that aortic stiffness values are approxi- mately normally distributed in both populations cheap 160 mg valsartan with visa blood pressure diet chart. Before computing t0 we calculate w ¼ 1 2 2 ð 5:29 =15 ¼ 1:8656 and w2 ¼ 2:69 =30 ¼ :2412 cheap valsartan 40 mg without prescription blood pressure chart by time of day. On the basis of these results we conclude that the two population means are different discount valsartan 40mg on line arrhythmia heart failure. This will allow the use of normal theory since the distribution of the difference between sample means will be approximately normal proven 40mg valsartan pulse pressure ratio. When each of two large independent simple random samples has been drawn from a population that is not normally distributed, the test statistic for testing H0: m1 ¼ m2 is ð x1 À x2 m1 À m2 0 z ¼ sﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ (7. If the population variances are known, they are used; but if they are unknown, as is the usual case, the sample variances, which are necessarily based on large samples, are used as estimates. Sample variances are not pooled, since equality of population variances is not a necessary assumption when the z statistic is used. One focus of the study was to determine if there were differing levels of the anticardiolipin antibody IgG in subjects with and without thrombosis. McNearney, “Analysis of Risk Factors and Comorbid Diseases in the Development of Thrombosis in Patients with Anticardiolipin Antibodies,” Clinical Rheumatology, 22 (2003), 24–29. The statistics were computed from two independent samples that behave as simple random samples from a population of persons with thrombosis and a population of persons who do not have thrombosis. Since the population variances are unknown, we will use the sample variances in the calculation of the test statistic. Since we have large samples, the central limit theorem allows us to use Equation 7. When the null hypothesis is true, the test statistic is distributed approximately as the standard normal. These data indicate that on the average, persons with thrombosis and persons without thrombosis may not have differing IgG levels. When testing a hypothesis about the difference between two populations means, we may use Figure 6. Alternatives to z and t Sometimes neither the z statistic nor the t statistic is an appropriate test statistic for use with the available data. When such is the case, one may wish to use a nonparametric technique for testing a hypothesis about the difference between two population measures of central tendency. The Mann-Whitney test statistic and the median test, discussed in Chapter 13, are frequently used alternatives to the z and t statistics. For each exercise, as appropriate, explain why you chose a one-sided test or a two-sided test. Discuss how you think researchers or clinicians might use the results of your hypothesis test. What clinical or research decisions or actions do you think would be appropriate in light of the results of your test? The investigators recruited 31 postmenopausal women with ankle fractures and 31 healthy postmenopausal women to serve as controls. One of the variables of interest was the length from the most superoanterior point of the body of the hyoid bone to the Frankfort horizontal (measured in millimeters). Do these data provide sufficient evidence to allow us to conclude that the two sampled populations differ with respect to length from the hyoid bone to the Frankfort horizontal? Eighty-two subjects with essential hypertension were randomly assigned to an intervention or a control group. The intervention group received monthly monitoring by a research pharmacist to monitor blood pressure, assess adherence to treatment, prevent, detect, and resolve drug-related problems, and encourage nonpharmaco- logic measures for blood pressure control. The changes after 6 months in diastolic blood pressure (pre À post, mm Hg) are given in the following table for patients in each of the two groups. Intervention Group Control Group 2 2 24 6 10 12 2 2 8 3 26 À 2 À 20 8 14 6 10 0 12 0 2 À 14 14 10 8 14 10 28 À8 30 8 2 16 4 À2 À18 16 18 20 18 À12 À2 2 12 12 6 À6 Source: Data provided courtesy of Jose Garcao,S~ M. The sample sizes and means and standard deviations of the test scores were as follows: Sample n x s 1 15 4. Group 2 subjects delivered by either cesarean section or the vaginal route following spontaneous labor. The sample sizes, mean cortisol levels, and standard deviations were as follows: Sample n x s 1 10 435 65 2 12 645 80 Do these data provide sufficient evidence to indicate a difference in the mean cortisol levels in the populations represented? Sample 