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  • Professor, Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee

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The requirements of the new law were effective for plan years beginning on or after one year from the date the legislation was signed into law treatment 360 purchase careprost 3 ml overnight delivery. As a result medicine administration buy careprost 3ml with amex, the provisions applied to medications cause erectile dysfunction trusted 3ml careprost new contracts and renewals on or after Oct medicine rocks state park trusted 3 ml careprost. The extent of outpatient benefits available to any given member is defined by the member’s benefit plan and state law. Telepsychiatry refers to behavioral health services rendered by a Psychiatrist via a simultaneous audio and video telehealth setting permitting 2-way, live interactive communication between the patient and the distant site health care provider. Telepsychiatry can also be offered by licensed Nurse Practitioners and Physician Assistants operating within the scope of their license. Telepsychiatry may include a range of services, such as medication management, psychiatric evaluations, therapy (individual therapy, group therapy, family therapy) and patient education. Visits are considered to be mental health visits when the primary purpose is to provide psychotherapy services. A determination about additional visits beyond the initial mental health evaluation can be made once the evaluation of the member has been completed. Outpatient mental health benefits are available for a member with a mental illness whose clinical record or psychological testing results demonstrate a need for outpatient therapy. Members should be referred to a mental health professional (defined as a psychiatrist, psychologist, psychiatric social worker, or other mental health professional working under the guidance of a physician) for covered services. Marriage counseling for those members in a qualified Domestic Partnership, Civil Union or marriage is also a covered service. These problems may by noted by family members, school officials, law enforcement officials, or others. Children with such problems should be considered for evaluation for an underlying mental health condition. Each visit, regardless of length, counts as one mental health visit for purposes of copayment. Psychiatrists, Nurse Practitioners and Physician Assistants are the only type of providers who should be performing telepsychiatry. Advanced Nurse Practitioners and Physician Assistants may render Telepsychiatry services provided they are operating within the scope of their license. Under this law, all previous day/visit limits were removed for a member being treated by a mental health provider. The labeled antibodies are injected and the member undergoes imaging 2-7 days later. Technetium-99m nofetumomab merpentan (Verluma) for imaging in members who have biopsy-proven small cell lung carcinoma, but who have received no treatment. Monoclonal antibody imaging using agent 2 may be used for the localization of primary and metastatic neuroendocrine tumors bearing somatostatin receptors. Interpretation: Naprapathic Medicine is a specialized system of health care that employs hands-on manual medicine, nutritional counseling, and a wide variety of therapeutic modalities. Naprapathy focuses on conditions caused by contracted, injured, spasmed, bruised, and/or otherwise affected myofascial and connective tissue. Rental of the transcutaneous stimulator permits the physician to study the effects and benefits of, and member compliance with the device. Purchase should occur only if chronic or long-term pain is present and efficacy has been proven. Benefits are provided for implantation of the electrical nerve stimulator, as well as for the purchase of the device (Durable Medical Equipment). Interpretation: Neuromuscular stimulation is used to halt or reverse spinal curvature in idiopathic scoliosis. Nutritional services can be broken down into three categories: Medical need Nutritional services for the resolution or maintenance care of a condition resulting from a disease, injury, surgery, congenital or genetic abnormality or eating disorders are covered. Examples include: special diets for hypertensive and cardiac members; newly diagnosed diabetic members; post gastro-intestinal surgery members; individuals with celiac disease or other malabsorption syndromes; members diagnosed with anorexia or bulimia. These members should be referred to a nutrition professional (physician, nurse, or registered dietitian) at the discretion of the Primary Care Physician. The Primary Care Physician, who determines the number of visits, should