|
HomeA Dozen StepsA Healthy Blog A Hearty Life Acne Cream Treatment Acne Treatment Alzheimer's Notes American Pharmacists Association Answers at MyShrink ASHP Health System Pharmacy New Capsules ASHP Health System Pharmacy News ASHP Health System Pharmacy Press Releases and Announcements Autism Vox Better Health Channel Beverly Hills Health Canada Communicable Disease Report Canada Pharmacy News Cancer News Articles Information CBC Health News Chronic Diseases in Canada Dalhousie Medical Schoo lNews Dentists Daily News Dermatology Diabetes Notes Diet Weight loss News Discover Glutathione The Master Antioxidant Drug and Alcohol Addiction Rehab Drug Topics Drug Information Drug Topics Drug Topics Daily News Drug Topics Drug Topics Exclusive Surveys Drug Topics FDA Alerts Drug Topics Latebreakers Drug Topics Medicare Part D News Drug Topics New Drug Approvals Drug Topics New Health And Beauty Drug Topics New Home Health Care Drugs Pharmacy eating disorders Eating Fabulous Essential health news Facial Plastic Surgery Find Articles Search Alert Find Me A Cure Foreign Pharmacy News Section International Drug Mart FT.com Drugs and Healthcare Gamat Emas Jeli Gamat General Psychiatry Generations for Life Genetics and Health Genetics Health Grounded Fitness Hair Transplant Help Health Health and Fitness Official Blog Of International Drug Mart Health and Men Health current issue Health Education Resources Health Information Health News from NHS Choices Health recent issues Healthbolt Help My Hurt Informative Vitamin News Doc1Vitamins Internal Medicine Katz Bad Breath Blog Kids Health Notes Latest Biology News Latest Biology Technology Latest Health News Latest Medical News Latest Medical Technology latest science and technology news Lifeinthe HEALTH lane Lively Women Lovaas Blog Treatment for Children with Autism Madelyn Fernstrom male sexual health information Medicine Mesothelioma News Neurology New Hampshire Fitness Personal Trainer NHS Choices Live well NHS Choices Video NPR Topics Health Care NPR Topics Health Science Online Pharmacy News Opthalmology Otolaryngology Pediatrics Penis Enlargement Pharma Industry Pharmacy and medical medicine news Plastische chirurgie Priveklinieken Psyche Science Society Public Health Agency of Canada Public Health Agency of Canada Media Room Public Health Agency of Canada Travel Health Advisories Raising Breast Cancer Awareness Real Food For Life Science Based Medicine SECRETS TO WEIGHTLOSS SUCCESS Sizegenetics Review some news from the world of health Spine Health Back Pain Information Surgery The NobleDentist Blog The Pharma Compliance The Weighting Game Veggie Chic Vidyya Medical News Service weekly primary-science peer-reviewed medical journal Weight Loss Blog Weighting Line Weightloss Worriers Weightloss Worries Womb Within |
Archives of Facial Plastic Surgery recent issuesArchives of Facial Plastic Surgery is a semimonthly peer-reviewed original science journal-rich in content, highly graphic in format, and international in perspective. Archives is a journal for all the specialties of medicine that perform cosmetic and reconstructive surgery of the face. It is the official publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc. and the International Federation of Facial Plastic Surgery Societies. About This Journal [About This Journal] Highlights of Archives of Facial Plastic Surgery [Highlights of Archives of Facial Plastic Surgery] Reconstruction of the Nasal Septum Using Polydioxanone Plate [Original Article] Objectives To evaluate the usefulness of resorbable polydioxanone plate attached to nasal septal cartilage in external septoplasty, to assess its mechanical stability until healing of cartilage fragments, and to describe the surgical technique and clinical experience. Design External septoplasty with polydioxanone plate has been performed in 396 patients since 1996. Indications were severe septal deformities (usually posttraumatic). Surgery included removal of the quadrilateral cartilage and division into straight fragments, which were sutured to resorbable polydioxanone plate and replaced as a free graft. If the nasal septal cartilage was partly or completely missing because of prior surgery or trauma, the missing cartilage was supplanted with auricular conchal cartilage. The study settings were Medicent Linz, Linz, Austria, and the Ear, Nose, and Throat Department, General District Hospital Steyr, Steyr, Austria. Results Functional and cosmetic outcomes were satisfactory. All patients experienced varying degrees of improvement in nasal blockage. There were no immediate (bleeding, septal hematomas, inflammatory reactions, or necrosis) or long-term (septal perforation, thickening of the nasal septum, or rejection of the implant) complications. Conclusion Use of polydioxanone plate attached to nasal septal cartilage facilitates surgical correction of severe septal deformities and supports the nasal dorsum until healing. Mandibular Distraction Osteogenesis Used to Treat Upper Airway Obstruction [Original Article] Objective To evaluate whether mandibular distraction osteogenesis relieves tongue-based