By J. Yorik. Georgia Southern University.

The most common types of anesthesia to injection sites include: lidocaine with epinephrine order elavil from india pain treatment for arthritis in dogs, topical lidocaine 33 generic 50 mg elavil amex pain medication for dogs tylenol. Applying an icepack to the nose decreases been injected in various ways discount elavil 50mg mastercard lateral knee pain treatment, with any of the follow- sensation and provides good analgesia order elavil cheap chronic pain treatment vancouver. Our preference is a 27 gauge ½ overly aggressive injection can create a “pin-cushion” in. If the skin is lax, a the authors’ approach is to address the nose from top good outcome can be expected from a nasal tip to bottom. Because it is abundant in sebaceous If there is a dorsal hump, injection cephalad to it, or glands, the nasal tip should be approached preferably caudal to it may mask that hump (Fig. Very few times the nasal nares need be done to achieve symmetry by injecting unequal to be augmented. If anesthesia were not used, injections Doses vary depending on individual patient character- can alternatively be coupled to loosening of subcuta- ® istics, but suggested maximum doses include: 1. Similarly, the thick, white texture of Radiesse mum doses to each specifc area [19]. W e recommend may make it visible under thin skin, which is not aes- limiting the initial total injection to 1. Superfcial injections can lead to tension on the overlying skin as well as overcorrection. Even so, some correction can often Ice should be applied during breaks between injec- still be achieved in such areas [8]. Care should be tions and for a period afterward to reduce edema and 33 Injection/Filler Rhinoplasty 379 Fig. Splint placement for a few days after Injection is followed by massaging, which molds injection may prevent displacement of the fller [6]. M olding may be enhanced by micropore taping ward, but encourage patients to place cold compresses 380 G. The authors have not also been used to improve post-rhinoplasty contour seen the fller being displaced by this follow-up care. Other dates include people with ethnic noses: Asians, M iddle adverse effects include soreness, numbness, contour Easterners, African–Americans, and Hispanics. Overall, Radi- because, in general, such people have thicker skin, esse® rhinoplasty is typically well-tolerated and patient lower nasal dorsums, and bulbous tips compared to satisfaction for non-surgical nasal augmentation is Caucasian patients. W hen performing a rhinoplasty on any patient popu- Removal of excess Radiesse® with an 18-g needle lation it is important to take cultural issues into consid- can lead to correction if Radiesse® is injected into the eration. Radiesse® has a 1:1 injec- defects, most patients also cherish subtleties and preser- tion-to-augmentation ratio, thus it requires no addi- vation of their ethnicity. Rhinoplasty should refne facial tional post-treatment augmentation monitoring [27]. W hen they Additional touch-ups may be required after 2 weeks to arise, also recognize language and cultural barriers. Patients are seen 2–3 weeks after injections to ensure that they are satisfed after most of the edema and ecchymosis has subsided. As with any aesthetic procedure, satisfaction depends A common misconception is that such rhinoplasty is not only on surgical technique, but realistic expecta- done to look more “W estern,” despite the fact that high, tions from patients, as well as proper prior communi- narrow bridges are aesthetically pleasing in many Asian cation between surgeons and patients. To achieve such results, surgical augmen- rhinoplasty with Radiesse® has a high rate of patient tation is performed with autogenous or alloplastic mate- satisfaction in the literature [8, 12, 15, 17–21], as well rial placed into the nasal dorsum to make the nasion as at our institute. Over the years, there relation between patient satisfaction scores and demon- has been a debate over the more preferable material. To this end, it has been found that surgeons performing In the rhinoplasty literature, the standard for mea- augmentation rhinoplasty on Asian patients have had suring patient satisfaction is through patient-reported to recognize that many are unhappy with autogenous outcome measures. The most common instruments implants and prefer alloplasts, particularly silicon, despite used to measure patient satisfaction after surgical rhi- long-term side effects [29]. Such surgery, however, may noplasty are the Rhinoplasty Outcomes Evaluation, produce conspicuous and unsatisfactory results [30], the Glasgow Beneft Inventory, and the Facial Appear- particularly due to exposure and