refer these members to a nutrition professional. Such items include, but are not limited to, infant formula, weight-loss supplements, over-the-counter food substitutes, and liquid nutrition or high-calorie liquid nutrition products, with or without special formulation. Supplies and equipment for proper functioning and effective use of an Enteral Nutrition system is also in benefit. Interpretation: Nutritional supplements are dietary products that either substitute for or complement natural food. The law is Exception: specific to the diagnosis and treatment of (1) eosinophilic disorders and (2) short – bowel syndrome when the prescribing physician has issued a written order stating the formula is medically necessary. Enteral Nutrition (available only by physician’s prescription) is administered via a feeding tube. Enteral Nutrition may be necessary for a member with a functioning gastrointestinal tract who cannot eat because of difficulty swallowing, or because of structural problems in the head, neck, or thorax. Examples of these conditions are head and neck cancer and central nervous system disease leading to interference with the neuromuscular mechanisms of ingestion. Interpretation: Obesity is caused by caloric intake persistently higher than caloric utilization. Obesity can also aggravate a number of cardiac and respiratory diseases, diabetes, and hypertension. Morbid obesity (or "clinically severe obesity") is a condition of persistent and uncontrollable weight maintenance or gain that constitutes a present or potential serious health risk. Medical Treatment Medical management of obesity is in benefit except for the cost of food supplements. Surgical procedures in benefit include, but are not limited to: Gastric bypass using a Roux-en-Y anastomosis (short limb up to 100cm, open or laparoscopic) Vertical banded gastroplasty (open or laparoscopic) Adjustable gastric banding (adjustable Lap-Band) performed laparoscopically or open and consisting of an external adjustable band placed high around the stomach creating a small pouch and a small stoma. Removal of the Gallbladder at the time of an Approved Gastric Bypass Surgical Procedure Coverage is allowed for gallbladder removal at the time of a covered gastric bypass surgical procedure, either for documented gallbladder disease or for prophylaxis. Significantly disrupted sleep patterns are associated with such physiologic findings as oxygen (O2) desaturation or cardiac arrhythmia. Central: Cessation of respiratory effort without evidence of airway obstruction 3. Mixed: Cessation of both air flow and respiratory effort Sleep apnea is best evaluated in a sleep study lab designed specifically to measure various body functions as the member sleeps. Polysomnograms can also be done in the member’s home, as deemed medically necessary by the Primary Care Physician. These devices supply air under pressure through a tight fitting mask to overcome obstruction. Surgical treatments include any procedure designed to remove or correct any identifiable airway obstruction. Anticipation of significant member improvement, not necessarily complete recovery, meets the criteria. Interpretation: Occupational therapy is constructive therapeutic activity designed and adapted to promote restoration of useful physical function. Treatment may include: Initial evaluation Exercises to increase range of motion Graded exercises to increase muscle strength Exercises and functional activities to improve coordination Exercises to upgrade physical tolerance Training in all areas of activities of daily living. Sometimes, a trial of therapy may be helpful in determining whether or not ongoing occupational therapy is appropriate. Not in benefit: Occupational therapy for social or psychological well-being or recreation Homemaking evaluation and training Work simplification training Vocational training Family consultation Home visits to assess the home situation Most benefit plans have a maximum number of treatments that are in benefit for outpatient rehabilitation therapies (Speech Therapy, Physical Therapy and Occupational Therapy combined. These include congenital deformities and conditions resulting from injury, tumors or cysts, disease, or previous therapeutic processes. Interpretation: Benefits include: • Consultation by an oral surgeon or appropriate specialist. Included with this would be the cost of X-rays or other diagnostic tests performed in conjunction with given evaluation. Any abutment or dental prosthesis resting on these implants is not covered, except to replace a tooth that had originally been injured, as described above. Conditions of dental origin include, but are not limited to, those resulting from tooth decay or inflammation of the gums.

