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Delivery of injectable agents for treatment of stress urinary incontinence in women: Evolving techniques buy generic ethambutol 400 mg online bacteria definition biology. Antegrade techniques of collagen injection for post-prostatectomy stress urinary incontinence: The Washington University experience order 400mg ethambutol with visa bacteria klebsiella infections. A multicentre evaluation of a new surgical technique for urethral bulking in the treatment of genuine stress incontinence cheap ethambutol 400mg overnight delivery infection ear. Results of transurethral injection of silicone micro-implants for females with intrinsic sphincter deficiency ethambutol 400mg sale antibiotic essentials 2015. Bulking agents for stress urinary incontinence: Short-term results and complications in a randomized comparison of periurethral and transurethral injections. Comparison of transurethral versus periurethral collagen injection in women with intrinsic sphincter deficiency. Transurethral implantation of macroplastique for the treatment of female stress urinary incontinence secondary to urethral sphincter deficiency. New periurethral bulking agent for stress urinary incontinence: Modified technique and early results. Evaluation of the poly-L-lactic acid implant for treatment of the nasolabial fold: 3-year follow-up evaluation. Simple aspiration technique to address voiding dysfunction associated with transurethral injection of dextranomer/hyaluronic acid copolymer. Massive prolapse of the urethral mucosa following periurethral injection of calcium hydroxylapatite for stress urinary incontinence. Large urethral prolapse formation after calcium hydroxylapatite (Coaptite) injection. Delayed presentation of pseudoabscess secondary to injection of pyrolytic carbon-coated 784 beads bulking agent. Periurethral abscess following polyacrylamide hydrogel (Bulkamid) for stress urinary incontinence. Abscess formation and local necrosis after treatment with Zyderm or Zyplast collagen implant. Periurethral mass formations following bulking agent injection for the treatment of urinary incontinence. Particle migration after transurethral injection of carbon coated beads for stress urinary incontinence. New onset vesicovaginal fistula after transurethral collagen injection in women who underwent cystectomy and orthotopic neobladder creation: Presentation and definitive treatment. Three-dimensional ultrasonography: An objective outcome tool to assess collagen distribution in women with stress urinary incontinence. Role of three-dimensional ultrasound in assessment of women undergoing urethral bulking agent therapy. Urethral bulking with polymethylmethacrylate microspheres for stress urinary incontinence: Tissue persistence and safety studies in miniswine. Directed in vitro myogenesis of human embryonic stem cells and their in vivo engraftment. Autologous muscle derived cell therapy for stress urinary incontinence: A prospective, dose ranging study. Clonal isolation of muscle-derived cells capable of enhancing muscle regeneration and bone healing. Autologous muscle-derived cells for the treatment of female stress urinary incontinence: A 2-year follow-up of a Polish investigation. Over time, its use has expanded for the treatment of a variety of multiple conditions, including migraine headaches, limb spasticity, cosmetic surgery, muscular dystonia, and lower urinary tract dysfunction [1]. Biology and Mechanism of Action Clostridium botulinum is a Gram-positive anaerobic bacterium, whose strains produce seven immunologically distinct neurotoxins (types A–G). Types A and B have been used to treat medical conditions, with type A being used most often as it is relatively easily obtained and stable. The neurotoxin component is synthesized as a biologically inactive single-chain polypeptide activated by cleavage of the polypeptide chain into a 100-kDa heavy chain and a 50-kDa light chain linked by a disulfide bond [8,9]. There are a variety of type A botulinum toxin products available; these products are not equivalent and the doses are not interchangeable. Under normal circumstances in striated muscle, each muscle fiber is innervated by a single motor neuron at a site near the middle of each muscle fiber. Within each nerve terminal are cystoplasmic vesicles containing Ach transmitter molecules. The Ach collects within clusters of these synaptic vesicles and each vesicle aligns with a patch of dense material forming an active zone. At the active zone in response to a propagated neural impulse, vesicles fuse with the plasma membrane resulting in the release of the Ach transmitter molecules into the synaptic