1 consisted of 50 adult male alcoholics with ring sideroblasts in the bone marrow. The mean protoporphyrin levels and standard deviations for the two samples were as follows: Sample x s 1 340 250 2 Can one conclude on the basis of these data that protoporphyrin levels are higher in the represented alcoholic population than in the nonalcoholic population? The mean levels, standard deviations, and sample sizes for the two samples studied were as follows: Sample n x s With condition 35 8. Subjects in group A were subjected to a 10-day period of sensory deprivation, while subjects in group B served as controls. At the end of the experimental period, the alpha-wave frequency component of subjects’ electroencephalograms was measured. The following are the cell diameters mm of 40 lymphocytes and 50 tumor cells obtained from biopsies of tissue from patients with melanoma: Lymphocytes 9. A hypothesis test based on this type of data is known as a paired comparisons test. Reasons for Pairing It frequently happens that true differences do not exist between two populations with respect to the variable of interest, but the presence of extraneous sources of variation may cause rejection of the null hypothesis of no difference. On the other hand, true differences also may be masked by the presence of extraneous factors. One method would be to select a simple random sample of subjects to receive sunscreen A and an independent simple random sample of subjects to receive sunscreen B. We send the subjects out into the sunshine for a specified length of time, after which we will measure the amount of damage from the rays of the sun. Suppose we employ this method, but inadvertently, most of the subjects receiving sunscreen A have darker complexions that are naturally less sensitive to sunlight. Let us say that after the experiment has been completed we find that subjects receiving sunscreen A had less sun damage. We would not know if they had less sun damage because sunscreen A was more protective than sunscreen B or because the subjects were naturally less sensitive to the sun. A better way to design the experiment would be to select just one simple random sample of subjects and let each member of the sample receive both sunscreens. We could, for example, randomly assign the sunscreens to the left or the right side of each subject’s back with each subject receiving both sunscreens. After a specified length of exposure to the sun, we would measure the amount of sun damage to each half of the back. If the half of the back receiving sunscreen A tended to be less damaged, we could more confidently attribute the result to the sunscreen, since in each instance both sunscreens were applied to equally pigmented skin.
Sacrospinous vault suspension and abdominal colposacropexy: Success rates and complications buy generic valsartan 40mg online heart attack maroon 5. Sacrospinous ligament colpopexy: New instrumentation applied to a standard gynaecologic procedure discount valsartan online arteria digitalis palmaris communis. Transvaginal sacrospinous colpopexy by palpation—A new minimally invasive procedure using an anchoring system purchase valsartan on line arteria spanish. Correction of the vaginal vault prolapse using Capio suture capturing device: Our experience order valsartan 80mg with visa blood pressure instrument. Vaginal sacrospinous colpopexy using the Capio suture-capturing device versus traditional technique: Feasibility and outcome. Long-term patient satisfaction with Michigan four-wall sacrospinous ligament suspension for prolapse. Uterosacral and sacrospinous ligament suspension for restoration of apical vaginal support. Anterior or posterior sacrospinous vaginal vault suspension: Long-term anatomic and functional evaluation. Massive eversion of true vagina: Pathogenesis, diagnosis, and therapy of the “true” prolapse of the vaginal stump. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: A prospective randomized study with long-term outcome evaluation. Preoperative and postoperative analysis of site-specific pelvic support defects in 81 women treated with sacrospinous ligament suspension and pelvic reconstruction. Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction. Should sacrospinous ligament fixation for the management of pelvic support defects be part of a residency program procedure? Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse. Outcomes study: A comparison of cure rates in 695 patients undergoing sacrospinous ligament fixation alone and with other site-specific procedures—A 16-year study. Anatomic and functional assessment and risk factors of recurrent prolapse after vaginal sacrospinous fixation. Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: A prospective randomized study. Long-term outcome of vaginal sacrospinous colpopexy for marked uterovaginal and vault prolapse. Suture erosion rates and long-term surgical outcomes in patients undergoing sacrospinous ligament suspension with braided polyester suture. Long-term follow-up after vaginal sacrospinous fixation: Patient satisfaction, anatomical results and quality of life. Clinical outcome of transvaginal sacrospinous fixation with the Veronikis ligature carrier in genital prolapse. Heterogeneity in anatomic outcome of sacrospinous ligament fixation for prolapse: A systematic review. Transvaginal sacrospinous colpopexy for vaginal vault and complete genital prolapse in aged women. Recurrent pelvic support defects after sacrospinous ligament fixation for vaginal vault prolapse. Management of vaginal vault prolapse: Retrospective comparison of abdominal versus vaginal approach. Initial report of anatomic and clinical comparison of the sacrospinous ligament fixation to the high McCall culdoplasty for vaginal cuff fixation at hysterectomy for uterine prolapse. Vaginal length and sexual function after colpopexy for complete uterovaginal eversion. An anatomic approach to pelvic hemorrhage during sacrospinous ligament fixation of the vaginal vault. Intraligamentous nerves as a potential source of pain after sacrospinous ligament fixation of the vaginal apex. Massive evisceration: A complication following sacrospinous vaginal vault fixation. A review of the current status of laparoscopic and robot-assisted sacrocolpopexy for pelvic organ prolapse. Pelvic relaxation and repair including prolapse of the vagina following vaginal hysterectomy. Bilateral attachment of the vaginal cuff to iliococcygeus fascia: An effective method of cuff suspension. Repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia. Comparison of vaginal length after iliococcygeus fixation and sacrospinous ligament fixation. Iliococcygeus fixation or abdominal sacral colpopexy for the treatment of vaginal vault prolapse: A retrospective cohort study. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Bilateral extraperitoneal uterosacral vaginal vault suspension: A 2-year follow-up longitudinal case series of 123 patients. Outcomes of transvaginal uterosacral ligament suspension: Systematic review and metaanalysis. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Posterior culdoplasty: Surgical correction of enterocele during vaginal hysterectomy: A preliminary report. Randomized comparison of three surgical methods at the time of vaginal hysterectomy to prevent posterior enterocele. One-year objective and functional outcomes of a randomized clinical trial of vaginal mesh for prolapse. Laparoscopic sacral colpopexy versus total vaginal mesh for vaginal vault prolapse: A randomized trial. Efficacy and safety of transvaginal mesh kits in the treatment of prolapse of the vaginal apex: A systematic review. Single-incision vaginal approach to treat cystocele and vault prolapse with an anterior wall mesh anchored apically to the sacrospinous ligaments. Comparison between Elevate Anterior/Apical system and Perigee system in pelvic organ prolapse surgery: Clinical and sonographic outcomes. Elevate anterior/apical: 12-month data showing safety and efficacy in surgical treatment of pelvic organ prolapse. The vaginal apex is normally supported by the uterosacral–cardinal ligament complex and the levator ani musculature, nominated by DeLancey  as Level 1 support. This defect in most cases occurs secondary to weakness in the muscular levator ani complex, which can occur as a result of obstetric injury with muscular tearing or denervation, aging, or even congenital defects such as spina bifida or bladder extrophy. Apical loss of support secondary to muscular injury may be unilateral or bilateral resulting in apical prolapse. This often occurs in the presence of anterior and/or posterior compartment prolapse.