Name underlying systemic pathologies that may present with carpal tunnel syndrome keratin smoothing treatment generic 3ml careprost with visa. Median motor studies include stimulation of the median nerve proximal to medicine while pregnant discount 3 ml careprost otc the carpal tunnel with recording over the abductor pollicis brevis muscle medications kidney damage cheap careprost 3 ml overnight delivery. Median sensory studies can be antidromic symptoms quotes safe 3 ml careprost, which means that the stimulus is opposite of the physiologic direction of response transmission. In a sensory antidromic study, the nerve is stimulated proximally with a recording over that same nerve distally. Apalmarsegmentcanbestudiedtomorecloselyanalyze the carpal tunnel involvement by performing the same antidromic study with digital recording and stimulation in the palm. The distal portion (from the palm to the fingers) is subtracted from the entire 14-cm distance to calculate the nerve conduction velocity across the carpal tunnel. Another method of evaluating the median sensory nerve involves stimulation of the nerve distally in the hand or palm and recording over the median nerve at the wrist. A focal conduction can be calculated directly when the median nerve is stimulated in the palm and the recording is made at the wrist. Median nerve compression at the wrist results in numbness or pain in the radial three and one-half digits. Patients note an increased frequency of dropping items, apparently attributable to sensory loss. Symptoms are exacerbated with sustained activity, such as cumulative trauma disorders or repetitive wrist flexion associatedwithassemblyoccupations. Two-point discrimination may be reduced along the second and third digits and the radial aspect of the fourth digit. Tinel’s sign (the presence of electric shock) provides clarification of pathology when it is positiveandgenerallyisdetectedonlywithmoderatetoseverecasesofmediannerveentrapment. Phalen’s test (wrist flexion test) is conducted with the wrists in complete volar flexion for up to 60 seconds. Thenar eminence manual muscle testing revealsreducedstrengthintheabductorpollicisbrevisinlong-standingcasesofmediannerveentrapment with muscle atrophy. Long-standing cases also are associated with deterioration of manual dexterity as sensorium and muscle atrophy persist. Tinel’s sign is used clinically to evaluate the status of peripheral nerve function. A tingling sensation, paresthesia, or electrical shock felt distally to the tapping site in the median nerve distribution to the thumb, index, middle, or ring fingers is considered a positive Tinel’s sign. Reported values of specificity range from 55% to 95%, and sensitivity ranges from 45% to 75%. Tinel’s sign may be present in normal people and is not descriptive of abnormality; therefore, it may be more useful to rule out carpal tunnel syndrome when it is negative. Median sensory studies typically show the earliest abnormalities in carpal tunnel syndrome. Reports can be interpreted more easily when there is an indication both of the site of median sensory nerve stimulation and recording and of the distance traveled by the stimulus between onset and recording. They examined the wrist to digit, palm to digit (subtracted from the wrist to digit), and palm to wrist median sensory studies in 44 normal and 136 symptomatic hands. They found that the short segment from the palm to wrist was the most sensitive (75%) for carpal tunnel syndrome. What is the clinical difference between an anterior interosseous nerve injury and median nerve injury at the wrist Theanteriorinterosseousnerve,which innervatesthe flexorpollicislongus, pronatorquadratus, and flexor digitorum profundus to the index and long fingers, may be injured traumatically or become inflamed spontaneously. Pain along the volar surface of the forearm may be associated with local trauma or heavy muscle exertion. Sensation to the volar surface of the forearm and median-innervated digits is intact. Percussion over the nerve may produce radiating pain along the path of the nerve distally to the pronator quadratus. To control for the effects of temperature, some examiners use comparisons between nerves in the same limb. The following are some guidelines: • Perform a median/ulnar sensory orthodromic study. If absolute values are used, the following are some commonly used criteria: Median motor latency greater than 4. There are several anthropometric characteristics associated with carpal tunnel syndrome to include the following: Body mass index/obesity Hand length–to–body height ratio Greater wrist width Wrist index greater than 0. Other risk factors have been identified as: Smoking Alcohol use Kidney disease Thyroid disease Pregnancy Lactation Diabetes 17. Scheie syndromealso presents with hernia, coarse facial features, joint contracture, bone deformities, hepatomegaly, and clouding of the cornea. Are there different classifications or degrees of carpal tunnel syndrome, and, if so, how would an electromyographer grade carpal tunnel syndrome They defined mild carpal tunnel syndrome as having a prolonged median motor distal latency from 3. Moderate carpal tunnel syndrome was defined as a prolonged median motor distal latency between 5. Severe carpal tunnel syndrome was defined as a prolonged median motor distal latency of greater than 7. A patient complains of numbness and tingling in the small and ring fingers on only the palmar side of the hand with no complaints of numbness in the forearm or in the dorsal hand. The