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Whatever the reason purchase acivir pills 200mg fast delivery hiv infection rates per country, personal or sociological purchase acivir pills once a day hiv infection rate nepal, contem- ing nasal tip that is in harmony with the nasal dorsum and porary Asian society is in general more comfortable with facial overall facial features purchase acivir pills overnight delivery hiv infection stages pdf. Specific ways Rhinoplasty is one of the most common facial plastic surgery to achieve this harmony can only be substantiated with suffi- performed in Asia acivir pills 200mg amex hiv infection rates heterosexual vs homosexual. Although the principles and goals may be cient understanding of the cultural environment and continu- similar, the actual execution is quite different from the Western ous exposure and dedication to the Asian patient. Anatomic characteristics of the Asian nasal tip each operation must be highly individualized. A harmo- been published highlighting these different approaches and niously matched projection of the nasal tip according to the techniques. In this chapter, characteristics of the Asian tip will be projection and definition, with aesthetically pleasing width and addressed with emphasis on anatomy and specific surgical flare at the nostrils while maintaining symmetry. One impor- techniques that the authors have used to obtain reliable and tant point that should be kept in mind is that many Asian consistent results. The amount of projection and rotation differ according to personal preference, age, sex, occu- 71. In general, because the dor- sum of Asians is relatively low, most undergo augmentation, Asian Nasal Tip and the amount of tip projection should be balanced accord- Geographically, Asia is the world’s largest and most populous ingly or more frequently the other way around. Nasal tip width continent, with ~4 billion people, hosting 60% of the world’scur- should always be evaluated in the context of other facial anat- rent human population. The term Asian people is a demonym based a narrow tip can appear conspicuous and operated. Although variation exists, most commonly it refers to people with ancestry coming from a partic- 71. Therefore, designating the collective Anatomically, the Asian tip is characterized by thick skin with term of Asian rhinoplasty to this group of patients is of minimal abundant subcutaneous fibrofatty tissue, weak cartilaginous value as the needs in each individual are complex and diverse. Gener- collectively contribute to poor tip support, resulting in lack of ally, the typical Asian tip appears wider and less projected, and projection and definition. Managing and reshaping a tip with as a consequence, the Asian nose appears more triangular when these characteristics can be more challenging because the fragile viewed from the front. Alar columellar disproportions, espe- cartilage-reshaping sutures or cephalic resection will often yield cially a retracted columella with acute nasolabial angle, are also inconsistent and incomplete results in the Asian tip, and this has quite common, requiring fundamental changes in the nasal tip. Weak cartilaginous structures and deficient caudal septum collectively contribute to poor tip support, resulting in lack of projection and definition. However, long-term complications with implant extrusion, skin break- down, and infection. Complexity of the deformity, choice of procedure, and surgeon’s preference will collectively dictate the approach. The drawback of the open approach, which is a noticeable columel- lar scar, can be a rare source of complaint considering the Fig. However, we think that it can be decreased support and minimal increase in tip projection. In the authors’ experience, problems associated with tip support and/or need substantial increase in tip projection. The the endonasal approach to patients whose tip support is second step is fine sculpturing of the nasal tip. This is done by sufficient and only requires a minor to moderate degree of combining sutures and a variety of grafts to obtain the desired manipulation. However, septal cartilage in Asians is