cleft. The Ach diffuses across the synaptic cleft, binding to and stimulating the postsynaptic Ach receptors on the muscle cell. Its heavy chain is involved in the binding of the neurotoxin and in the transportation of the neurotoxin into the neuronal cytosol (endocytosis). Without the release of Ach into the synaptic cleft, there is no muscle contraction. Additionally, many patients continue to experience urinary leakage despite maximum medical therapy. In such patients, initiation of intermittent catheterization is necessary to effect bladder emptying. Incontinence was resolved in 17 of 19 patients and the clinical effect was still present at 9 months in the 11 patients who were still being followed [3]. Patients received either 200 or 300 U of intradetrusor onabotulinumtoxinA or placebo (saline) injections. The two treatment groups had significant posttreatment decreases in incontinence episodes, while the placebo group did not. The primary endpoint of the studies was a change from baseline in the mean number of urinary incontinence episodes/week at week 6. Patients who received 200 and 300 U of onabotulinumtoxinA demonstrated significant improvements over placebo, with a decrease of mean urinary incontinence episodes. Urinary urgency is the sudden onset or desire to pass urine, which is difficult to hold. Frequency is the passage of urine, which is greater than the amount considered to be normal, usually more than 8 voids/day. Some patients are unable to tolerate side effects from anticholinergic medications (dry mouth, constipation), and some do not experience desired treatment effects. Patients with urinary incontinence have been shown to have higher health-care resource utilization and lower health-related quality of life and productivity [25].

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In z Extrahepatic atresia of bile duct term infants order ethambutol 600 mg with amex harbinger antimicrobial 58 durafoam mat, it appears on second or third day (between z Hereditary spherocytosis 30 and 72 hours) and reaches peak on 4th or 5th day proven 400mg ethambutol antibiotics for acne brands. It z Neonatal hepatitis is generally mild buy generic ethambutol 800mg virus transmission, the serum bilirubin seldom exceeding z Drug-induced hemolytic anemia 12–15 mg% generic ethambutol 400 mg on line bacterial folliculitis. Persistent jaundice during frst month In case of the preterm baby, physiological jaundice z Inspissated bile syndrome may appear little earlier (but always after 24 hours), may z Cretinism be relatively deeper (upto 15 mg/dL) and reaches peak on z Congenital hypertrophic pyloric stenosis. Nevertheless, the infant needs Te following points should be particularly noted: to be closely followed up for undue rise or persistence of Maternal and family history with special reference to maternal infections during pregnancy, drugs given hyperbilirubinemia. In the latter situation, he should be during pregnancy or labor, previous sibling(s) afected investigated for pathologic jaundice. Tis is termed as exaggerated General condition of the infant—whether healthy, physiologic jaundice or hyperbilirubinemia. Pathological Jaundice (Unconjugated Hyperbilirubinemia) Clinical Examination Te neonatal jaundice not conforming to time table or Gestational age, activity and general condition of the infant. Te cause may be insufcient lactation leading to inad- Clinical detection and grading of severity of jaundice equate feeding, dehydration and hemoconcentration. Laboratory Investigations Breast Milk Jaundice Serum bilirubin, both direct and indirect. Conjugated A small proportion of exclusively breastfed infants also tend (direct) bilirubin less than 0. Coombs test of mother as well as baby Occasionally, undue anxiety in the parents may warrant Blood culture temporary withdrawal of breastfeeding just for 2–3 days. Comparison of clinical features of physiological and pathological jaundice in Principles of Management neonates Phototherapy and exchange transfusion are the two major Parameter Physiological jaundice Pathological jaundice efective therapeutic modalities available today. Additional options include pharmacotherapy in the form of phenobar- Onset More than 24 hours of birth Less than 24 hours of birth bital, agar-agar, albumin infusion, n-mesoporphyrin and Serum Slow Rapid: 0. With light sources of this range, 311 Clinical methods of detection of neonatal Box 17. A small portion gets oxidized to Blanching Blanching the skin of tip of nose, sternum, abdomen, palms and soles biliverdin. A common observation during photo-therapy be made as follows: is the bleaching of the exposed areas. Te areas of skin that z Face: 5 mg/dL