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Erythematous papules appear in crops and intensify for 3 to Smallpox: See variola order liv 52. Complications include viral pneumo- nia purchase liv 52 with paypal, secondary bacterial infection order liv 52 200 ml on line, thrombocytopenia, glom- Theiler’s virus myelitis: Murine spinal cord demyelination erulonephritis, mycocarditis, and other conditions. This may be associated with the development of herpes zoster or Togavirus immunity: Lifelong immunity is induced by shingles later in life. Attenuated vac- cines have been used to successfully control Venezuelan Varicella-zoster virus immunity: Varicella-zoster virus equine encephalitis virus in horses. Antibodies against E1 protein infection, and reactivation of the virus in adulthood causes and the E2 protein can neutralize and passively protect against shingles, a dermatomal exanthem. Nonstructural chicken pox includes IgM response at the end of the incubation protein antibodies can recognize surface components of period when a vesicular rash appears. Chicken pox patients also develop nition of nonstructural proteins on infected cell surfaces by T a cellular immune response which reacts with the same viral lymphocytes is a signifcant immunity mechanism. The panel may be further refned by deter- virus remains dormant in the dorsal root ganglia for many mining IgM antibody specifc for certain microorganisms. It is important to give the globulin within 3 to 4 released during a cell-mediated immune response may acti- d after exposure to chicken pox. Vaccination is followed by the development of both are also formed in response to fungal infection. Variola (smallpox): Variola major is a Poxvirus variolae- Defects in host immunity associated with fungal infections induced disease that has now been eliminated from the are being identifed in order that cytokines such as interferon worldwide human population. It was produced by a different strain that was so weak it was unable to induce the formation of pocks on the chick chorio- Candida immunity: Resistance against Candida begins allantoic membrane. The term “variola” describes both the with the nonspecifc barriers such as intact skin and mucosal smallpox virus and the disease it causes. Once these protective barriers have Fungi are single-celled and multicellular eukaryotic micro- been breached, neutrophils are the major cellular defense by organisms such as yeast and molds. They readily invade and phagocytosing the Candida microorganisms with intracel- colonize a host with compromised immunity, producing a lular killing through oxidative mechanisms. Immunity to fungi involves both cell- eosinophils also participate in this process. Mononuclear cells constitute the main infammatory response in more chronic infections. IgG, IgM, and IgA immunoglobulin classes of Candida- specifc antibodies have been found in infected patients. Fungal immunity: Nonspecifc immune mechanisms of the Local mucosal immunity such as in the vagina is associated host that form a frst line of defense against fungal infec- with the development of IgA antibodies in secretions. Even tions include the mechanical barrier provided by the skin and though antibody titers were elevated in infected patients, the mucous membranes, competition by the normal bacterial fora humoral immune response does not have a principal role in for nutrients, and the respiratory tract’s mucociliary clearance host defense against Candida. Yet comple- chronic mucocutaneous candidiasis have increased suscep- ment components serving as opsonins facilitate phagocytosis tibility to Candida infections. Fungi are powerful activators of mined to be ineffective in preventing Candida infections. Neutrophils are very sig- nifcant in protection against various mycoses including dis- Coccidioides immunity: Immunity against Coccidioides seminated candidiasis and invasive aspergillosis. Bronchoalveolar mac- have a precise role in limiting infection before a specifc rophages play an important role in the immune response to immune response develops. It is also important for protection against humoral suppressor substance may sometimes suppress the dermatophyte infections. A Coccidioides-specifc response occurs in important role in protection against mucocutaneous candidi- some patients. Up to 90% of all infected individ- response facilitate the antifungal action of natural killer uals develop an antibody response to C. IgM 762 Atlas of Immunology, Third Edition forms early but disappears after 6 months, whereas IgG ele- capsulatum. The specifc cell-mediated response in humans vated titers may indicate dissemination. Immunity induced occurs in lymphoid organs and other tissues 7 to 18 d fol- by infection is species- and, in some instances, strain-spe- lowing exposure to conidia. This leads to the initiation