airway obstruction in patients with severe micrognathia. Design Retrospective medical review spanning a 7-year period in a tertiary care hospital. The inclusion criterion was defined as micrognathia associated with a severe tongue-based obstruction. The patients included 11 neonates and infants (mean age, 4.3 months) and 2 pediatric patients (mean age, 5.4 years). Two patients had already received tracheotomies, 11 had not. The intervention was bilateral mandibular osteotomies with distraction osteogenesis. The outcome measures were avoidance of tracheotomy and decannulation. Results Ten of 11 patients avoided tracheotomy. Two of 2 patients who had already undergone tracheotomies were successfully decannulated. Conclusion Mandibular distraction osteogenesis is an acceptable treatment alternative to tracheotomy in select pediatric patients with micrognathia and severe tongue-based obstruction. Temporal Branch of the Facial Nerve and Its Relationship to Fascial Layers [Original Article] Objectives To eliminate the inconsistency in the nomenclature, to anatomically and definitively describe the topographic relationship of the temporal branch of the facial nerve to the fascial layers and the fat pads, and to create an effective algorithm to define the safest approaches and planes for surgical procedures in this area. Methods The study was performed using 18 hemifacial cadaveric specimens. In 12 hemifacial specimens, the facial halves were coronally sectioned and dissected. In 6 hemifacial specimens, planar dissection was performed layer by layer. Results The temporal branch of the facial nerve that traversed inside the deep layers of the temporoparietal fascia and the superficial musculoaponeurotic system coursed along the zygomatic arch as 1 (14.3%), 2 (57.1%), 3 (14.3%), and 4 (14.3%) twigs in the specimens. The temporoparietal fascia had no attachment to the zygomatic arch and continued caudally as the superficial musculoaponeurotic system. Adhesions were between the temporoparietal fascia and the superficial layer of the deep temporal fascia around the zygomatic arch. In most specimens, the superficial layer of the deep temporal fascia continued as the parotideomasseterica fascia, and a deep layer abutted the posterosuperior edge of the zygomatic arch. Conclusion An easy and safe surgical approach in this area is to elevate the superficial layer deep to the intermediate fat pad directly on the deep layer of the deep temporal fascia descending to the periosteum along the zygomatic arch. Objective To evaluate changes in lower eyelid position using digital image analysis in patients who have undergone an orbicularis suspension flap combined with blepharoplasty. Methods A total of 68 patients (136 eyes) underwent a lower eyelid orbicularis oculi suspension flap combined with blepharoplasty. Digital image analysis was used to standardize each patient's preoperative and postoperative photographs for accurate objective comparison. The photographs were analyzed for lower eyelid position. Results The mean (SD) preoperative standardized distance from the center of the pupil to the lower eyelid margin (MRD2) in all procedures was 5.53 (0.74) mm. The mean (SD) postoperative standardized MRD2 was 5.22 (1.0) mm. There was a statistically significant difference in MRD2 position such that the postoperative MRD2 position decreased or the lower eyelid position was elevated by an average of 0.31 mm in comparison to the preoperative position (P < .001). Conclusions A well-performed suspension flap can elevate the lower eyelid position to a more natural and anatomically appropriate position. By resuspending the ptotic orbicularis muscle, the suspension flap also reinforces the underlying attenuated orbital septum. Such cases may not achieve the optimum level of rejuvenation if isolated lower eyelid blepharoplasty is performed. Objective To determine the force requirements, optimal vector, and appropriate materials of a novel eyelid sling device that will be used to rehabilitate eyelid closure (blink) in congenital or acquired permanent facial paralysis with an artificial muscle. Methods The force required to close the eyelids in human cadavers (n = 6) were measured using a load cell system. The eyelid sling using either expanded polytetrafluoroethylene (ePTFE) or temporalis muscle fascia was implanted. The ideal vector of force and placement within the eyelid for a natural eyelid closure were compared. Results The eyelid sling concept was successful at creating eyelid closure in a cadaver model using an upper eyelid sling attached to the distal tarsal plate. Less force was necessary to create eyelid closure using a temporalis muscle fascia sling (627 ± 128 mN) than for the ePTFE eyelid sling (1347 ± 318 mN). Conclusions The force and stroke required to close an eyelid with the eyelid sling are well within the attainable range of the electroactive polymer artificial muscle (EPAM). This may allow the creation of a realistic and functional eyelid blink that is symmetric and synchronous with the contralateral, normally functioning blink. Future aims include consideration