California College for Health Sciences.
When specifically queried buy xenical 60mg lowest price, only 1 of 54 reported seeing or using the system outside of their urogynecology rotation  purchase xenical australia. Concerns about taking too much time to complete are unwarranted as it only takes 2–3 minutes to complete the examination order generic xenical, even in neophytes . The remnant of the hymeneal ring is used as the reference point because it is a fixed and easily identified landmark, as opposed to the introitus, which is a nonstandardized anatomic structure (it is defined as the “entrance into the vagina”). All of the points recorded during the examination, with the exception of total vaginal length, are measured with the subject performing a Valsalva or a deep cough. Structures that lie above the hymeneal ring are recorded as negative, whereas structures that prolapse beyond the hymeneal ring are recorded as positive (both recordings in half centimeters) (Figure 81. Any structure that descends to the level of the hymeneal ring is recorded as 0 cm. Nine measurements are taken during the examination: two from the anterior vaginal wall, two from the apex of the vagina, two from the posterior vaginal wall, and one each recording the genital hiatus, perineal body, and the total vaginal length at rest (see Table 81. The nine points may be recorded in a convenient manner using a 1238 three-by-three grid as noted in the figure. Any rigid measuring device—such as a marked wooden Pap smear spatula, ruler, or engraved instrument—may be used. For descriptive purposes, an ordinal staging system is used whereby the prolapse stage is defined by 1239 the vaginal structure that demonstrates the greatest degree of prolapse (Table 81. At a practical level, an efficient method of performing the examination consists of placing a bivalve speculum in the vagina and measuring apical descent using the posterior blade of the speculum to measure anterior and then posterior structures, and then measuring the perineal structures. I The leading surface of the prolapse does not descend below 1 cm above the hymeneal ring. One aspect of this system that may be awkward, or even an anathema, to adherents of prior systems is the strict avoidance of terms such as cystocele, rectocele, or enterocele. The rationale behind this seemingly dogmatic practice is to avoid erroneous assumptions regarding the prolapsing organs. Since the vagina is relatively opaque, it is not possible to identify which organ is on the other side of the epithelium. It is often difficult even for experienced observers to discriminate between a high rectocele and a pulsion enterocele. Furthermore, patients who have had prior reconstructive pelvic surgery may have gross alterations in their vaginal axis, which result in unusual patterns of prolapse (e. Another change from previous systems is the avoidance of staging the individual vaginal segments, i. This idea stemmed from observations that several investigators were already reporting on simple ordinal staging for pelvic organ support without taking the nine measurements . Once the subject is positioned for examination, they are instructed to forcefully perform Valsalva or to cough—if the clinician feels the Valsalva is inadequate. The four areas to be examined and staged include the anterior and posterior vaginal walls, the apex/cuff, and the cervix. If a subject was status posthysterectomy, then only three measurements are taken: the anterior and posterior vaginal walls and the cuff scar/apex. For the exam of the anterior and posterior vaginal wall segments, a disarticulated Graves speculum or two fingers of the examiner are 1240 employed as a retractor. For examination of the anterior vaginal segment, the speculum or fingers are placed into the vagina and the posterior vaginal wall is retracted to allow for full visualization of the anterior vaginal wall. A point or rugal fold approximately 3 cm proximal to the urethral meatus on the anterior vaginal wall is identified. The patient is then instructed to perform Valsalva or cough in a forceful fashion and where that point or rugal fold previously identified descends in relation to the hymenal remnants is noted and recorded as the stage of the anterior vaginal wall (noted in the following under staging). The point chosen to represent the posterior vaginal segment is identified in a similar fashion retracting the anterior vaginal wall. The only difference is the point is approximately 3 cm proximal to the hymenal remnants instead of the urethral meatus. The cervix is evaluated by placing a speculum in the vagina and directly observing its descent during a Valsalva or cough to determine its stage in relation to the hymenal remnants. Care should be taken to make certain that the cervix is not inadvertently supported by the speculum during the exam. If the cervix, apex, or cuff scar descends beyond the hymenal remnants with Valsalva or cough, then a speculum is not necessary. If the subject has a cervix, then the vaginal apex or posterior fornix is described separately from the cervix. The subjects are assigned an overall stage as the highest value among the four segments, and each segment is assigned an individual stage. They noted that currently there are no