A randomized controlled trial of pubovaginal sling versus vaginal wall sling for stress urinary incontinence discount valsartan express blood pressure chart pediatric. Pubovaginal fascial sling for all types of stress urinary incontinence: Long-term analysis discount 160 mg valsartan free shipping blood pressure yoga. Our experience with pubovaginal slings in patients with stress urinary incontinence buy valsartan line blood pressure medication problems. Pubovaginal sling surgery for simple stress urinary incontinence: Analysis by an outcome score buy valsartan 80mg overnight delivery heart attack zine. Long-term outcome and quality of life after modified pubovaginal sling for intrinsic sphincteric deficiency. Long term follow up of the cruciate fascial sling for women with genuine stress incontinence. Pubovaginal cutaneous fascial sling procedure for stress urinary incontinence: 10 years’ experience. Expanded indications for the pubovaginal sling: Treatment of type 2 or 3 stress incontinence. Comparison of the treatment outcome of pubovaginal sling, tension-free vaginal tape, and transobturator tape for stress urinary incontinence with intrinsic sphincter deficiency. Comparison of autologous rectus fascia and cadaveric fascia in pubovaginal sling continence outcomes. Pubovaginal sling using allograft fascia lata versus autograft fascia for all types of stress urinary incontinence: 2-year minimum followup. The long-term results of pubovaginal sling surgery using acellular cross-linked porcine dermis in the treatment of urodynamic stress incontinence. Pubofascial versus vaginal sling operation for the treatment of stress urinary incontinence: A prospective study. Tissue strength analysis of autologous and cadaveric allografts for the pubovaginal sling. Patch procedure: Modified transvaginal fascia lata sling for recurrent or severe stress urinary incontinence. The fascia lata sling procedure for treating recurrent genuine stress incontinence of urine. Cadaveric fascia lata versus intravaginal slingplasty for the pubovaginal sling: Surgical outcome, overall success and patient satisfaction rates. Medium-term follow-up on use of freeze-dried, irradiated donor fascia for sacrocolpopexy and sling procedures. Outcome in 104 pubovaginal slings using freeze-dried allograft fascia lata from a single tissue bank. High failure rate using allograft fascia lata in pubovaginal sling surgery for female stress urinary incontinence. Comparison of solvent-dehydrated allograft dermis and autograft rectus fascia for pubovaginal sling: Questionnaire-based analysis. Cadaveric fascia lata sling for stress urinary incontinence: A prospective quality-of-life analysis. Cadaveric fascia lata pubovaginal slings: Early results on safety, efficacy and patient satisfaction. Pubovaginal sling using Duraderm graft: Intermediate follow-up and patient satisfaction. Pubovaginal sling using cadaveric allograft fascia for the treatment of intrinsic sphincter deficiency. Cadaveric versus autologous fascia lata for the pubovaginal sling: Surgical outcome and patient satisfaction. Pubovaginal sling using cadaveric allograft fascia for the treatment of female urinary incontinence. Vaginal paravaginal repair with porcine dermal reinforcement: Correction of advanced anterior vaginal prolapse. Solvent-dehydrated cadaveric dermis: A new allograft for pubovaginal sling surgery. Urodynamic and clinical assessment of the Lyodura sling operation for urinary stress incontinence. Comparison of Burch and Lyodura sling procedures for repair of unsuccessful incontinence surgery. Clinical and urodynamic assessment of the porcine dermis bladder sling in the treatment of genuine stress incontinence. Comparative analysis of urinary incontinence severity after autologous fascia pubovaginal sling, pubovaginal sling and tension-free vaginal tape. Porcine small intestinal submucosa as a percutaneous mid-urethral sling: 2- year results. Small intestinal submucosa for pubourethral sling suspension for the treatment of stress incontinence: First histopathological results in humans. Intense inflammatory reaction with porcine small intestine submucosa pubovaginal sling or tape for stress urinary incontinence. Minimally invasive synthetic sling suburethral sling operations for stress urinary incontinence in women. Deux incontinence apres adenonectomie queries par injection de paraffine daris de perinee. Transurethral polytetrafluoroethylene injection in female patients with urinary continence. Disappointing effect of endoscopic teflon injection for female stress incontinence. Pulmonary teflon granulomas following periurethral teflon injection for urinary incontinence. Pulmonary migration following periurethral polytetrafluoroethylene injection for urinary incontinence. Long-term follow-up of women treated with periurethral teflon injections for stress incontinence. Endoscopic injection of autologous adipose tissue in the treatment of female incontinence. Treatment of urinary stress incontinence using paraurethral injection of autologous fat. Periurethral injection of autologous fat for the treatment of sphincteric incontinence. Periurethral autologous fat injection as treatment for female stress urinary incontinence: A randomized double-blind controlled trial. A diagnosis of urodynamic stress incontinence can only be made after urodynamic investigation, and this is defined as the involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction . Stress incontinence is the most commonly reported type of urinary incontinence in women. In a large epidemiological study of 27,936 women from Norway , overall, 25% of women reported urinary incontinence, of whom 7% considered it to be significant, and the prevalence of incontinence increased with age.