remain covered continue to have yellow touch. Whether liver z Chest and upper abdomen: 10 mg/dL z Lower abdomen, thighs and upper arm: 12 mg/dL also plays signifcant role during photoexposure is being cur- z Thighs and upper arm: 12 mg/dL rently investigated. Icterometer It is now generally opined that blue light is superior to This is a noninvasive method which is more accurate and less sub- white light. The tool used is a transparent plastic with fve graded yellow sources are far better. Most neonatal units employ stand- stripes of diferent shades corresponding to the serum bilirubin levels. Alternatively, It is pressed against the tip of the nose (in case of very dark skin, gums make a better option). Tese lamps can be Transcutaneous bilirubinometer mounted with refectors in frames. The smaller size, focused area, lower scatter and higher irra- photoprobe is pressed against the skin of forehead or sternum (in case of very dark skin, a drop of blood on a flter paper make a better diance. Following analysis by the computerized spectrophotometer, acceptability to nursing staf. Such a phototherapy unit delivers about 200 foot can- dles of light to the infant. Te only problem with blue light is that it interferes with reasonable observations of the baby. Alternatively, white day-light lamps/tubes are reasonably efective and may be employed. A unit with a combination of both blue and white light tubes may also be employed. Length of Phototherapy Just 24–48 hours exposure is generally long enough to bring down serum bilirubin level to safe limits. Tough many authorities insist on giving continuous therapy, there is evidence to the efect that intermittent exposure is almost equally good. Te yellow color of the skin disappears or regresses much earlier than the return of serum bilirubin to near normal. It is, therefore, desirable that serum bilirubin estimation is done at intervals of 12 hours. In case 1500–2000 g 10 mg/dL of the male neonate, the external genitalia too need to be 1000–1500 g 7 mg/dL covered to prevent gonadal insult. Less than 1000 g 5 mg/dL Contraindication Mode of Action Congenital erythropoietic porphyria. Te value of phototherapy in lowering unconjugated hyper- Side Effects bilirubinemia is widely accepted. Immediate In order to understand its mode of action, it should z Loose motions (greenish or dark-brown) are due to be remembered that bilirubin absorbs blue-green light high content of photodegeneration products 312 baby from blood) and to replace the blood by healthy donor blood. Tus, overloading of the circulation as also congestive cardiac failure are avoided. Indications Any nonobstructive jaundice with serum bilirubin level of 20 mg/dL or more in fullterm and 15 mg/dL in preterm infants Kernicterus irrespective of serum bilirubin level Hemolytic disease of the newborn under the following situations: All above, plus z Cord hemoglobin 10% or less z Cord bilirubin 5 mg/dL or more Fig. It disappears soon after cessation of Choice of Donor Blood phototherapy with no permanent sequelae Te donor blood should be fresh (less than 3 days old). Te amount needed for an adequate exchange is about Delayed z Retinal damage and possible retardation of brain 160 mL/kg (double the blood volume). Also, it should be made sure that the z Delayed puberty because of long-term adverse blood is slowly warmed to infant’s temperature. If citrated or heparinized donor blood is used, one Directed at nursing staf: Headache and giddiness. Tis relatively new technique employs As a precaution, some authorities like to give injections of light from a fberoptic source which is fanned out on a calcium gluconate at regular interval when using citrated cummerbund wrapped round the neonate’s torso. Unlike the Warning Signs during Exchange conventional phototherapy in which irradiance is maximal Tese include vomiting and crying, grunting respiration at the body surface nearest to the light source, irradiant energy in this technique is uniformly distributed. It is as efective as the hyperkalemia, hypocalcemia, acidosis, thromboembolism, conventional phototherapy. Te mother Delayed Complications can pick up the baby without discontinuing phototherapy. While considering the late problems that may arise from It, therefore, does not interfere with mother-baby bonding. Te hemo- Remove excess bilirubin and other harmful substances globin should, therefore be estimated every week during (say, Rh positive cells which have become noxious to the frst month and then every fortnightly. Te hemo- globin of less than 7 g % during frst 2 or 3 weeks may be Obstruction/disappearance of intrahepatic bile duct 313 an indication for a small top-up transfusion.