ulnar nerve supplies sensation to the small and ring fingers and is a derivative of the C8 and T1 roots, the lower trunk and medial cord of the brachial plexus. As such it is possible that a lesion in any one of these sections could produce tingling in the small and ring fingers; however, a proximal lesion at the level of the lower trunk or proximal medial cord would most likely produce numbness in the medial forearm via the medial cutaneous nerve of the forearm, which is a derivative of the medial cord. In addition, tingling would be present on the dorsum of the small and ring fingers in a lesion at the level of the midforearm or proximal to this location because the supply to the dorsal aspect of the small and ring fingers is from the dorsal ulnar cutaneous sensory branch of the ulnar nerve proper that exits the ulnar nerve approximately 10 cm proximal to the wrist. An evaluation of gender, obesity, age and diabetes mellitus as risk factors for carpal tunnel syndrome. Performance of a high-repetition, high-force task induces carpal tunnel syndrome in rats. A prospective study to assess the outcomes of steroid injections and wrist splinting for the treatment of carpal tunnel syndrome. Body mass index and anthropometric characteristics of the hand as risk factors for carpal tunnel syndrome. Evaluation of age, body mass index, and wrist index as risk factors for carpal tunnel syndrome severity. Sensitivity, specificity, and variability of nerve conduction velocity measurements in carpal tunnel syndrome. Congenital carpal tunnel syndrome: Case report of autosomal dominant inheritance and review of the literature. What symptoms are truly caused by median nerve compression in carpal tunnel syndrome A systematic review of reviews comparing the effectiveness of endoscopic and open carpal tunnel decompression. Childhood onset of Scheie syndrome, the attenuated form of mucopolysaccharidosis I. Carpal tunnel syndrome: A literature review for the effect of the median nerve compression test on median nerve conduction across the carpal tunnel. Unpublished manuscript prepared by United States Army-Baylor University Graduate Program in Physical Therapy. The anterior spinal artery supplies 80% of the spinal cord, and paired dorsal arteries supply the remainder. It actually is 3 separate anterior arteries, with the superiormost artery supplying C1-T3, the middle supplying approximately T3-T8, and the inferiormost anterior spinal artery supplying the area from T8 to the conus. The middle and inferior sections are fed by direct radicular branches from the aorta.

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To meet this frst goal and become a good clinician treatment vaginitis generic careprost 3ml amex, it is helpful for stu dents to medicine klonopin buy careprost 3ml visa be carefully observant of their professors in important but unno ticed aspects medications kidney patients should avoid purchase 3ml careprost with amex, such as their demeanor treatment yellow jacket sting careprost 3 ml with mastercard, comments, and interaction with house staf and patients. The process starts with the student’s appearance (clothing and grooming), punctuality, composure, acceptance of responsibility, and interactions with patients and other healthcare team members. However, medical students frequently have extra time to spend with their patients, talking to the patients about their past medical problems, family, and social history as they pertain to their disease process. This type of relationship establishes the medical student as an important part of the healthcare team, benefcial to the overall care provided to the patient. For the medical student, it also establishes long-term behaviors that translate into the development of an excellent future physician. During the third year, there may be conficting responsibilities, such as being at a lec ture while needing to draw a patient’s blood. If it is an important blood test and you cannot get someone to do it for you, you may need to miss the lecture. Tese situations don’t actually come up that ofen, and if patient care is the main goal, over the long run, most people will respect these decisions. You should read textbooks because they cover the basics, and 90 percent of people do not know what is in them. It does not matter which textbook you read, because if the information is important, it will come up again in later reading. You are ready to read, and recall from your notes that your patient has hypertension, chronic obstructive pulmonary disease, diabetes, and a pleomorphic adenoma. Tere is no way you can read about all that tonight, and you have to get up at 5:00 a. So you go to bed, and the next morning you do not really know why we even treat asymptomatic hypertension in the frst place. Remember Darwin’s theory of medical education: “It cannot be that rare if you are seeing it. You will be very compassionate to all your patients and coworkers, and you will always be willing and ready to learn. However, there is one important caveat that is ofen not addressed in medical educa tion: It is as much your responsibility to know your limitations as it is to know about treating patients. If you are trying hard, reading an hour every day, and truly interested, then if you are asked a question to which you do not know the answer, it is perfectly legitimate, and indeed expected, that you simply answer, “I don’t know. If you use the information you already have, you will ofen do surprisingly well if you guess at an answer. But if your answer