of cifc, yet immunization with purifed antigens may induce healing of lesions and organs with the formation of granulo- heterologous protection. Lymph nodes that drain sites and is far more signifcant to resistance than is the humoral of infection are enlarged, encapsulated, and may calcify. Antibodies act Delayed-type hypersensitivity responses to histoplasmin are mainly against extracellular parasites to reduce invasion. Yeasts and conidia that are phocytes are more signifcant in later stages of infection. Yet Histoplasma yeasts fail to induce nosuppressed individuals, indicating that a specifc mucosal a respiratory burst when phagocytosed. Cytochalasins are metabolites of various species of fungi Mucocutaneous candidiasis: Cellular immunodefciency that affect microflaments. They bind to one end of actin fla- is associated with this chronic Candida infection of the ments and block their polymerization. Thus, they paralyze skin, mucous membranes, nails, and hair, with about 50% of locomotion, phagocytosis, capping, cytokinesis, etc. Cryptococcus neoformans immunity: the polysaccha- the individual manifests anergy following the injection of ride capsule of C. It blocks binding sites recognized by phago- tious agents, including other fungi, bacteria, and viruses, is cytic receptors for β-glucan and mannan that could mediate not impaired. The polysaccharide capsule may candidiasis with granuloma and hyperkeratotic scales on the also induce suppressor T cells that synthesize a factor which nails or face. These have an associated endocrinopathy in inhibits binding of the organism by macrophages. The second type is late-onset chronic immunity to this fungus is the recognition of encapsulated mucocutaneous candidiasis, which involves the oral cavity C. The third form is transmitted as an immune response is essential to control encapsulated C. The fourth form is known as juvenile familial poly- T cell-mediated immunity is critical for acquired immunity endocrinopathy with candidiasis, which may be associated against C. Those individuals in whom endocrinopathy is associated with mucocutaneous candidiasis may demonstrate autoan- Histoplasma immunity: Cell-mediated immunity is the tibodies against the endocrine tissue involved. In addition main host defense against infection with Histoplasma to the immunologic abnormalities described above, there Immunity against Microorganisms 763 is diminished formation of lymphokines, e. Recommended treatment includes antimycotic IgG antibody responses specifc for the parasite, but most agents and immunologic intervention designed to improve individuals respond to only a subset of parasite constituents. Immunocompromised patients the IgE response appears to be protective in ascariasis and have an increased likelihood of developing infections by is believed to be a protective mechanism in other helm- Nocardia. Whereas T cell-defcient athymic antigens, it remains to be proven that this serves as an effec- mice show increased susceptibility to nocardial infection, tive mechanism to evade the host immune system.

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Calcification in the Achilles tendon (arrow) is seen as a well-defined area with echogenic margin and posterior shadowing in this long-axis extended-field-of-view image generic 60 ml liv 52 with visa. Longitudinal extended-field-of-view ultrasound showing severe insertional Achilles tendinosis generic 60 ml liv 52 visa. The distal one-third of the Achilles tendon (arrowheads) is thickened and hypoechoic with disruption of the normal fibrillar pattern discount liv 52 express. Color Doppler imaging (not shown) revealed mild peri- and intratendinous hyperemia. The tendon gradually tapers to a more normal caliber in the mid- to proximal one-third (arrows). Note mild distension of the retrocalcaneal bursa (asterisk) and a large posterior plantar calcaneal spur (open arrow). Longitudinal ultrasound image demonstrating bruising of the Achilles tendon from direct trauma as well as extensive tendinosis with significant tearing of the tendon substance. Longitudinal ultrasound image of the posterior leg demonstrating retrocalcaneal bursitis. Longitudinal ultrasound 1162 image of the Achilles tendon shows it to be inhomogeneous. The posterior margin of the calcaneus is prominent, and fluid distends the retrocalcaneal. Longitudinal extended-field-of-view ultrasound of partial chronic Achilles tendon tear. The Achilles tendon (arrowheads) is elongated, although still continuous with a retracted tendon mass (arrow) close to the musculotendinous junction. Transverse ultrasound image demonstrating significant tendinosis of the Achilles tendon with an intrasubstance tear. Longitudinal extended-field-of-view image of the Achilles tendon demonstrates advanced tendinosis with a superimposed irregular fluid-filled anechoic