thin, and the Projection and Rotation) portion of the graft higher than the dome may bend or rotate cephalically, making the nose look short and overrotated. This Because many Asians have weak tip support, tip projection and can be prevented by a buttress graft behind the shield graft or rotation are more effectively modified using structural grafts. The choice of is that tip grafts usually augment only the infratip lobule seg- maneuvers to augment the nasal tip depends on two factors: ment of the tip and can result in an unnatural-looking tip if too the degree of tip support and the amount of projection needed 4 much grafting is placed. Tip support can be estimated by careful preoperative palpa- tion with emphasis on tip recoil, skin thickness, integrity of the 71. Not only does it provide a the patient’s wishes, anatomic characteristics, and overall aes- firm foundation upon which the lower lateral cartilages can be thetics of the nose and the face. Therefore, by varying its shape and loca- projection, onlay grafts alone or in combination with suture tion, it can be efficiently used to augment, rotate or derotate, modifications can be performed. The choice depends on the underlying deformity, desired outcome, sculpted graft can be sutured, inserted in a symmetric pocket, surgeon’s preference, strength of the cartilage, integrity of the or fixed externally using a tagging suture tapped to the skin caudal septum, and amount of available grafting material. It can be performed unilaterally or bilaterally, overlapping the For the typical Asian patient with weak tip support, augmen- caudal septum or in an end-to-end fashion, secured only to the tation is usually accomplished in two steps. The first step is sta- caudal septum, based on the anterior nasal spine, or integrated bilization of the nasal tip. The objective is to establish a firm ent shapes and sizes, depending on the desired changes of the foundation on which further grafting can be added on. Tip support is restored by applying a septal extension graft followed by fine sculptur- ing with additional onlay tip grafts. Care is taken to bevel or ponent, which can cause an unnatural appearance on the basal thin this portion of the graft overlapping the septal cartilage and lateral view. Another preventive measure in addition to fixation of the caudal septum to the anterior nasal spine is adding strength to the caudal septum with batten grafts or extended spreader grafts in case the caudal septum is weak. This is achieved by thorough dissection of the lower lateral cartilages laterally to the pyriform aperture and cephalically releasing the scroll area between the upper lateral cartilages. Increasing Definition) Because of this diversity, there have been limited attempts to try to classify the bulbous nose. The common features of a bulbous of the Asian nasal tip render it to be more round and perhaps tip include rounded shape, broad or absent tip-defining point, more bulbous to start with. The basal view looks more natural because the columellar and infratip components have been augmented simultane- ously. This shows that vari- One additional issue to consider in managing a bulbous nose ety exists among the same ethnic group, and the assumption is that most Asian noses need dorsal and tip augmentation. A of characteristics according to ethnic backgrounds can be tip may appear less bulbous and more balanced without any misleading. Procedures to aug- Techniques to manage a bulbous nose are targeted to correc- ment the tip can also reduce tip bulbosity. An algorithm for the manage- the alar cartilages and procedures that reduce volume of the ment of the bulbous nose in Asians should include all these alar cartilages. Diverse suture techniques and/or grafts are considerations and the strategy need to be personalized employed for the former, and excision techniques are employed. Managing the thick skin is the most challenging aspect of managing a bulbous nose. Soft tissue trimming is the most commonly performed Alar base modification in Asian noses is focused on two points: procedure. We usually limit our soft tissue trim- correction of alar flaring and alar base narrowing.