is only a guess, qualify it by pointing out that you do not specifcally know the answer. Although you may not know that much yet in your clinical career, you have one secret weapon as a student: enthusiasm. Residents are ofen tired and grouchy, as you probably have noticed, but having an enthusiastic stu dent around makes a diference. Since the great majority of you will not become otolaryngologists, it becomes much more important for you to understand how to recognize potentially dangerous problems that should be referred to an otolaryngologist, as well as how to manage uncompli 6 cated problems that can be taken care of at the primary care level. Your highest professional priority throughout your third year and the rest of your career should be . One way to learn as much as possible, without feeling overwhelmed, during the third year is to . When faced with two conficting responsibilities, should always be your highest priority. The key to a happy career in medicine is to make your highest professional priority. In all countries of the world, a common vein through medicine is to keep as the frst priority . The follow ing is a short list that can be used: • General/systemic symptoms (fever, chills, cough, heartburn, dizziness, etc); • Otologic (tinnitus, otalgia, otorrhea, aural fullness, hearing loss, ver tigo); • Facial (swelling, pain, numbness); • Nasal (congestion, rhinorrhea, post-nasal drip, epistaxis, decreased smell); • Sinus (pressure, pain); • Troat (soreness, odynophagia, dysphagia, globus sensation, throat clearing); • Larynx (vocal changes or weakness, hoarseness, stridor, dyspnea); and • Neck symptoms (pain, lymphadenopathy, torticollis, supine dyspnea). The head and neck exam involves inspection (and palpation if practical) of all skin and mucosal surfaces of the head and neck. Otolaryngologists utilize special equipment to better assess the ears, nose, and throat. A bin ocular microscope provides an enlarged, three-dimensional image, giving the physician a superior view of the ear canal and tympanic membrane. Fiberoptic instruments provide a similar ability to examine these regions, but with superior optics. The Ear Assess the external auricle for congenital deformities, such as microtia, promin auris, or preauricular pits. The external auditory canal should be examined by otoscopy afer being thoroughly cleaned if it is blocked by cerumen. The canal should be assessed for swelling, redness (erythema), narrowing (stenosis), discharge (otorrhea), and masses. Changes in the appearance of the eardrum may indicate pathology in the 10 middle ear, mastoid, or eustachian tube. White patches, called tympano sclerosis, are ofen clearly visible and provide evidence of prior signifcant infection. An erythematous, bulging, opacifed tympanic membrane indi cates acute bacterial otitis media. Healed perforations are ofen more trans parent than the surrounding drum and may be mistaken for actual holes. Pneumatic otoscopy should be performed to observe the mobility of the tympanic membrane with gentle insufation of air. Eustachian tube func tion may be assessed by watching the eardrum as the patient executes a gentle Valsalva. Tuning forks can be used to grossly assess hearing and to diferentiate between conductive and sensorineural hearing loss. A tuning fork placed in the center of the skull (Weber test) will normally be perceived in the mid line. The sound will lateralize and be perceived as louder on the afected side in cases of conductive hearing loss. If a sensorineural loss exists, the sound will be perceived in the better or normal hearing ear. The tuning fork is then placed just outside the external auditory canal for the Rinne’s test of air conduction hearing. Placing the base of the tuning fork over the mastoid process allows bone conduction hearing to be assessed. In conduc tive hearing loss, the tuning fork is heard louder behind the ear (bone con duction is better than air conduction in conductive hearing losses). This is indicated in any patient with chronic hearing loss, or with acute loss that cannot be explained by canal occlusion or middle ear infection. Topical vasoconstriction with oxymetazoline permits a more thorough examination and allows for assessment of turbinate response to deconges tion. Nasal patency may be compromised by swollen boggy turbinates, septal deviation, nasal polyps, or masses/tumors. The remainder of the nasal cavity can be more carefully examined by performing fexible fberoptic or rigid nasal endoscopy. This allows a more thorough evalua tion of the nasal cavity and mucosa for abnormalities, including obstruc tion, lesions, infammation, and purulent sinus drainage. The sense of smell is rarely tested due to the difculty in objectively quantifying 11 responses. However, ammonia fumes can be useful for distinguishing true anosmics from malingerers because ammonia will stimulate trigeminal endings, and thus produce a response in the absence of any olfaction. The Mouth An adequate light and tongue depressor are necessary for examining the mouth. The tongue depressor should be used to systematically inspect all mucosal surfaces, including the gingivobuccal sulci, the gums and alveo lar ridge, the hard palate, sof palate, tonsils, posterior oropharynx, buccal mucosa, dorsal and ventral tongue, lateral tongue, and the foor of mouth. The parotid duct orifce (Stenson’s duct) can be seen on the buccal mucosa, opposite the upper second molar. The submandibular and sublingual glands empty into the foor of the mouth via Wharton’s ducts.