clinically or scientifically validated definitions and felt that any proposed definition should take into account both a subject’s anatomy and their symptoms . If one carefully reads the literature, this definition, while not recognized, is slowly becoming the standard. A recent review article has suggested that we should define the disease and outcomes regarding management strategies using composite scores based on objective and subjective findings . Generally, the literature defines prolapse in one of two ways—either anatomically by examination or by surgical admission for corrective surgery. The concern regarding surgical admissions is that they miss those patients that manage their prolapse conservatively; the concern regarding anatomic descriptions is that no two studies use the same anatomic cutoffs [19,21,23,25,27,35–39]. This plethora of definitions makes it difficult to evaluate trends in the literature into the various etiologies and can lead to conflicting results. Regardless of the definition used, this factor is always identified as a risk for prolapse, and most estimates suggest that there is roughly a doubling in the risk of prolapse with every completed decade of life [18,19,25,35]. In addition, other areas that have been investigated include prior pelvic surgery and genetic factors. While it is generally recognized that any parity is associated with an increased risk of prolapse, what role the delivery mode plays is more controversial [18–21,23,33–36,38]. Studies suggest that anywhere from a 4- to an 11-fold increase in the risk of prolapse is dependent on parity, with increasing parity imparting greater risk [19,21,35]. When women who delivered only by cesarean section were compared to women who had any vaginal delivery, the data are inconclusive and do not suggest a protective effect . The data on instrumented vaginal delivery are sparse, and in one study forceps delivery was not identified as a risk factor for the development of prolapse . In addition, there is one study suggesting that episiotomy protects against prolapse . The data regarding infant weight are more consistent, with most studies demonstrating an increase in prolapse with increasing fetal weight; delivery of a macrosomic infant carries the greatest risk [19,23,35,36]. The data on occupation, as a risk for prolapse, stem from an article published in 1994 on nursing assistants in Denmark. Since then, two large studies have incorporated job description into their data collection [19,36]. Both found that manual workers and housewives had a slightly increased risk of prolapse over women who classified themselves as professionals. It is felt that the increasing weight from abdominal adipose tissue increases the pressure on the intra-abdominal organs, leading to pelvic floor weakness and prolapse. Here, the literature is divided, with several studies suggesting it as a risk factor [19,21,25,27,37] and several studies finding no association [23,35,37].
Enhanced sensitivity to fentanyl generic 60mg xenical visa, alfentanil order xenical 120mg otc, and sufentanil is primarily pharmacodynamic discount xenical 60mg visa. Use of sedative and antinausea agents with anticholinergic and antidopaminergic properties may produce adverse effects in patients with Parkinson disease. Muscle Relaxants The response to succinylcholine and nondepolarizing agents is unaltered with aging. Decreased cardiac output and slow muscle blood flow may result in a twofold prolongation in onset of neuromuscular blockade. Renal excretion (pancuronium, doxacu- rium) and hepatic excretion (rocuronium and vecuronium) may be delayed because of organ dysfunction. It is imperative to distinguish between changes in physiology that normally accompany aging versus the pathophysiology of diseases common in the geriatric population. Age -Re la te d Ph ys io lo gic Ch a n ge s a n d Co m m o n Dis e a s e s o f Eld e rly Ad u lts No rm a l Ph ysio lo gic Ch a n ge s Co m m o n Pa th o p h ysio lo gy Ca rd iova scu la r De cre ase d arte rial e lasticity At h e r o s c le r o s is Ele va t e d a ft e rlo a d Co ro n a ry a rte ry d ise a se Ele va t e d s ys t o lic b lo o d p re s s u re Es s e n t ia l h yp e rt e n s io n Le ft ve n t r i c u l a r h yp e r t r o p h y Co n ge stive h e a rt fa ilu re De cre ase d adre ne rgic activity Ca rd ia c a rrh yth m ia s De cre ase d re sting he art rate Ao r t ic s t e n o s is De cre ase d m axim al he art rate De cre ase d barore ce ptor re fle x S/ Sxs of pa thologic disea se in ge riatric pa tie nts: (1) systolic murmur, (2) irregular rhythm, (3) bradycardia despite pain or anxiety, (4) exercise intolerance, or (5) easily fatigued. Diastolic dysfunction prevents the ventricle from relaxing and consequently creates higher pressures during diastolic ventricular filling, this leading to lower end-diastolic ventricular volumes (preload). Therefore, geriatric patients are at greater risk for low cardiac output, hypoten- sion, decreased oxygen delivery, and ischemia in the setting of both routine and emergent operative procedures. Clinical manifestations: Marked diastolic dysfunction may occur with systemic hypertension, coronary artery disease; cardiomyopathies; and valvular heart disease, particularly aortic stenosis. Patients