defect corresponding to a high-grade partial tear within the substance of tendon (arrow). The retracted ends of the tendon are shown (arrows) with the tendon gap filled with fluid. There is also an intact slightly swollen plantaris tendon (arrowheads) traversing the tendon gap. A fluid-filled gap and fluid within the sheet of the flexor hallucis longus tendon is seen. B: Longitudinal sonogram shows a normal linear fibrillar pattern in the left calf, and a full-thickness Achilles tendon tear on the right. Longitudinal extended-field-of-view image demonstrates moderate diffuse tendinosis of the Achilles tendon with a complete muscle–tendon junction tear (white arrow). Note the abnormal morphology and marked attenuation of the tendon at the muscle–tendon junction. Typical acute Achilles tendon rupture, 4 cm from the calcaneal attachment (thinnest and possibly least vascular portion of the tendon), showing retraction and fluid in the tendon gap. Longitudinal extended-field-of-view ultrasound showing diffusely thickened Achilles tendon (arrowheads) in a patient with familial hypercholesterolemia. The tendon thickening is due to deposition of cholesterol-rich material between the collagen fibers. There is a more discrete hypoechoic area of cholesterol deposition on the deeper aspect of the mid-tendon, which could be termed a “xanthoma” (arrow). Longitudinal ultrasound showing Achilles fracture avulsion from calcaneal insertion. The Achilles tendon (arrowheads) is attached to a large fragment of bone (closed arrow) avulsed from the calcaneum. Longitudinal color Doppler images of right (A) and left (B) feet demonstrating tendinitis of the left foot. Early identification of pathology associated with tendinopathy of the Achilles tendon is crucial to avoid tendon rupture (Fig. Ultrasound evaluation is also useful in assessment of healing of surgically repaired tears and ruptures of the Achilles tendon (Fig. It is 1165 also important to identify the plantaris tendon which lies medial to the Achilles tendon and can sometimes be confused for residual Achilles tendon in the setting of complete Achilles tendon rupture (Fig. Recent clinical experience has suggested that injection of platelet-rich plasma may be beneficial in patients with Achilles tendinosis to promote healing (Fig. A longitudinal power Doppler sonogram of the Achilles tendon showing hypoechoic flame-shaped partial tear (arrow) that begins interstitially and extends to the deep surface of the tendon. A power Doppler sonogram showing proliferation of neovessels in and around the tendon. Note that the normal tendons do not show a detectable flow on the power Doppler sonography. The appearances vary according to the site and type of repair performed, although typically the tendon (arrowheads) remains thickened with clearly recognizable suture material (arrows). The tendon is situated deep to the medial head of the gastrocnemius and medial to the Achilles tendon. It may become confluent with the Achilles tendon or have a separate insertion onto the calcaneus. In this extended-field-of-view image of the posterior calf, the tendon is apparent as a curvilinear echogenic band within a dissecting hematoma between the medial head of the gastrocnemius and soleus muscles in a patient with a complete rupture of the Achilles tendon. It is important to recognize the plantaris tendon, which can sometimes be mistaken for intact residual Achilles tendon. Transverse ultrasound image demonstrating injection of platelet-rich plasma to treat Achilles tendinosis. The bursa is subject to the development of inflammation after overuse, misuse, or direct trauma as is the Achilles bursa which lies posterior to the Achilles tendon at its insertion on the calcaneus. The Achilles tendon is the thickest and strongest tendon in the body, yet also very susceptible to rupture. The common tendon of the gastrocnemius muscle, the Achilles tendon, begins at mid-calf and continues downward to attach to the posterior calcaneus, where it may become inflamed. The Achilles tendon narrows during this downward course, becoming most narrow approximately 4 to 5 cm above its calcaneal insertion (Fig. Tendinitis, especially at the calcaneal insertion, may mimic retrocalcaneal bursitis and may make diagnosis difficult. It is an adventitious bursa which when inflamed is also known as “pump bump” due to its association with the hard back of ill-fitting pump style shoes. Typical acute tendon rupture, 4 cm from the calcaneal attachment (thinnest and possibly least vascular portion of the tendon), showing retraction and fluid in the tendon gap. The retrocalcaneal bursa, which is also known as the subtendinous calcaneal bursa, lies between the Achilles tendon and its insertion on the calcaneus (Figs. The bursa serves to cushion and facilitate sliding of the Achilles tendon over the calcaneus.