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Recurrent urinary tract infections in women with symptoms of pelvic floor dysfunction 600 mg ethambutol with visa antibiotic overuse. Dynamic assessment of pelvic floor and bony pelvis morphologic condition with the use of magnetic resonance imaging in a multi-ethnic order ethambutol 400 mg mastercard virus d68 symptoms, nulliparous buy ethambutol 600 mg line antibiotic resistance korea, and healthy female population generic ethambutol 800mg on-line hm 4100 antimicrobial. It is uncertain whether it should be linked to 1A(2) (stress urinary incontinence) or 1A(3) (urgency urinary incontinence). This then becomes a significant, generally intercurrent, diagnosis likely to require treatment additional to that planned for the other diagnoses found. The chronic (present for at least 3 months) pain syndromes have not been included till consensus is reached. The chronic (present for at least 3 months) pain syndromes have not been included till consensus is reached. There is the difficulty of balancing the practical clinical definition and the scientific one. Records of diagnostic tests are often inaccessible over the medium to longer term. A pessary or ring might, at times, obstruct the urethra, giving a false negative for this sign. These sites and the methodology behind the measurement format [15] have therefore not been included here. Consensus was not reached on inserting a valuation of the different prolapse stages into the report, though it will be subject to ongoing discussion, for example, considering stage 0 or 1 as different degrees of normal support and considering stage 2 or more, where the leading edge is at or beyond the hymen, as definite prolapse [17,18]. Coupled with the brevity of these terms and their clinical usage for up to 200 years [19], the inclusion of these terms is appropriate. Some regard it as important to surgical strategy to differentiate between a central cystocele (central defect with loss of rugae due to stretching of the subvesical connective tissue and the vaginal wall) and a paravaginal defect (rugae preserved due to detachment from the arcus tendineus fascia pelvis). Coupled with the brevity of these terms and their clinical usage for up to 200 years [19], the inclusion of these terms is appropriate. Some regard it as important to surgical strategy to differentiate between a central cystocele (central defect with loss of rugae due to stretching of the subvesical connective tissue and the vaginal wall) and a paravaginal defect (rugae preserved due to detachment from the arcus tendineus fascia pelvis). Coupled with the brevity of these terms and their clinical usage for up to 200 years [19], the inclusion of these terms is appropriate. Some regard it as important to surgical strategy to differentiate between a central cystocele (central defect with loss of rugae due to stretching of the subvesical connective tissue and the vaginal wall) and a paravaginal defect (rugae preserved due to detachment from the arcus tendineus fascia pelvis). This diagnosis may be made in the absence of the symptom of stress (urinary) incontinence in women who have the sign of occult or latent stress incontinence. Objective findings of prolapse in the absence of relevant prolapse symptoms may be termed “anatomic prolapse. There is a 10% lifetime incidence for women of undergoing surgery to correct pelvic organ prolapse [56]. This then becomes a significant, generally intercurrent, diagnosis likely to require treatment additional to that planned for the other diagnoses found.. These reports have had a huge impact on usage of terminology in the field, achieving an unprecedented degree of harmonization between researchers around the globe. Not all the recommendations, however, have been universally accepted [19], particularly for the 2002 lower urinary tract function terminology report [9], which made many controversial changes. As in previous terminology reports, the description of each disorder is spread through multiple sections, separately describing the symptoms, examination findings, investigations, and holistic diagnoses. In order to maintain user- friendliness, the document is however extensively footnoted and cross-referenced both between sections and to previous standardization reports. This commentary on the 2009 standardization report aims to highlight the major changes from previous reports and suggest areas of new controversy that may need to be addressed in future revisions. In each definition, the new report has replaced the term “involuntary urine leakage,” with “involuntary urine loss,” recognizing that leakage might be adequately contained by pads or other products, but still be a significant bothersome symptom. The 2002 report recommended that the term “urinary” be included when describing stress, urge, and continuous incontinence, to distinguish urine leakage from fecal or flatal incontinence. This has certainly been adopted to some extent, but in many contexts is unnecessary. The terms urge and urgency have always