extrusion of implants. For non-surgical rhinoplasty Implant exposure can lead to scarring, which can be with Radiesse®, there is a need for the use of such diffcult to treat with revision surgery [31]. As inhabitants of the largest continent, Asian’s noses vary depending on different geographical reg- ions. Filipinos and Polynesians typically have “fat” noses which start At the nasal radix and dorsum, Radiesse® can be used to off narrow at the bridge and gradually become wide augment height, to give a wider appearance or correct and blunt at the tip [29]. By correcting retracted columellas, of rhinoplasty in Asian patients can generally be seen 33 Injection/Filler Rhinoplasty 381 as similar to the goal of Occidental rhinoplasty: a Non-surgical rhinoplasty with Radiesse® in Asian strong dorsum with a prominent origin but not com- patients (Fig. Approximately 50% of mentation is also frequently done as part of revision or African–Americans are good candidates for augmen- after removal of an implant. African–American patients with American Indian heritage frequently also have dorsal humps and high nasions that may extend on the glabella [29]. Dorsal augmentation addition, African–American patients commonly com- with Radiesse® is also advantageous because the cau- plain of short columella, small nasolabial angle with dal end of the nose tends to be mobile, therefore rigid 384 G. Radiesse® can also give a more prominent appearance the dorsum is typically wide, and the goal is to con- to an otherwise bulbous, fattened tip. African–American patients has also been described as This is diffcult to address with Radiesse®. The tip is feshy, fat, wide, depressed, pendulous, or depressed, ptotic and Radiesse® can provide a more prominent while the aim is to create a more sculpted tip [29]. Another problem site is the columella, which is Flared nares cannot be treated with Radiesse® rhino- often weak and found to lie above the alar rim. A mestiso nose typically has a narrow and defcient W hile generalizations should be avoided, morphologi- radix that may be augmented with Radiesse® to balance cally the M iddle Eastern nose falls somewhere between 33 Injection/Filler Rhinoplasty 385 Fig. Some of the most In addition, these patients commonly have thick, common features of M iddle Eastern noses are: wide sebaceous nasal skin – especially at the tip [34]. M iddle nasal bones, slight alar faring, ill-defned bulbous tips, Eastern noses can also have dorsal humps and high bulky infratip lobules, over-projecting radix, high and nasions extending onto the glabella [29].

If the patient with deep lines an injection is made perpendicularly into the belly of actively contracts the muscle during speech and ani- the muscle buy 75mg elavil pain and spine treatment center dworkin. Dysport 12–14 U is usually suffcient in a mation buy 50mg elavil otc pain treatment center of the bluegrass lexington ky, look for dermatochalasis and consider sparing female patient purchase 25 mg elavil visa pain medication for dog ear infection, but up to 20 U may be required in a frontalis to avoid brow ptosis and hooding purchase elavil no prescription achilles tendon pain treatment exercises. To inject the medial part of corrugator, elderly patients with excess skin under the brow should the thumb or fnger is placed along the orbital rim to be treated conservatively [21]. The author directs the small 4–5 U aliquots of Dysport across the superior needle along the long axis of the muscle, depositing aspect of frontalis are suffcient to smooth lines com- 8–10 U Dysport in the medial part in a female patient. This is usu- the muscle fbers extend more superiorly toward the ally at least 1 cm from the orbital margin, but the site hairline, two rows of injections can be placed of injection is determined by the muscle itself and (Fig. Over the lateral frontalis, even less toxin should not be dictated by bony landmarks here. This injection is made perpendicularly just above the cerus is gently pinched and a perpendicular injection is made periosteum and deep to frontalis. Just 1 U the lateral frontalis is treated with low doses high in the fore- Dysport is placed close to the lateral brow to prevent frontalis head. W hen the forehead is treated, the glabella is always treated activity creating creases or “peaking” here. Diagram brow lift, a further injection is made in fbers of orbicularis oculi shows units of Dysport at each injection point at the temporal crest line near the tail of the brow depends on the morphology and strength of the muscle in this region. In patients with a very weak frontalis and almost no movement over the lateral brow, the lat- eral forehead can be avoided completely. By