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Performs reconstructive and by the American Board of Otolaryngology and aesthetic procedures treatment zap buy careprost 3 ml line, both surgical and the American Board of Facial Plastic and nonsurgical medications 563 buy generic careprost 3ml line. Some only focus on cosmetic dency in ophthalmology and a fellowship in procedures medications qid generic careprost 3ml without a prescription. Specializes in providing reconstructive and cosmetic procedures to treatment 8th march discount careprost 3 ml without a prescription the eye and around the eye. Word of Warning Because many nonsurgical aesthetic treatments can be uncomfortable, topical anesthetics are often used to numb the face. However, using them in large amounts, even if purchased over the counter, can lead to serious health problems, including 23 irregular heartbeat, seizures, coma and even death. Should be board A medical spa can be anything from a certified by the American Board of Dermatology or the American physician’s office staffed with licensed Osteopathic Board of Dermatology. Should be name doesn’t necessarily mean a board-certified by the American Board of physician or someone with medical Dermatology or the American Osteopathic training oversees it. Specializes in To avoid confusion and protect cosmetic dermatologic treatments, such as laser resurfacing and injections. Other states work in spas (medical or otherwise) or der simply require that a physician oversees matology offices performing facials and the services delivered and the nonphysi body wraps. And still other states make remove hair and care for the skin in a no such requirements at all. Most states license the key is to check what services the aestheticians, so check with your state spa offers. An electrologist is specially and dermabrasion, these treatments must trained in electrolysis. Most states regulate electrologists, requiring licensure and be performed by a licensed physician or, proof of training. As always, ask about the training of the person performing the service; ask to see evidence of licensure; and, if the spa is overseen by a physician, ask about the doctor’s credentials. If you have realistic expecta effectiveness of all drugs and medical tions of the results, understand that most devices before approving them for mar treatments are not permanent and may keting in the United States. Some prod need to be repeated in a few months or a ucts have years of clinical history for year to maintain results, and carefully other conditions before being approved research your options and the doctor for cosmetic procedures. Botox, for who will provide the treatment, you can instance, has been approved in the achieve a natural, refreshed look that United States for more than 17 years to enhances your appearance. If you are pregnant, nursing or have a medical condition, make sure Is it really true that I can get a Q you discuss the possible risks with “lunchtime facelift Most products are That depends on what treatment not recommended for pregnant or A you’re having. Others, such as dermabrasion and laser resurfacing, may take days or even weeks to heal. Also, your who provides nonsurgical aesthetic physician might offer financing options. Go to the Web sites of the major the idea of getting shots in my Q A plastic surgery and dermatologic face gives me the willies. A Facial resurfacing with microder Also talk to friends who have had treat mabrasion, for instance, is needle-free. Just treatments, your doctor may use either a make sure you check physician creden local anesthetic—to numb the area being tials carefully, ensuring they are qualified worked on—or a general anesthetic, to to perform the specific treatment. If you opt for injec tions, most doctors use topical anesthet Even though many of these non ics to numb the area. Q surgical cosmetic treatments are less expensive than surgery, they’re How do I know if my doctor Q still too expensive for me. Is there any is qualified for the aesthetic chance my insurance company will pay treatment I want In what specialty did he/she do treatments like those discussed in this a residency What are his/her board certi filler for a medical reason, like restoring fications Also ask where your doctor your appearance after an accident, or if trained on the treatment