of different sling materials and development of both the EPAM device and an articulation between the EPAM and sling. The biocompatibility and durability studies of EPAM in a gerbil model are under way. The successful application of artificial muscle technology to create an eyelid blink would be the first of many potential applications. Biomechanical Analysis of Anchoring Points in Rhytidectomy [Original Article] Objective To quantify tissue tearing force at various anchoring points on the face. Methods This is a prospective anatomic study using 4 fresh cadavers of persons aged 60 to 70 years at the time of death, for a total of 8 sides. Standardized 1-cm distances were measured at the various anchor points, and a single 0 Prolene suture loop was tied at each standardized anchoring point. Steady force was applied perpendicular to the plane of the face with a digital hanging scale. The scale was pulled until the suture ruptured the tissue at the anchoring point. The values at which the tissue ruptured were recorded, averaged, and compared. Results The average tissue force was 7.01 kg for the root of the zygoma vs 3.44 kg for the temporalis fascia (P < .05). The average tissue force was 5.50 kg for infralobular tissue vs 4.09 kg for tissue of the superficial musculoaponeurotic system located 1 cm anterior to the infralobular tissue (P < .05). The force for the fascia of the sternocleidomastoid was 3.89 kg vs 5.57 kg for the mastoid fascia (P < .05). There was a statistically significant difference between vertical bites of the temporalis fascia at 1.90 kg vs horizontal bites of the temporalis at 5.01 kg (P < .05). Conclusion The tissue tearing force varies by location on the face as well as suture orientation. Bipolar Electrocautery: A Rodent Model of Sunderland Third-degree Nerve Injury [Original Article] Objective To determine the Sunderland classification of a bipolar electrocautery injury. Methods Twenty-two rats received crush (a reproducible Sunderland second-degree injury) or bipolar electrocautery injury and were evaluated for functional, histomorphometric, and immunohistochemical recovery at 21 or 42 days. Animal experiments were performed between July 3 and December 12, 2007. Axonal regeneration and end plate reinnervation were evaluated in double transgenic cyan fluorescent protein–conjugated Thy1 and green fluorescent protein–conjugated S100 mice. Results Compared with crush injury, bipolar electrocautery injury caused greater disruption of myelin and neurofilament architecture at the injury site and decreased nerve fiber counts and percentage of neural tissue distal to the injury (P =.007). Complete functional recovery was seen after crush but not bipolar electrocautery injury. Serial live imaging demonstrated axonal regeneration at week 1 after crush and at week 3 after bipolar electrocautery injury. Qualitative assessment of motor end plate reinnervation at 42 days demonstrated complete neuromuscular end plate reinnervation in the crush group and only limited reinnervation in the bipolar electrocautery group. Conclusion Bipolar electrocautery injury in a rodent model resulted in a Sunderland third-degree injury, characterized by gradual, incomplete recovery without intervention. Objective To establish whether nimodipine, a calcium channel blocker, accelerates or otherwise improves functional recovery of whisking after facial nerve crush injury in the rat. Methods Thirty rats underwent exposure of the left main trunk of the facial nerve followed by a standard crush injury and subsequent quantitative facial movement testing. Animals were randomized into an experimental group (n = 15) and a control group (n = 15). Four days prior to facial nerve manipulation, experimental animals underwent subcutaneous implantation of a nimodipine-secreting pellet. All animals were tested preoperatively and on postoperative days 2, 8 to 17, 20, 22, 24, and 31 using a validated, quantitative whisking kinematics apparatus. Whisks were analyzed for amplitude, velocity, and acceleration. Results Animals receiving nimodipine demonstrated significantly better whisking on 5 days (postoperative days 9, 11 to 13, and 20) compared with control animals (P < .001, P = .003, P = .009, P = .009, and P = .009, respectively; 1-tailed ttest). Overall, the nimodipine-treated animals showed earlier recovery compared with the untreated animals. Conclusions We demonstrate that nimodipine improves recovery of whisking after facial nerve crush. This finding corroborates the semiquantitative findings of others, and provides complete whisking kinematic data on its effects. Given the low adverse effect profile of nimodipine, there may be clinical implications in its administration in patients experiencing facial nerve injury. Endoscopic Brow-lift in the Male Patient [Surgical Technique] Objective To report our experience with the endoscopic brow-lift in male patients at a university-affiliated outpatient surgery center. Methods Retrospective case series. Results From 1995 to 2007, a total of 244 endoscopic brow-lift procedures were performed, 21 of which involved men. Thirteen of