treating the medial frontalis only, resting tone in fbers of the lateral part increases, creating a slight lateral brow lift. W hen contraction of frontalis produces bunching of skin immediately above the lateral brow, minute doses should be placed in the area of maximal wrinkling to soften the lines and prevent “peaking” above the brow (Fig. Although brow ptosis is less likely when extremely small doses are placed immediately above Fig. A small dose of the brow, an additional injection of 3 U should be made botulinum toxin should be placed within the area marked by the in fbers of orbicularis oculi near the tail of the brow to circle to soften these lines. If no injections the X to prevent lateral brow ptosis are placed in a lateral frontalis that is strong, the “M ephisto” or “Spock” appearance is likely (Fig. The injection in the Dysport 2 U placed superiorly near the hairline and 1 U depressor part of orbicularis oculi serves two purposes. This should be corrected with a small dose lateral brow, presumably to avoid the risk of lateral brow ptosis. Secondly, its action-halo affects patients usually beneft from two rows of injections, fbers of frontalis just above the lateral brow, thus soft- with 6 U aliquots of Dysport typically required. Before ening the “peaking” or wrinkle above the tail of the treatment, asymmetries in the brow and muscle activ- brow that commonly occurs when frontalis is spared. A loss of resistance should be felt as the should raise minimally but be pulled down strongly at needle tip traverses the dermal-subcutaneous junction. The pattern of injections in the male If the needle tip remains in the dermis, excessive resis- patient differs, with more aggressive chemodenerva- tance is felt and the solution may leak onto the surface tion over lateral frontalis to maintain an aesthetically of the skin. M icrodroplets of botulinum toxin injected intrader- mally in the cheeks may improve cheek lines, but the risk of mouth asymmetry still exists [22]. Although rare, lateral injections should be made at least 1 cm from the bony orbital margin to prevent spread into the globe, resulting in extraocular muscle weakness and diplopia [23]. The fnger is placed on the rim as injec- tions are made superfcially, either in the dermis or subcutaneous plane between the visible blood vessels (Fig. As a general rule, 3–4 injections can be made, keeping the inferior injection lateral to an imag- inary line dropped vertically from the lateral canthus (Fig. Infraorbital injections can be made in the pretarsal portion of orbicularis oculi, however, to reduce lid bulging (Fig. Before treating the lower eyelid, example, 114 U Dysport is used for treatment of the frown and the snap test should be performed. Higher doses may be required, particularly in the gla- gazing forwards, gently retract the lower eyelid inferi- bellar muscles orly away from the eye. If it returns sluggishly, avoid Every effort should be made to avoid the visible veins treating this area to prevent complications. Bleeding should be stemmed immediately with external pressure for 90s to avoid ecchymosis. The brow elevates when the depressors are treated and the elevators, or parts of them, are pre- the crow’s feet or lateral orbital rhytids are commonly served. Subtle elevation of the lateral brow is treated with 3–4 injections of botulinum toxin achiev- achieved by denervating the lateral orbicularis oculi ing excellent periorbital rejuvenation (Fig. Further lat- patient should understand prior to treatment that the eral brow elevation occurs when the medial frontalis aim is to soften lateral lines, and that some “smile is treated and fbers of lateral frontalis are preserved lines” at the upper cheek will remain. Prendergast avoid unopposed action of the depressor muscles to denervate inferior most fbers of procerus that act to pull the brow inferiorly. Rarely, dilator naris is injected with 4 U under treat lateral frontalis and allow the brow to lift, Dysport to reduce the faring associated with wide rather than over treat, with a risk of brow ptosis. The tip of the nose can also be made to ele- abnormally elevated lateral brow can easily be vate in patients with active depressor septi muscles. If the tip of the nose tugs inferiorly with movement of the mouth, injecting depressor septi is appropriate. This may also elongate the of the nose, the compressor naris portion of nasalis is upper lip and should be avoided in older patients where targeted with about 6 U Dysport injected under the the upper lip is already lengthened. In these patients, skin on either side of the nose where there is maximal the injection can be made at the insertion point of the wrinkling.