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A bifunctional antibody is an immunoglubulin molecule in which the Fab variable regions have different antigen- a catalytic function through the enzyme portion order 200 ml liv 52. These molecules are ies are artifcially formed immunoglobulins that manifest capable of catalyzing various chemical reactions and show double cheapest liv 52, well-defned antigen specifcity purchase 60 ml liv 52 free shipping. They are used to great promise as protein-clearing antibodies, as in the dissolu- focus the activity of an effector cell on a target cell by their tion of fbrin clots from occluded coronary arteries in myocar- ability to bind with one combining site on the effector cell dial infarction. Antibodies to helper and cytotoxic effector T cell receptors can mimic antigen and Designer antibody is a genetically engineered immunoglobu- activate the T cells to proliferate, release lymphokines, or lin needed for a specifc purpose (Figure 7. Bispecifc antibodies that bind to both been used to refer to chimeric antibodies produced by linking effector cell and to target cell can activate the effector cell mouse gene segments that encode the variable region of immu- and guarantee intimate contact between effector and target noglobulin with those that encode the constant region of a human cells. This technique provides the antigen specifc- molecules: (1) heteroconjugate bispecifc antibodies are ity obtained from the mouse antibody, while substituting the less produced by chemical linkage of two immunoglobulin mol- immunogenic Fc region of the molecule from a human source. Examples of passive immunization include (1) the recognizes a cell surface antigen on the cytotoxic effector administration of γ globulin to immunodefcient individu- cell, while the other limb is specifc for a tumor antigen. Single-chain bispecifc antibodies antibodies may be human blood donors, immunized humans are composed of linked variable domains fused to human or other animals, or hybridoma cell lines. The cytoplasmic tails of the Fcγ cells, and (3) inhibition of T cell responses by antigen/anti- receptor transduce inhibitory signals inside the B cells. An antiidiotypic antibody is an antibody that interacts with the use of Rh immune globulin to prevent erythroblastosis antigenic determinants (idiotopes) at the variable N-terminus fetalis in the infants of Rh negative mothers is an example of of the heavy and light chains comprising the paratope region antibody feedback. Secreted IgG antibodies may downregu- of an antibody molecule where the antigen-binding site is late antibody production when antigen–antibody complexes located. The idiotope antigenic determinants may be situated simultaneously engage B cell membrane immunoglobulin either within the cleft of the antigen-binding region or on the periphery or outer edge of the variable region of heavy and light chain components. An antiidiotypic vaccine is an immunizing preparation of antiidiotypic antibodies that are internal images of certain exogenous antigens. To develop an effective antiidiotypic vaccine, epitopes of an infectious agent that induce protective immunity must be identifed. An antiidiotypic antibody prepared using these protective antibodies as the immunogen, in some instances, can be used as an effective vaccine. Antiidiotypic vaccines have effectively induced protective immunity against such viruses as rabies, coro- navirus, cytomegalovirus, and hepatitis B; such bacteria as Listeria monocytogenes,Escherichia coli, and Streptococcus Antibodies pneumoniae; and such parasites as Schistosoma mansoni. Monoclonal antiidio- Umbilical typic vaccines represent a uniform and reproducible source cord for an immunizing preparation. An incomplete IgG antibody that, when diluted, may body molecule, such as IgG, with two identical antigenic combine with red blood cell surface antigens and determinants or epitopes on the same antigen molecule, in inhibit agglutination reactions used for erythrocyte contrast to each Fab region of the IgG molecule uniting with antigen identifcation. This can lead to errors in blood an identical antigenic determinant on two separate antigen grouping for Rh, K, and k blood types. An IgG antibody specifcally induced by exposure of the antigen molecule in such a manner that the binding of one allergic subjects to specifc allergens, to which they are Fab region to an epitope can position the remaining Fab of sensitive, in a form that favors IgG rather than IgE pro- the IgG molecule for easy interaction with an adjacent identi- duction. Interaction of this type represents high affnity they are sensitized, competes within IgE molecules of binding, which lends a stability to the antigen–antibody bound to mast cell surfaces, thereby preventing their complex. The combination of one IgM molecule to multiple degranulation and inhibiting a type I hypersensitivity epitopes on a single molecule of antigen represents monoga- response. A specifc immunoglobulin molecule that may inhibit the combination of a competing antibody molecule Fc receptor is a structure on the surface of some lym- with a particular epitope. Blocking antibodies may phocytes, macrophages, or mast cells that specifcally binds the Fc region of