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If more than 3 hours elapse between ring expulsion and reinsertion, contraceptive effects may be diminished, and hence backup contraception should be used for 7 days. Initiating ring use is done as follows: • For women not currently using contraception, ring use should start anytime during days 1 through 5 of the menstrual cycle, even if bleeding is ongoing; backup contraception should be used during the first 7 days. The most common adverse effects are vaginitis, headaches, upper respiratory infection, leukorrhea, sinusitis, weight gain, and nausea. Common reasons for discontinuing the ring include foreign body sensations, coital problems, ring expulsion, vaginal symptoms, headache, and emotional lability. Long-Acting Contraceptives Subdermal Etonogestrel Implants A subdermal system [Nexplanon] for delivery of etonogestrel is available for long-term, reversible contraception. Description Nexplanon consists of a single 4-cm rod that contains 68 mg of etonogestrel, a synthetic progestin. The rod is implanted subdermally in the groove between the biceps and triceps in the nondominant arm. Etonogestrel then diffuses slowly and continuously, providing blood levels sufficient for contraception for 3 years, after which the rod is removed. Mechanism of Action Etonogestrel suppresses ovulation and thickens cervical mucus. In addition, it causes the endometrium to become involuted and hence hostile to implantation. Pharmacokinetics Daily release of etonogestrel is 60 to 70 mcg initially and gradually declines to 25 to 30 mcg over 3 years. Adverse Effect: Irregular Bleeding In women using Nexplanon, bleeding episodes are irregular and unpredictable. In clinical trials, amenorrhea occurred in 22% of women; infrequent bleeding (less than three bleeding or spotting episodes in 90 days) occurred in 34% of women; frequent bleeding (more than five bleeding or spotting episodes in 90 days) occurred in 7% of women, and prolonged bleeding (more than 14 days of bleeding in 90 days) occurred in 18% of women. The general pattern of irregular and unpredictable bleeding does not change while using Nexplanon. Use During Breastfeeding Nexplanon is safe to use during breastfeeding after the 21st postpartum day. In a controlled clinical trial, there were no significant effects on the physical or psychomotor development of infants. Also, Nexplanon had no effect on the production or quality of milk, even when implanted just a few days postpartum. The drug thereby (1) inhibits follicular maturation and ovulation, (2) thickens the cervical mucus, and (3) causes thinning of the endometrium, making implantation unlikely. When injections are discontinued, return of fertility is delayed (by an average of 9 months). To ensure that the recipient is not pregnant, the first dose should be given either (1) during the first 5 days of a normal menstrual period, (2) within the first 5 days postpartum (if not breastfeeding), or (3) at the sixth week postpartum (if exclusively breastfeeding). Most adverse effects are like those seen with other progestin-only contraceptives. Menstrual disturbances are common; menstruation may be irregular at first and then, after 6 to 12 months, may cease entirely. Women may also experience abdominal bloating, headache, depression, and decreased libido. ParaGard can remain in place for 10 years, Mirena for 5 years, and Liletta and Skyla for 3 years. These devices prevent conception by producing a harmless local inflammatory response that is spermicidal. Mirena, whose active ingredient is levonorgestrel, also causes endometrial involution and thickening of the cervical mucus. Spermicides Spermicides are chemical surfactants that kill sperm by destroying their cell membrane. These drugs are available in the form of a foam, gel, jelly, suppository, vaginal film, and contraceptive sponge. The spermicide must be applied before intercourse, but no more than 1 hour in advance (when used alone). Containers for foam preparations must be shaken thoroughly before each use to ensure dispersal of the spermicide. Suppositories should be inserted at least 10 to 15 minutes before intercourse to allow time for dissolution. The contraceptive sponge [Today Sponge] is a soft, porous, polyurethane disk impregnated with 1000 mg of nonoxynol 9. When inserted to cover the cervix, it protects against conception by (1) releasing spermicide, (2) absorbing seminal fluid, and (3) blocking penetration of sperm. Unlike other spermicide products, which must be reapplied before each act of intercourse, a single sponge is effective for 24 hours, regardless of how often coitus takes place. The rates of unintended pregnancy with the sponge are high: 16% among typical nulliparous users, and 32% among parous users. In the United States nearly 50% of women aged 15 to 44 years report having had at least one unintended pregnancy. Progestin-Only Emergency Contraception Pills Three progestin-only products are available: Plan B One-Step, Next Choice One Dose, and Next Choice. These products are packaged and marketed specifically for emergency contraception. Plan B One-Step and Next Choice One Dose Plan B One-Step and Next Choice One Dose consist of a single, high-dose (1. The package insert calls for taking the tablet within 72 hours of unprotected intercourse. Plan B One-Step reduces the odds of pregnancy by 89% and Next Choice One Dose prevented 84% of expected pregnancies, which is better than it may seem. In the absence of these two medications, the pregnancy rate from a single act of unprotected intercourse is about 8% (i. Plan B One-Step and Next Choice One Dose work primarily by delaying or stopping ovulation.

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