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Distribution of channels in the membrane: the num- Important Note ber of protein channels for the substance in the mem- Partition coefficient: Partition coefficient is the solubility of the brane determines the permeability of the substance substance in oil compared with the solubility in water buy discount elavil 25 mg on line blue ridge pain treatment center harrisonburg va. Pressure gradient: In addition to the electrochemical diffuse at a much faster rate through the membrane buy cheap elavil 75mg line alternative pain treatment center tacoma. Dif- Saturation Kinetics fusion is more from high pressure to low pressure order generic elavil pain medication for pancreatitis in dogs, as In simple diffusion order elavil online pills pain treatment center bethesda md, the rate of diffusion is proportional to the pressure causes greater number of molecule to hit the concentration of the substance and there is no satura- the membrane. In facilitated diffusion, the number of carrier proteins available determines the rate of diffusion. When Properties of the Membrane all the available binding sites on the carrier proteins are In addition to the concentration gradient of the substance occupied, the system operates at the maximum capacity. These factors sion is faster in facilitated diffusion compared to simple are governed by Fick’s law of diffusion. The rate of diffu- diffusion, as there is no involvement of carrier protein in sion of a molecule through a membrane is proportional to simple diffusion. Thus, the net diffusion in facilitated type the surface area (A) available for diffusion, and inversely is more than in simple type (see Fig. According to Fick’s law, for a substance whose inside Competitive Inhibition and outside concentrations are respectively Ci and C0 Many substances share same carrier protein for their mmol/l: transport. Also, Na and Ca com- –6 branes is fairly constant at 10 cm, D/T simplifies to the pete for the sodium-calcium cotransporter on the mem- permeability coefficient ‘P’ of the membrane, and brane and excess presence of one inhibits the transport of Flux = –P × A (C – Ci 0) the other. However, it should not be confused with sodium- calcium exchanger and sodium-glucose cotransporter. It should not be confused with sodium-calcium exchanger that promotes the transport of both ions, When diffusion is facilitated by a carrier protein in the in which increased concentration of one on one side membrane, the process is called facilitated diffusion. This of the membrane increases the transport of the other is also called carrier-mediated diffusion as a carrier pro- from opposite side of the membrane. Also, this should not be confused with carrier-mediated is the transport of various sugars into red cells, adipose transport mechanisms by co-transporters like sodium- tissue, skeletal and cardiac muscles. Like simple diffusion, glucose cotransporter that are essentially facilitatory facilitated diffusion is also a downhill transport that does for transport of more than one substance (Application not require energy. However, specificity is not the solutions are separated by a semipermeable membrane. Facilitated diffusion occurs through ion and, therefore, exhibit random movement (called thermo- channels as occurs in sodium-glucose cotransport, in dynamic activity of water). They pass through a semipermeable membrane, and their passage is proportional to the solvent molecules Factors Affecting Facilitated Diffusion on that side. If the membrane that separates two solutions of dif- tated diffusion as described above. However, the major ferent solute concentrations is semipermeable, which allows the passage of solvent and not the solute parti- cles, the solution with higher concentration solute will Table 6. Mode of diffusion No carrier molecule Carrier molecule tion with a higher thermodynamic water activity to the Involved involved solution with lower thermodynamic water activity, i. Thus, the net flux of water (or solvent) through a semi- reached permeable membrane from a solution of lower solute 3. Competitive Absent Substances that share concentration to that of higher solute concentration is inhibition the same carrier known as osmosis. Specificity No specificity Carrier protein may be A substance to maintain a stable osmotic pressure should specific be confined to one side of the membrane. Solvent movement from ‘b’ to ‘a’ is prevented by application of osmotic pressure on ‘a’. A better example of osmotically most effective sub- Osmole and Milliosmole stance is plasma protein as it is neither transferred from the concentration of osmotically active particles is usu- nor metabolized in the compartment. If a solute is a non-ionizing compound like glucose, Normal saline