immunoglobulin, often when the Fc IgE Antigen molecule Mast cell Allergen Identical Allergen intercepted IgG epitopes Blocking IgG Ab’s before reaching IgM molecule IgE on mast cells figure 7. B and T lymphocytes, natural killer cells, poly- the release of infammatory mediators and cytokines. The Fc receptors for IgG are complexes, the cell may produce leukotrienes, prostaglan- designated FcγR (Figure 7. Those for IgE are desig- dins, modulate antibody synthesis, increase consumption nated FcεR (Figure 7. IgM and IgD Fc receptors have of oxygen, activate oxygen metabolites, and become phago- yet to be defned. In When the Fc region of immunoglobulin binds to the cation humans, it binds IgG1 and IgG3. In humans, it binds IgG1 be present in increased number, often accompanied by a and IgG3. Fcϵ receptor (FcϵR): Mast cell and leukocyte high affnity receptor for the Fc region of IgE. When immune complexes bind to Fcε receptors, the cell may respond by releasing the mediators of immediate hypersensitivity, such as histamine and serotonin. It is found on mononuclear phago- action of multivalent antigen with multiple IgE molecules cytes, B lymphocytes, eosinophils, and platelets. It is a 321-amino acid single polypeptide chain that ing vasoactive amines that produce local infammation and is homologous with a sialoglycoprotein receptor. Allergic individuals also express it on monocytes, eosinophils, B and T cells, but not mast cells or Langerhans cells, eosinophils, and monocytes. Specifc antigen interaction with the C cell-bound IgE molecules leading to cross-linkage results in cell activation and degranulation. FcαR represents the high affnity receptor for IgA and is comprised of an α chain that binds IgA and FcRγ chain dimer. It is expressed in fve splice variants found on eosinophils, monocytes, and alveolar macrophages. The genetic code includes the codons and nucleotide trip- the polyimmunoglobulin receptor is an attachment site for lets correlating with amino acid residues in protein synthe- polymeric immunoglobulins located on the basolateral mem- sis. After binding, the receptor–immunoglobulin complex is endocy- Immunoglobulin genes encode heavy and light polypep- tosed and enclosed within vesicles for transport. Exocytosis tide chains of antibody molecules and are found on differ- takes place at the cell surface where the immunoglobulin is ent chromosomes (i. A similar mechanism in chromosome 2 for κ light chain, and chromosome 22 for λ the liver facilitates IgA transport into the bile. The receptor a complete immunoglobulin heavy or light polypeptide segment that is bound to the polymeric immunoglobulin is chain. Separate gene segments that are widely distributed known as the secretory component which can only be used in somatic cells and germ cells come together to form these once in the transport process. In B cells, gene rearrangement leads to the cre- ation of an antibody gene that codes for a specifc protein. Poly-Ig receptor is the abbreviation of polyimmunoglobu- Somatic gene rearrangement also occurs with the genes lin receptor. Gene rearrangement of this type permits the great versatility of the immune Polymeric immunoglobulins (Ig) are immunoglobulin system in recognizing a vast array of epitopes. Three molecules that are comprised of numerous identical H2L2 forms of gene segments join to form an immunoglobu- monomers linked by a J chain. Heavy and A genome consists of all genetic information that is light chain genes have a closely similar organizational contained in a cell or in a gamete. There are 100 to 300 Vκ genes, fve Jκ genes, and one C gene on the κ locus of chromosome 2. Several Hypothetically, gene conversion was an evolutionary event as Vλ, six Jλ, and six Cλ genes are present on the λ locus of well as an ongoing one, giving rise to new mutations; there- chromosome 22 in humans.

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To avoid embolism buy on line liv 52, never inject fat in a centripetal direction but inject it when the cannula is being withdrawn liv 52 200 ml with amex. Fat grafting in penis best 200 ml liv 52, with the goal of enhanc- ing the organ is a simple procedure. It must be done very carefully to avoid complications and to have satis- epinephrine is used for a radius at the base and at the fed patients. For getting better proportion, in 9 cm long, 1 mm wide with eye) needle or a Keith some cases it may be necessary to combine fat aspira- needle with similar dimensions, these threads are tion from the pubis as well as fat injection into the passed from the base distally (Fig. M ore threads are passed in a similar fashion going pensory ligament of the penis could increase the length all around except inferiorly and superiorly in the mid- of the organ [17]. As shown complex and invasive may cause more signifcant in the above diagram, the entry points 4–6 and 10–12 complications. The exit points 1–3 and related to a larger incidence of bleeding, hematomas, 7–9 are at the coronal sulcus. In general, when a procedure is dorsal surface (vein area) and ventral surface (urethra simple, safe, and provides good results, it is more read- area) are avoided for thread insertion. Fat is har- more, there is always the risk of immunological reac- vested from the pubic area as