Unlike ﬁllers with a basis of collagen purchase valsartan once a day hypertension questions, hyaluronic acid persed in solution with hyaluronic acid (60 %) quality 160mg valsartan blood pressure and stroke. This drawback makes it neces- The agarose that belongs to the family of galactans buy 160 mg valsartan free shipping hypertension patho, sugars sary to repeat the outpatient injection sessions before one with ﬁve carbon atoms buy discount valsartan 40 mg on-line hypertension guidelines canada, is a polysaccharide that has the char- gets good lasting results. It does not require testing of acteristic of becoming hydrocolloid in the presence of water immune reaction. Its inﬁltration does not cheekbones, and small areas of skin depression, it is also require evidence of allergic sensitization as the agarose is suitable for the correction of medium-sized deep skin fur- highly biocompatible and doesn’t stimulate immune rows, wrinkles, and scars. It’s suitable not only in the correction of skin blem- ishes such as grooves, wrinkles, or scars, but it also increases volumetric tissue or corrects traumatic injuries. Although used in the past, silicone oil is no longer used in its original form because of it s signiﬁcant side effects both in 2. It does not require allergy testing the migration of silicone molecules which are able to trigger because there are no reports of immune sensitization reac- systemic autoimmune diseases . It is completely absorbed by the body and transformed Moreover, very often, the inﬁltration of this substance into water and carbon dioxide. The formulations on the mar- produces cosmetic damage difﬁcult to resolve as distorting ket present it in a clear gel form that, once inoculated subcu- hyperﬁbrosis and hardening of the treated areas. Currently, taneously for the correction of wrinkles, has a long duration the clinical use of silicone as a ﬁlling material is limited to of action with a resorption after approximately 1 year after substances whose formulation needs microspheres of Filler 1087 silicone rubber at 25–35 % suspended to 65–75 % in a bio- The ﬁller creates a capsule in the injection site which compatible injectable gel (Figs. It is preferentially suitable for the treat- methacrylate is marketed in the form of microspheres in a ment of nose, cheeks, or chin area blemishes. While the ﬁrst remains within tissues for long periods, collagen, on the contrary, is readily reab- 2. The injection should be in-depth and requires a skin The use of ﬁllers consisting of calcium hydroxyapatite, a sensitivity test 30 days before the procedure. Once inﬁltrated, synthesis analogue of inorganic constituents of bone tissue, adjustments but not the removal of the substance can be made. This allows a longer duration effect of the ﬁller since the new matrix is able to compensate the slow absorption of calcium hydroxyapatite. Because of its physical and biological characteristics, the aesthetic clinical use is the correction of the ipovolumet- rie of the bridge of the nose. The product is marketed as a microspherule form suspended in an aqueous gel that, once injected into the desired site, is not able to migrate in the nearby areas as it generates a tissue response that leads to the formation of microcapsules that surround the microspherules. As with any procedure, you conoma at the level of the lower lip must undergo a thorough physical examination before F i g. Note the excessive projection of the lips of the face and the complete disharmony 1088 M. We must then assess this information and the if injected in a different location, an immediate degradation, contraindications or the beneﬁts of a given treatment and thus reducing its clinical effect or producing side effects and recommend the most beneﬁcial in relation to the defect to be anti-aesthetics. The interview with the patient is important to under- The depth of the implantation, then, depends strictly on stand what he/she needs and expects. Once you have the con- the degree of ﬁlling and therefore compromise the result of sent, it is advisable to take pretreatment photos that will the session (Fig. The area to be treated must have optimal lighting and The injection site and technique of inﬁltration vary depend- must always be thoroughly disinfected. While for some patient in