may be asymptom- atic or complain of exercise intolerance, dyspnea, cough, or fatigue. Diastolic dysfunction results in relatively large increases in ventricular end-diastolic pressure with small changes of left ventricular volume. The atrial contribution to ventricular filling becomes even more important in the setting of diastolic dysfunction. Diminished cardiac reserve in elderly patients may be manifested as exaggerated drops in blood pressure dur- ing induction of general anesthesia. A ratio of greater than 15 between the peak E velocity of transmitral diastolic filling and the early relaxation velocity on tissue Doppler (E′) is associated with elevated left ventricular end-diastolic pressure and diastolic dysfunction. Elasticity is decreased: small airway collapse occurs due to overdistention of the alveoli. Decreased respiratory muscle function or mass and a less compliant chest wall can greatly increase the work of breathing. Perioperative Issues Longer preoxygenation periods are required to prevent hypoxia before induction. Aspiration pneumonia is a common and potentially life-threatening complication in elderly patients. Causes of this increase risk include a progressive decrease in protective laryngeal reflexes with age and worse ven- tilatory impairment in the recovery room. Common risks for postoperative pulmonary complications include age older than 64 years, chronic obstruc- tive pulmonary disease, obstructive sleep apnea, malnutrition, and surgical site or type (thoracotomy). These changes are particularly prominent in the renal cortex, where glomeruli are replaced by fat and fibrotic tissue. Decreases in muscle mass and creatinine production with aging lends to lower overall creatinine and the appear- ance of no change in the setting of significant alterations in renal performance. When serum creatinine levels are “high normal” in the geriatric patient, it may be demonstrating renal insufficiency or more significant impairment. The combination of reduced renal blood flow and decreased nephron mass increases the risk of elderly patients for acute renal failure in the postoperative period. Other physiologic renal changes predispose elderly patients to develop dehydration or fluid overload because of the inability to handle sodium loads, concentrate, or dilute (offload volume) when conditions are right. This is exacer- bated further by reduction in response to antidiuretic hormone and aldosterone. Perioperative issues: Excretion of drugs is greatly affected in elderly patients, and care must be given to administration and dosing. Fluid management is more difficult and may lead to acute electrolyte disturbances (hypokalemia and hyper- kalemia). Preoperative outpatient use of diuretics further complicates intraoperative fluid and electrolyte management. Additionally, neurons decrease in size and lose complexity of their dendritic tree. Physiologic changes: The synthesis of some neurotransmitters and the number of their receptors are reduced. Aging is associated with an increasing threshold for nearly all sensory modalities, including touch, temperature sensation, proprioception, hearing, and vision. Cerebral blood flow also decreases about 10% to 20% in pro- portion to neuronal losses. Administration of a given volume of epidural anesthetic results in more extensive cephalad spread with a shorter duration of analgesia and motor block. About 30% of geriatric patients demonstrate s/sxs of these syndromes after surgery, including 10% to 15% of patients older than 60 years of age demonstrating cognitive dysfunction up to 3 months after major surgery. She has a history of atrial fibrillation and has been treated with warfarin for 3 years. The patient states she has been on a couple of medications for her blood pressure, but she forgets to take them intermittently. The patient verifies that she is a current smoker and uses inhalers at least once a day. Despite multiple medical issues, the patient states she does a lot of her own lawn work and walks on her farm, where she fell and was injured. This patient has medical issues that need to be dealt with before surgery, but it is reasonable to expect that surgery could occur in the next few hours upon further evaluation. Optimal anesthetic management of geriatric patients depends on an understanding of the normal changes in physiology, anatomy, and response to pharmacologic agents that accompany aging, which is similarly seen in pediatric patients. Decreased ability to increase heart rate in response to hypovolemia, hypotension, or hypoxia Decreased lung compliance Decreased arterial oxygen tension Impaired ability to cough Decreased renal tubular function Increased susceptibility to hypothermia Although there are similarities among patients at the extremes of the age continuum, geriatric patients demon- strate an even wider range of physiologic variation with increasing age then pediatric patients. Geriatric patients usually present with an impressive list of outpatient medications; Review them! These should generally be administered to patients perioperatively if they are on such medications chronically to avoid the effects of β-blocker withdrawal. The use of regional techniques is becoming increasingly popular in the outpatient setting, and the