you’re having. Sculptra is often used off treatments like dermabrasion and laser label for cosmetic reasons other than its therapies. Resources the following provide consumer information about various cosmetic procedures, and most have searchable indexes of their members. American Academy of Facial Plastic American Society for Laser American Society of Ophthalmic and Reconstructive Surgery Medicine and Surgery Plastic and Reconstructive Surgery Plastic Surgery Statistics Cosmetic and Reconstructive 14 Portrait Skin Regeneration Procedure (patient brochure). Beauty versus Regeneration Technology in Low-Energy Full-Face medicine: the nonphysician practice of dermatologic Rejuvenation. Like lasers, peels can now be used to treat acne and acne IngredIents, MechanIsM of scars, superfcial to deep wrinkles, melasma or lentigines, white actIon and forMulas striae, hyperpigmentation or hypopigmentation, and provide skin toning or long-lasting tightening. Learning the art and science of this chapter will focus on chemical peels for all skin types(Fitzpatrick chemical peeling requires more extensive mentoring than lasers, 1988) (Table 12. We will discuss new combination chemical hopefully reclaim their status as the ‘gold standard’ in resurfacing peels (including the modifed phenol peel used by one of the authors the aging face. When evaluating a patient for a skin-resurfacing procedure, nationality and ethnicity should not be equated with skin color type. In general, they are classifed by level of injury (very light, light, medium, deep) (Table 12. For very light peels, 1 layer of Jessner’s, 30% salicylic acid, or bufered V Dark brown glycolic acid peels (30–70%) can be used. Medium depth and deep peels penetrate peels, which penetrate to the epidermis and papillary dermis, can through the papillary dermis into the mid to upper-reticular dermis. Vi Peel Melanage Peel Croton oil this is prepared from the seeds of Croton tigliu. Medium Deep Blue Peel Monheit Peel Arbutin Deep Two-day modifed phenol with croton oil 0. Mechanism of action Peels Azelaic acid is an efective melanogenesis inhibitor that helps to Caustic Trichloroacetic acid brighten uneven complexions. Its exfoliating and disinfecting properties are most Croton oil efective when used in combinations with a-hydroxy acids. Azelaic Metabolic Arbutin acid helps to normalize keratinization in the skin and is an antioxidant. Citric Citric acid acid increases the hyaluronic acid content in the dermis and epider Glutathione mis, helping the skin attract and hold moisture more efectively. It Glycolic acid can exfoliate the skin’s impacted surface cells and is a natural skin Kojic acid brightener and softener. Lactic acid Glutathione Mandelic acid is is a combination of three amino acids: cysteine, glutamic acid, and Phytic acid glycine. It is a potent, endogenous antioxidant that is produced naturally by Pyruvic acid the body to prevent cellular damage. Topical glutathione use provides Retinol (vitamin A) maximum free radical quenching capabilities. It is able to break down the bonds Resorcinol between the cells (desmosomes), loosening the horny layer, and caus Salicylic acid ing exfoliation. It causes changes in classifed as bufered or unbufered (stronger) and range from 20% to cell membrane permeability, which leads to cell death and exfolia 99% in commercial concentrations. Enrique Hernandez-Perez uses his Golden Peel (53% resorcinol) or his Golden Peel Plus (Jessner’s plus Kojic acid 53% resorcinol) to treat aging skin of the face or body, cellulite, or this is an antibacterial agent and melanogenesis inhibitor. It decreases the abnormal shedding of cells within the follicles, reduc Lactic acid ing the impactions that can exacerbate breakouts. It bonds between cells (desmosomes) to allow for easier exfoliation is made from sodium phenolate, is related to phenol, and thus shares of dead surface cells while hydrating the skin. Combination and commercial peels Mandelic acid ere has been a growing emergence of commercial and combination this is an aromatic a-hydroxy acid, used as an antibacterial agent, peels on the market (Table 12. The appeal of the Jessner’s Peel was the use of diferent substances that combined Phytic acid caustic, metabolic, and toxic efects (Dewandre & Tenebaum 2011).

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