the male patients had receding hairlines or some degree of baldness. Two male patients had postoperative complications; 1 male patient had temporal branch neurapraxia that resolved; and 1 male patient had in-office scar revision. Conclusions We have found that the endoscopic brow-lift procedure is well suited for male facial rejuvenation. Furthermore, our combined stair-step approach and suture suspension technique provides consistent results and high satisfaction regardless of the patient's hairline. Arguing the Ethics of Facial Transplantation [Ethics and Public Policy] While 7 face transplants have been performed around the world, to date, there remains debate regarding the validity of this procedure. We submit that performing a facial transplant—in the appropriately selected patient—is technically defensible and ethically sound. By outlining the technical and ethical boundaries of the debate, responding to the key arguments against the procedure, and describing its motivations and potential benefits, we state our justification of facial transplantation. Revision Surgery in Otolaryngology [Book and Multimedia Review] Eyelid and Periorbital Surgery [Book and Multimedia Review] Abstracts: In Other Archives Journals [Abstracts: In Other Archives Journals] Sir Edward Coley Burne-Jones's Hope [Beauty] About This Journal [About This Journal] Highlights of Archives of Facial Plastic Surgery [Highlights of Archives of Facial Plastic Surgery] The Evolution of the Archives of Facial Plastic Surgery [Editorial] Objective To discuss the technical and anatomical analysis and design of an osteocutaneous allograft transplant incorporating the donor maxilla and the execution of the operative protocol during the transplant. Methods The Cleveland Clinic reported the world's first successful combined face and maxilla transplant in December 2008. Unlike the 3 prior face transplants, this surgical procedure was done as a salvage operation in a patient who had undergone 23 major reconstructive procedures. The additional complexity due to significant postoperative scarring and recipient vessel depletion presented a unique challenge in this case. The extensive 3-dimensional losses of facial structures in multiple tissue planes required a Le Fort III osteomyocutaneous allotransplant incorporating the donor maxilla. Results We report the first successful transfer of a complete bony framework and soft-tissue envelope. The allograft has shown excellent integration and no long-term rejection. The traditional conception based on anatomical studies suggested that this transfer would require independent dissection of the internal maxillary vascular system. This was not required in our patient whose allograft was based solely on the facial arterial system and its arcades. Conclusions Successful near-total face and maxilla allograft transplant can be accomplished based on the facial arterial system and its arcades. This presents a novel method for reconstructing massive facial injuries with significant involvement of the facial skeleton. Objective In 1993, Kridel and Konior published a preliminary report (in the Archives of Otolaryngology–Head and Neck Surgery) on the use of irradiated homologous costal cartilage (IHCC) or homograft cartilage in the nose. This is a follow-up study to share our experience in answering fundamental questions: (1) What are the major long-term complications of IHCC, and are they any greater than with the use of the patient's own cartilage? (2) Is IHCC a reliable and safe implant? (3) Does IHCC resorb over time? (4) What measures are implemented in our practice to minimize the sequelae? Design We performed a retrospective review of patient medical charts in a university-affiliated private practice setting. A total of 357 patients underwent primary or revision rhinoplasty using IHCC grafts with postoperative follow-up duration ranging from 4 days to 24 years (mean [SD], 13.45 [2.83] years). A total of 1025 IHCC grafts and 373 other grafts (including 218 autogenous cartilage [AC] grafts) were used. A total of 201 grafts were dorsal onlay grafts, and 74 of them have been further followed up since the previous report. The grafts were evaluated for warping, infection, infective resorption, noninfective resorption, mobility, and extrusion. Patient satisfaction evaluation was performed in 42 patients. Results The total complication rate related to IHCC grafts was 3.25%, which included 10 warped grafts of 941 palpable or superficial IHCC grafts (1.06%), 9 infections of 1025 IHCC grafts (0.87%), 5 cases of infective resorption of 1025 IHCC grafts (0.48%), 5 noninfective resorptions of 943 palpable IHCC grafts (0.53%), and 3 cases of graft mobility of 941 palpable grafts (0.31%). Nine cases of local infection were treated and could have arisen from any of the 1025 IHCC grafts as well as from the 373 other grafts. Among the 9 cases of infection, in 2 patients IHCC grafts were used alone, and in 7 patients IHCC grafts were used in combination with other types of graft materials; therefore, the actual infection rate related to the pure use of IHCC was 2 of 1025 