is effective in hypovolemia: the application of osmotic one osmole is equal to 1 mole of solute particle. A 1 molar solution of glucose has a concentration of solution used to restore circulating blood volume should be the one whose active osmotic constituent remains within the circulation for a 1 Osm (1 osmole per liter). If the solute is an ionizing compound like NaCl, each with plasma, it is usually not used to treat hypovolemia as it is rapidly ion is an osmotically active particle. When the membrane is impermeable to an osmoti- Osmolality and Osmolarity cally active solute, osmotic flow of water ensues and con- tinues into the side containing the solute until either the Osmolality of a solution refers to the number of osmoles membrane bursts (osmotic lysis of cells), or some hydro- (number of osmotically active particles) dissolved in a static pressure prevents further osmotic flow. Osmolarity refers to the number of static pressure necessary to prevent osmotic flow of water osmoles in one liter of plasma. Unlike osmolality, the value in osmolarity is affected by Osmotic pressure depends on the number of mole- the volume of other solutes in the solution. In case of nondissociated solutes, 1 gm mol wt of any the difference between osmolality and osmolarity is substance shall contain similar number of molecules negligible. Osmoles determine osmotic pressure: Note that the important factor Osmotic pressure in body fluid is mainly exerted by determining the osmotic pressure of a solution is the concentration of osmotically active solutes dissolved in the fluid such as the particles released in solution (i. The osmotic pressure due to presence of plasma proteins is called oncotic pressure. Oncotic pressure significantly contributes very little, even though their molecules are large in size. Therefore, edema occurs in the normal plasma osmolality is 290 mOsm per kg, out of hypoproteinemia. Chapter 6: Transport Across the Cell Membrane 49 Measurement of Osmotic Pressure Measuring Equivalent Hydrostatic Pressure By Freezing Point Depression In experimental set up, osmotic pressure can be measured Osmometers are used to measure osmotic pressure. The by measuring the hydrostatic pressure applied to prevent molar concentration of a solute in a solution determines water from entering the solution with higher solute con- the osmotic pressure, and also the vapor pressure and centration. One mol Filtration, Bulk Flow and Solvent Drag per liter depresses the freezing point of water by 1. Passage of water and solutes through capillary wall is the For human plasma, the average freezing point is –0. Water moves out of Tonicity capillaries when the net hydrostatic pressure exceeds Tonicity refers to the osmolality of a solution in relation to net osmotic pressure and from interstitial space into the plasma (same osmotic pressure or freezing-point depres- capillaries when the net osmotic pressure exceeds the net sion as plasma).

Infuenza virus antigenic shift is attributable mainly to alterations in the hemagglutinin antigens with less frequent alterations in figure 3 cheap elavil 10mg fast delivery lower back pain treatment exercise. Heterophile antigens induce the formation of hetero- saccharides order elavil in united states online pain treatment consultants of wny, glycolipids purchase elavil 75mg amex midsouth pain treatment center reviews, and nucleic acids discount elavil 75mg overnight delivery tennova comprehensive pain treatment center. When T lympho- phile antibodies when introduced into a species where they cytes and macrophages are depleted, no antibody response are absent. Forssman antigen is a heterophile or heterogenetic glyco- An xid gene is an X-chromosome mutation designated xid. Its broad phylogenetic distribution spans to some thymus-independent antigens, limited decrease in both animal and plant kingdoms. The antigen is present in responsiveness to thymus-dependent antigens, and defective guinea pig and horse organs, but not in their red blood cells. Forssman tures are diminished when the xid gene is bred into auto- antigen occurs in both red blood cells and organs in chickens. As originally defned, it is present chemically induced tumor; (4) a low-frequency epitope pres- in guinea pig kidney, is heat stable, and is alcohol soluble. Thus, it is found only on one mem- ber of a group of proteins, such as alloantigens of the major histocompatibility complex, even though it may also apply to other alloantigenic systems. A public antigen is one such blood group antigen that is present in greater than 99. In blood banking, there is a problem fnding a suitable unit Public antigen of blood for a transfusion to recipients who have developed antibodies against public antigens. Antigens and Immunogens 175 Forssman antigen occur in the