use of ultrasound and nerve stimulation has improved regional block success rates. The surgeon and anesthesia provider must identify patients in whom an ambulatory or office-based setting is likely to provide benefits (ease for patients, reduced costs) that outweigh risks (the lack of immediate availability of all of the services a hospital provides). Patient Considerations for Ambulatory Anesthesia Each patient must be considered in the context of comorbidities, the type of surgery to be performed, and expected response to anesthesia. Other factors considered when selecting patients for ambulatory procedures include airway management problems, sleep apnea, morbid obesity, previous adverse anesthesia outcomes, allergies, and the patient’s social network. Procedures suitable for ambulatory surgery should have a minimal risk of perioperative hemorrhage, airway com- promise, and no requirement for specialized postoperative care. Cardiac conditions: Increasingly, patients present to ambulatory surgery with a variety of cardiac conditions treated both pharmacologically as well as mechanically. Patients should remain on β-blockers perioperatively; antiplatelet agents should not be discontinued unless a discussion has occurred between the patient, cardiologist, and surgeon regarding both the neces- sity of surgery and the necessity of discontinuing antiplatelet therapy.
I do not think that targeting these individual sites is better than targeting “early” sites generic xenical 60mg on-line. Certainly order generic xenical canada, elimination of all pulmonary vein potentials is the end point that most investigators use discount xenical on line. It is important that one demonstrates isolation of pulmonary vein potentials from the left atrium. This requires proximal positioning of the lasso at the ostium so that both left atrial and pulmonary vein potentials are recorded (Fig. Failure to ablate at a proximal site may leave an ostial cuff of arrhythmogenic tissue but isolate the distal areas of the pulmonary vein. Other investigators have used small versions of the basket catheter placed within the pulmonary vein instead of the lasso to provide longitudinal and circumferential activation data. This technique theoretically provides a better visual approximation of large circumferential lesions that can be used to isolate the veins. I have not found this generally advantageous since the lassos are often placed more distal in the vein. As such the circumferential lesions are not that much different than ostial lesions placed using a single lasso. Review of the published data supports this contention, since with loss of pulmonary vein potentials, no left atrial potentials are recorded. I do find it useful when veins are small and you want landmarks to keep the ablation sites removed from the ostia. Atrial fibrillation is present with a lasso placed in the left superior pulmonary vein. Recordings from the ablation catheter, coronary sinus (bottom two recordings), and 10 bipolar pairs from the lasso. During radiofrequency application proximal to lasso poles 2, 3 there is abrupt loss of activity on the lasso. At best this represents entrance block, since the recordings are done during sinus rhythm, coronary sinus pacing, or atrial fibrillation. Ablation at sites of earliest left atrial capture eliminates this conduction, producing exit block (Fig. Simultaneous recordings from the appendage can help to distinguish appendage capture from pulmonary vein conduction. Using the ablation catheter to pace is often misleading since only a small area can be simulated, which is frequently missed by the P. Preablation during sinus rhythm, a local left atrial potential is associated with a complex pulmonary vein potential at the ostium and two discrete pulmonary vein potentials more distally. Postsegmental ablation, all that is seen during sinus rhythm is a local left atrial electrogram. Ectopic impulse formation in the muscle sleeve of the vein generating this electrogram cannot lead to propagated responses. Catheter ablation of chronic atrial fibrillation targeting the reinitiating triggers. Mapping of these evanescent triggers is typically difficult, as they often cause the prompt initiation of atrial fibrillation, just as is the case with pulmonary vein triggers. Circular mapping catheters are positioned in the left (top) and right (bottom) pulmonary veins to guide circumferential ablation. During circumferential ablation around the right superior pulmonary vein during atrial fibrillation, sinus rhythm occurred, but atrial fibrillation persisted, trapped within the pulmonary vein. The experience that launches this thought experiment comes from series of lung transplant surgery, in which “cut and sew” isolation of the pulmonary vein is performed to reimplant the graft. In these series, atrial fibrillation is essentially absent following the healing phase, although it is prevalent in patients with thoracic surgery in general. Natale and coworkers champion the former strategy, based on the idea that the entire posterior wall arises from the same tissue as the pulmonary veins in an embryologic sense. The posterior wall has also been implicated in stretch-related changes in electrophysiology that may be important for the atrial remodeling