caused some confusion and certainly should not be interchangeable. A strong urge to void is a normal bladder sensation, whereas urge incontinence is a pathological symptom. Over recent years, the term “urgency urinary incontinence” had been recommended to resolve this ambiguity (241) and has now been approved by the new report. Three “new” subtypes of incontinence have been introduced: “postural,” “insensible,” and “coital incontinence. In the absence of consensus, the 2009 report has elected to leave both definitions largely unchanged. Increased, reduced, and absent bladder sensation now have their own section in the report and exactly match their cystometric counterpart signs. The prognostic significance of symptomatic altered bladder 1808 sensation is however unclear. Even in healthy volunteers, there is a wide variation in the volumes at which bladder sensations occur [27]. The reliability of reporting of sensations at differing bladder volumes is variable with many groups reporting poor results [28,29], and others finding near perfect reliability [27,30]. There are even conflicting results regarding sensations associated with sham cystometry [31,32]. These new definitions should help researchers reach new understanding regarding the relationships between symptoms and signs. Bernard Haylen, who spearheaded the joint report, has been a pioneer in the objective assessment of voiding symptoms in women. The list of voiding symptoms has been expanded from 8 to 11, with the loss of “terminal dribble,” a more characteristically male symptom, and the introduction of “need to immediately revoid” and “position-dependent micturition. The present report now contains both terms, with dysuria being a special case of urethral pain associated with voiding. Five core symptoms are now listed, namely, vaginal bulging, pelvic pressure, bleeding/discharge/infection, splinting/digitation, and low backache. The symptoms of vaginal bulging [33] and pressure [34] are usually thought to be most important. It would, however, be useful for future unified standardization documents to include cross-references to other key symptom areas affected by prolapse, including sexual dysfunction, incontinence, voiding symptoms, and anorectal dysfunction, as in the previous pelvic floor standardization report [15]. The section on anorectal dysfunction is entirely new in keeping with the expanded remit. Most anorectal symptoms are now couched in terms that exactly match their corresponding urinary symptom. For example, fecal (rectal) urgency is a “sudden compelling desire to defecate that is difficult to defer,” and a feeling of incomplete (bowel) evacuation is the “complaint that the rectum does not feel empty after defecation. Although assessment of stress (urinary) incontinence, with a cough test, has an extensive supporting literature, some sources have cast doubt on the validity of patient reports of a “sudden compelling desire to void” [25,35], as a useful indicator of urgency. For the first time, occult or latent stress incontinence is formally defined and properly termed “stress incontinence on prolapse reduction. Although “stress incontinence on prolapse reduction” may be found in half of women considering prolapse surgery [37], current evidence is inconclusive [38,39] about optimal treatment.

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The permanent that aim at a symmetrical result discount ethambutol 600 mg visa antibiotics for sinus infection webmd, irrespective of the extent of scars on the skin depend on the type of correction and are the reduction buy ethambutol 800mg low cost virus repair. That is the purpose of tracing the median line not perceivable as they are well camouflaged by their which goes from the contour to the frenulum and the transi- location discount ethambutol 600 mg without a prescription antibiotic virus, but their evolution also depends on the skin type tion line ; they will serve as a reference in programming the and in the third month after the operation may appear quantity of the excess tissue to be resected proven ethambutol 600mg antibiotics not working. They must be hypertrophic and will stabilize around the sixth month perpendicular to each other at the end of the operation. This phenom- The suture is carried out with a rapidly re-absorbing enon is rare in the scars in the vermilion and the mucosa. As in all operations complications may arise, such as The consensus form is a document where the patient declares oedemas, sieromas and infections. After having carefully read and discussed each unclear term entific context guaranteeing complete anonymity with the surgeon, the patient signs the form as a confirmation. The different surgical corrective procedures used are not covered by a single general consent form. Information rela- tive to all procedures to be communicated to the patient fol- 10. Alka Seltzer, 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 [4]. 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.

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