needed and also from the tions, slow resolution of granulomas, sterile abscesses, lower abdomen and hip if required. W hen this occurs removed from the pubic area via a 3 mm keel cobra in the facial skin, it constitutes a diffcult problem; but tip cannula. After decantation, purifed fat is transferred using two points distally at 3 and 9 o’clock positions with a smaller fat transfer cannula (8 cm long , 1 mm broad) 37. It is important to avoid the midline areas Threads (urethral and vascular areas ) for fat transfer cannula entry points. Triple antibiotic ointment and oral antibiotics fuoroethylene) and silk threads alone, and with fat (cefadroxil monohydrate) are continued for 7 days together as lipo-Gore-Tex in the penis with satisfac- postoperatively. Patient preparation is the same as for fat in penis have remained stable, providing a high degree grafting in the penis. Fat stays in the penis 37 Penile Enhancement Using Fillers 463 a injection should be gentle and retrograde, avoiding larger spurts of fat in one area [27]. W hile injecting close to the base, assistant should compress the base with forefnger and thumb to avoid dispersion of fat in the liposuctioned pubic area. It is important that Gore-Tex threads are inserted frst, and later fat is injected. If fat is injected frst, needle and threads inserted subsequently can cause more damage to the transplanted fat. Fine Prolene 4/0 sutures should be applied to the fat transfer entry points to avoid extrusion of fat. Femoral vessels (artery and vein) should be marked beforehand before proceeding to liposuction of pubic area and Gore-Tex insertion in the penis after palpating these vessels in the groin fold. This is not really a side effect for some patients who appreciate rigidity of the organ and its turgescence during intercourse. Palpability of the implant due to thin overlying skin, and stinging from the ends during intercourse are other minor problems encountered in some patients. If Gore-Tex threads are not used all around, or are used in lesser numbers, Gore-Tex migra- tion can take place [28]. However, while using the proper afore- mentioned technique, and using fat and Gore-Tex together, this does not take place. However, due to the monoflament nature of these threads, infec- due to the peculiar anatomy and blood supply of the tion is more common as compared to Gore-Tex threads organ. The Gore-Tex proper broad spectrum antibiotic coverage, this hap- implants should be inserted subcutaneously [28]. M ore threads should are soft; however, fbrosis takes place in and around not be used to avoid extrusion. This hardening starts after a few weeks, and fat together, fat should be injected in moderate and can linger on for a year or so. It provides rigidity amounts (no more than 50 cc) to decrease the chance to the organ. After a year or more after insertion of the of cysts and pressure point skin necrosis [28]. Dermatol Surg 23(12): 1169–1174 It is important to avoid longitudinal midline areas 8. Dorsal vein of the penis can be rup- 135–138 tured on the dorsal surface while inserting threads. On the ventral midline area, urethra is pres- Clarifying concepts in modern liposuction. It can be punctured with subsequent leakage of Restor Surg 14:275–280 urine subcutaneously. Jones J, Lyles M (1997) the viability of human adipocytes after closed-syringe liposuction harvest. Am J Cosmet Surg M oreover, fbrosis of threads in the vicinity of urethra 14:275–280 can cause frequency of micturation, hesitancy, dis- 12. Johnson G (1992) Autologous fat graft by injection: ten torted urinary stream, and stasis via pressure on the years experience. Am J Cosmet Surg 4:73–75 urethra can predispose to calculi formation in the uri- 13. Am J Cosmet Though, this is not really a treatment for impotence, Surg 14:339–343 patients have reported improvement in sex and inter- 15. Hernández-Pérez E (1992) Bi-level lipoinjection for facial course after Gore-Tex implants and fat. Brandow K, Newman J (1996) Facial multilayered micro of Gore-Tex counters faccidity encountered during lipoaugmentation. Sito G, Sorrentino L (1998) the mushroom technique for improved and this also helps in erection of the organ. Am J Cosmet Surg 15:165–166 the psychological beneft to the patient is tremendous. Int J Aesth Restor Surg 1:63–68 remained stable providing long lasting results with a 20. Boyce B (1982) Physical characteristics of expanded poly- tetrafuoroethylene grafts. Aula M édica, M adrid, pp rafuoroethylene (Gore-Tex soft tissue patch) in facial aug- 563–569 mentation. Bircoll M (1992) A nine-year experience with autologous 1008–1014 fat transplantation. Newman J, Ftaiha Z (1987) the biographical history of fat 109(7):427–433 transplant surgery. Hernández-Pérez E, M arroquin-Burgos R (1993) Fat injec- in cheek-lip groove rejuvenation. M cGraw-Hill, New York, pp Int J Cosmet Surg Aesthet Dermatol 4(2):131–138 267–275 28. Hernández-Pérez E, M achado A (1996) Fat transplants in guidelines for use, complications, prevention and treatment. In the United the concept of using ultrasound to emulsify fat prior States alone, over 200,000 liposuction cases were per- to or during aspiration for body contouring is not new formed in 2009 [1].

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