that fosters atrial fibrillation. Walters and coworkers recently examined the role of acute stretch on atrial–pulmonary vein electrophysiology in an intraoperative mapping study. Frequent sites include the posterior left atrium (which would be encompassed by wide antral isolation in many cases), the left and right sides of the fossa ovalis, the Eustachian ridge and the superior vena cava. Catheter stability is negatively affected by the movement of the heart caused by excursion of the diaphragm. This is a huge problem with conscious sedation and spontaneous breathing, but remains a problem with mechanical ventilation during general anesthesia. The three groups were stratified by exposure to improvements in technology, including image integration, steerable sheaths, and jet ventilation; none of these were used in the first group, image integration and steerable sheaths for the second and all three in the third. Of interest, similar observations have been reported in the past;228 229, however, most felt these results were due to the relatively ineffective catheter technology available at that time, though irrigated ablation was used in some subjects in the Pratola study. Although the methodology of that study was challenged at the time (particularly because of the difference in catheter technology used in the two groups) it showed a slightly better outcome with the nonmap-guided approach using symptomatic atrial fibrillation as an endpoint. Second, single center studies (even with the best of intentions) are often contradictory or misleading when compared to well-constructed multicenter controlled studies (see below). Role of Linear Lesions to the Mitral Annulus and/or Across the Roof or Posterior Left Atrial Wall Several investigators employ additional linear lesions to more closely mimic the Cox surgical Maze procedure (see below). Substrate-based ablation including the use of linear lesions has been demonstrated to have a 15% to 30% incidence of left atrial flutter after ablation. I do not think that these linear lesions are necessary unless one documents a clinically relevant macroreentrant circuit. Moreover the potential collateral damage done by this additional ablation, including stroke, proarrhythmia, coronary occlusion, phrenic nerve paralysis, and esophageal fistulas, far exceeds the benefit. Fifty percent of patients had organized atrial tachycardia postablation, but half of these resolved within 8 weeks. Monitoring for asymptomatic recurrence was very limited, but 81% of patients were free of symptomatic recurrence at a mean follow-up of 836 days. They may also be recorded if the electrode records different simultaneous wavefronts. They may represent overlapping wavefronts of activation in a three-dimensional (3D) structure and/or nonuniform anisotropic conduction. Recordings from a 20 pole flower electrode demonstrate fractionated signals appear at short cycle lengths and disappear at longer cycle lengths, suggesting they are a consequence of not a driver of the arrhythmia. High- density activation mapping of fractionated electrograms in the atria of patients with paroxysmal atrial fibrillation. As such I believe an electrophysiologic approach with well-defined endpoints should be the goal in the management of an electrophysiologic disorder.
The different surgical corrective procedures used are not covered by a single general consent form proven 120mg xenical. Information rela- tive to all procedures to be communicated to the patient fol- 10 purchase xenical overnight. Alka Seltzer buy generic xenical on line, Ascritptin, Aspirin, Bufferin, Cemerit, Vivin • The operation will take place in the surgery under local C) or other non-steroid anti-inﬂammatory drugs. Scott published the ﬁrst reports using Botulinum toxin joined by a disulﬁde bond to a 50-kDa light chain. When the type A for the treatment of blepharospasm, strabismus, and heavy chain attaches to the proteins on the surface of axon glabellar frown lines in the early 1980s. It is a sterile, homogenous, lyophilized complex rarely, F and G are associated with human botulism . Multiple factors including molecular weight, protein size, serotype strain, and prepara- genetics, photoaging, smoking, underlying disease, gravity, tion/puriﬁcation process. These factors determine their onset and muscular hypertrophy affect our appearance and facial of action, longevity of effect, and migration to the surround- expressions as time goes by. No systemic spread or anaphylactic reactions have The Horizontal Forehead Lines been reported, however. The prod- • Lateral ﬁbers of the orbicularis oculi muscle uct should be administered within 24 h of being • Neck bands: platysma reconstituted. The patients procerus, corrugator supercilii, and orbicularis oculi should be informed about the possible minimal side effects muscles). Other Function of the primary smile muscle, the zygomaticus important factors to consider are the patient’s occupation and major, results in the elevation of lateral upper lip diago- physiological and aesthetic differences between men and nally with actions of laughing, smiling, and chewing. Relative contraindications are tion produces synergistic effects in the periorbital region, patients with of neuromuscular transmission