sera of patients recovering Active immunization is the induction of an immune from infectious mononucleosis. Human serum may contain Forssman cal disease or subclinical infection or vaccination may be antibody as a natural antibody. Booster immu- nization injections given at intervals after primary exposure A booster response is the secondary antibody response may lead to long-lasting immunity through the activation of produced during immunization of subjects primed by ear- immunological memory cells. Parenteral refers to administration or injection of a sub- stance into the animal body by any route except the alimen- Immunization is the deliberate administration of an anti- tary tract. Activated lymphocytes may undergo the inductive phase is the time between antigen adminis- transformation or blastogenesis. Costimulation and cytokines animal to induce immunity, usually to protect against an are also necessary to activate naïve cells. Transformation is a heritable alteration in a cell as a conse- quence of investigative manipulation. The lymphocyte activation threshold is the number of receptors for antigen required to be aggregated and activated, 1. Lymphocyte transformation: the stimulation of a together with costimulatory signals, to produce a prolifera- resting lymphocyte with a lectin, antigen, or lym- tive signal. The frst signal mediated by antigen guar- living pneumococci can become virulent after antees that the immune response will be specifc. Cells can undergo neoplastic transformation in are induced when required to defend against microorgan- culture and acquire the capacity for unrestricted isms or other offending agents but not against self-antigens proliferation, thereby resembling neoplastic cells. The second costimulatory signal is frequently mediated by professional antigen-presenting cell Immunize refers to the deliberate administration of an anti- membrane molecules including B7 proteins. This is expressed as antibody consequence of contact between the antigen or immunogen production and/or cell-mediated immunity or immunologic and immunologically competent cells of the host, specifc tolerance. Immune response may follow stimulation by a antibodies and specifcally reactive immune lymphoid cells wide variety of agents such as pathogenic microorganisms, are induced to confer a state of immunity. Infectious agents Challenge refers to antigen deliberately administered to may also induce infammatory reactions characterized by induce an immune reaction in an individual previously the production of chemical mediators at the site of injury. Phagocytes, natural killer cells, and complement rep- Antigen A Antigen A + resent key participants in natural innate immune responses. Primary Antigen B the immune response consists of a recognition stage in Primary Anti-A response which the inducing agent is identifed as nonself or danger- Anti-B response ous to self and an effector stage aimed at elimination of the immunogen. Following this initial drop of preformed antibody in the circulation, there is a rapid and pronounced rise in anti- immune responsiveness and susceptibility to selected dis- body titer, representing immunologic memory. This results in a primary antibody response if recipient animals are immunized with immune response. This is in contrast to the secondary immune response in which the latent period is relatively brief and IgG is the Primed refers to a lymphoid cell or an intact animal that has predominant antibody. The most important event that occurs been exposed once to a specifc antigen and which mounts a in the primary response is the activation of memory cells that rapid and heightened response upon second exposure to this recognize antigen immediately on their second encounter same antigen. Products of the reaction may be manifested with it, leading to a secondary response. A similar pattern is as either increased antibody production or heightened cell- followed in cell-mediated responses. The primary response is the frst response to an immuno- A primed lymphocyte is one that has interacted with an gen to which the recipient has not previously been exposed. Failure pigs of strain-13 are nonresponders, whereas strain-2 guinea of an individual to generate an immune response to immuno- pigs and (2 × 13) F1 hybrids are responders. Polygenic inheritance is phenotypic inheritance based on genetic variation at multiple loci. Numerous genetic loci the secondary immune response describes a heightened may contribute to the inherited phenotype. Certain forms of antibody response following second exposure to antigen in Antigens and Immunogens 177 animals that have been primed by previous contact with the Freund’s adjuvant, synthetic polynucleotides, or other agents.

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