the upright position or sitting in order to assess the best conditions possible, defects to be treated, and the effects of gravity on the tissues. Any residual makeup or other substances must be removed before performing the inﬁltration of the ﬁller. This is pro- portional to the surface to be treated; one to three vials can be used, but a good rule would be not to exceed 3–4 ml per ses- sion dose. Depending on the substance used, besides the most effective technique, you should choose the most suit- able materials. If for some substances such as collagen or hyaluronic acid a 30-gauge needle can be used, for other substances, such as calcium hydroxyapatite, a 27-gauge needle can be used. More superﬁcial imperfections do not usually require a very deep injection, placing the needle in a parallel way to the skin, placing the needle in the sub- cutaneous tissue surface, and releasing the product as the F i g. This technique is particularly suit- effect, the place of inﬁltration can be superﬁcial, medium, or deep able for lips (Fig. The needle is inserted parallel to the line of the thread and the product is released as the needle is withdrawn ion, it is important to highlight the ﬁller with some deeper injections that give volume to the lip itself. Even in the case of the treatment of the nasolabial crease, the place- ment of the product is superﬁcial and is in front of the same furrow. In contrast, in defects that are more pronounced and where there is a need of volume, such as hypoplasia of the malar, the site of the injection is deeper and the needle must penetrate the skin with an acute angle that can vary from 25° to 45° and almost reach the bone. When ﬁnally the defect is serious, repeated sessions of deep planting are needed; the injection must be performed preferentially in the subcutaneous tissue by injecting the needle with an inclination of 90° reaching the periosteum and injecting the ﬁller to give the desired volume evenly. The whole procedure should take place in the shortest time possi- ble, so the patient has less trouble mainly because the result- ing edema may easily deceive the doctor over- or underestimating the quantity of product to continue to inject. In case there is an excess of the product, the mistake can be resolved by injecting hyaluronidase; if the product injected is hyaluronic acid being the hydrolytic enzyme, a delicate mas- sage should follow. In the case of annoyance or strong pain, it is better to use topical or injectable anesthetics. The substance can be carried out using two special par- ticular techniques: the linear threading or the “serial punc- tures” (Figs. Each of them requires a good manual dexterity and excellent precision in the depth of the implan- tation. The ﬁrst technique is to insert the product within the depressed tissue and for its entire length. Once within the tissue to be treated, a substance is released gradually and is directed linearly. The product can be inﬁltrated in layers, repeating the It is created by inserting the needle parallel to the skin sur- second inﬁltration along the same line of the ﬁrst, in this face at the level of the mid-dermal surface. This technique causes gradually released by tracing parallel lines that intersect at minor discomfort because of the small number of injec- 90 degrees with other lines of injection forming a grid. It allows for a better calibration of the amount used Once the product is released, it’s better to gently massage as well as its distribution in the tissue. After the technique is a better implantation control and a greater implantation, the site must be gently massaged for a few accuracy of the injection, yet it needs more injection with minutes to improve the distribution of substance. Another technique, Posttreatment medication is not needed and the use of cold although used less, is the “fan” injection, that is, entering compression if the patient feels a slight tenderness is rarely into the skin using a single site that becomes the heart from needed. This technique is particularly indicated when the strenuous exercise the use of alcohol and cigarette smoking defect to treat is very large. Finally, the patient should be the cheeks, “the grid” inﬁltration technique can be used. The volume increase of the upper lip produces a shortening of philtrum and the upper incisors are covered by the lip itself a b Fig. Gottfried L, Vera M (2003) Ulrich charrier, human histology and persistence of various injectable ﬁller substances for soft tissue 1. Aesthetic Plast Surg 27(5):354–66; discussion 367 new ﬁller material in corrective and cosmetic surgery: DermaLive 9.
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