disorders (e. If the patient’s current medical history includes use of This muscle is in part an antagonist to the lip elevators. Eyelid ptosis responds well to alpha-adrenergic agonist eye drops phenylephrine (Neo-synephrine 2. Remember that Neo- synephrine is contraindicated in patients with narrow angle glaucoma. These mydriatic agents work via stimulating Muller’s muscle and elevate the upper eyelid, restoring it to its normal position (Fig. While talking with the patient, we can easily notice pain levels in sensitive patients as well as to reduce the risk various patterns of facial animation and other features such of bruising and swelling, patients may use an ice pack or as brow asymmetry. Small subcutaneous wheals applied to the injection sites for sterility but should be fully of 0. Attention is then turned to corrugator function on the Post procedure, patients are given ice packs and asked not brow; here it is helpful to palpate the muscle while the patient to engage in vigorous physical activity for 24 h to prevent is contracting. Both the lateral canthal injections and inferomedial brow injections can be expected to “open up” the aperture of the eye. It has proven useful both as a primary treatment for certain facial 10 Speciﬁc Considerations: Glabellar rhytids and as adjunctive agent for a variety of facial aes- Frown Lines thetic procedures to obtain optimal results. Prior to the injec- tion, patient is asked to smile broadly; while patient is Glabellar frown lines result from the overaction of procerus smiling, physician should notice the center of the crow’s feet and corrugator supercilli. In a good seen in patients with excessive sun exposure, nearsighted- candidate, a thick muscle band can be seen in lateral orbital ness, and habitual frowning. The horizontal male brow is characterized ﬁcially at the side that is approximately 1. The medial ﬁbers of the mus- if severe lower lid weakness occurs, the patient can be at risk cle usually are more bulky than the lateral ﬁbers, thus requir- for keratitis. Occasionally, after the injection, a side effect such as brow asymmetry can be expected [6 ]. These muscles include the corrugator tom portion of the eyes due to hyperkinetic contraction of supercilii, procerus, and the superolateral ﬁbers of orbicu- orbicularis oculi and hypertrophy of it ﬁbers over the time, laris oculi, which as a group are the brow depressors. As mentioned above, one should avoid total paralysis ish the hyperactive muscle function that relaxes this area. This of frontalis, since this will likely worsen brow ptosis and lead way patients can expect an aesthetically pleasing high arching to loss of expression as described above (Figs. The naso- labial fold furrows with ptosis of the malar fat pads, and the corners of the mouth droop into deep marionette lines, which give an unhappy appearance. Patients desiring lipstick line treatment are asked to “pucker” and 3 U superﬁcial injec- tions are made within furrows well above the vermilion bor- der at 1 cm intervals. Patients should understand that they may not be able to drink through a straw or whistle but they will not drool or look strange after upper lip injections. The effect can take months to appreciate and can last more than a unaffected side (Figs. The central mentalis mus- year in most patients using a high-dose approach; in patients cle is responsible for contracting the chin and helping to using the low-dose approach, every 3 months the treatment is raise it. The platysma muscle originates inferiorly from the pectora- lis and deltoid fascia. The lateral bands of the platysma mus- cle facilitate facial expression by lowering the corners of the Most patients dislike signs of aging around the mouth. Vertically oriented platysmal bands may be injected in patients with a hypertrophied or sagging muscle. For treatment of the platysmal bands, patients are asked to strain their neck, and dominant bands are injected at intervals of several centimeters (Fig. Very rarely, injection into platysma muscles can result in dysphagia from diffusion of toxin into the mus- cles of deglutition. If the sternocleidomastoid muscle is injected additionally either by mistake or due to a diffusion effect, some patients can experience neck weakness, which is especially noticeable when a patient attempts to raise the head from a supine position. Avoidance of adverse effects is achieved by using the lowest effective dose and precisely placing toxin into the platysma. Different anatomic components of the Dermatol Clin 22(2):131–133 face contribute to different expressions and cosmetic 3. An understanding of facial anatomy, muscu- toxin: Justinus Kerner (1786–1862) and the “sausage poison. Neurology 53(8):1850–1853 lar functions, and an individual patient’s needs when ® 4. Plast Reconstr Surg 115(2):573–374 In: Jankovic J, Hallett M (eds) Therapy with botulinum toxin. Fagien S (1998) Extended use of botulinum toxin a in facial aes- Marcel-Dekker, New York, pp 119–157 thetic surgery. Finzi E, Wasserman E (2006) Treatment of depression with botuli- group: consensus recommendations on the use of botulinum toxin num toxin A: a case series. Beer K (2010) Cost effectiveness of botulinum toxins for the treatment 11–15 of depression: preliminary observations.