or 0.2%. Of the 218 AC grafts used at the same operative intervention along with IHCC grafts, 3 grafts (1.37%) underwent minimal resorption. The overall comparative resorption rates were 1.01% (IHCC) vs 1.37% (AC). The complication rate in conjunction with the use of 162 IHCC s in 53 cases of septal perforation repair was 2.46% (4 cases), including only 1 case of infection, 1 case of mobility of the graft, 1 case of warping, and 1 case of infective resorption (0.61% for all). Of the 25 AC grafts used in septal perforation cases, there were 2 cases of noninfective resorption (8%). The overall comparative complication rates in septal perforation cases were 2.46% for IHCC vs 8% for AC, which indicated a 3.25-times higher complication with the AC than with IHCC. No allergic reaction or systemic disease was reported by patients as a result of use of the IHCC. Irradiated homograft cartilage also proved to be a reliable graft in 2 patients with progressive autoimmune diseases over 2.08 years and 10 years of follow-up. The average rates of patient satisfaction increased during a mean follow-up of 7.87 years, from 91.31% to 94.18%, in 4 categories, including nasal appearance, nasal breathing, nasal symptoms, and quality of life. Conclusions Based on careful and extensive review of the data, we have concluded that IHCC is well tolerated as a grafting material in rhinoplasty and yields superb functional, structural, and cosmetic results in the most complex and challenging operative cases necessitated by previous unsuccessful nasal surgery, septal perforations, and even in autoimmune diseases that led to nasal deformity. Not only did very few complications occur following the use of 1025 IHCC grafts in 357 patients after 386 rhinoplasties over 24 years (rate, 3.25%), but the rate of complications was no greater than rhinoplasty complication rates when AC grafts are used. The results indicate safety and reliability and justify the convenient use of IHCC grafts for primary and revision rhinoplasty without creating donor site morbidity. Irradiated homograft cartilage grafts are quite stable in the nose and maintain structural contour and support in most cases. Irradiated homograft cartilage grafts should be considered as an alternative or even a primary grafting material when the patient does not have adequate quantities of septal or auricular cartilage remaining to provide the correction or when the shape or quality of such an AC does not adequately provide the structure required. Autogenous rib cartilage is also an alternative material but also increases operative and anesthesia time and adds potential morbidity. The use of IHCC is both cost- and time-effective. Objectives To measure the orbital volume of unilateral pure blowout fractures with computed tomography before and after surgery and to compare 3-dimensional (3-D) imaging systems. Methods Twenty-four patients were evaluated with facial computed tomographic scans before and after surgery. Both the orbital volume and the displaced soft tissue volume were measured by 2 operators using 2 different 3-D software programs (Vitrea; Vital Images Inc, Minnetonka, Minnesota; and Dextroscope; Bracco AMT Inc, Princeton, NJ). Results The mean (SD) normal orbital volumes calculated by Vitrea and Dextroscope were 25.5 (2.4) mL and 24.8 (3.0) mL, respectively. The average preoperative orbital volumes were 28.3 (2.3) mL and 27.6 (3.1) mL, while the postoperative volumes were 25.8 (2.5) mL and 24.9 (3.0) mL. Vitrea showed that the average volume of displaced orbital soft tissue was 2.8 (1.9) mL before surgery and that it was reduced to 0.3 (1.3) mL after surgery, while Dextroscope showed that the average displaced orbital soft tissue was 2.9 (1.4) mL before surgery and that it was reduced to 0.1 (1.2) mL after surgery. There was no statistical difference between the 3-D analysis programs. Conclusions Consistent volume measurements can be obtained using different 3-D image analysis programs. Measuring preoperative and postoperative volume changes and postoperative reduction can ensure a good surgical result and thereby decrease the incidence of enophthalmos. Background Otoplasty is the current standard of care for treating prominent ears, a psychologically and sometimes functionally disabling disorder. The technically demanding procedure carries many risks such as poor aesthetic outcome, need for revision surgery, and need for general anesthesia. This study investigates the use of laser irradiation combined with cryogen skin cooling and stenting to reshape cartilage in the ears of New Zealand white rabbits. Methods In this prospective, randomized, internally controlled animal study, the right ears of 9 rabbits were mechanically deformed with a jig and then irradiated with a 1450-nm diode laser combined with cryogen skin cooling (14 J/pulse with cryogen spray for 33 milliseconds per cycle and a 6-mm spot size). The left ear served as the control. The ears were splinted for 1, 3, or 4 weeks. The rabbits were then given a lethal dose of intravenous pentobarbital, and the splints were removed and ears examined and photographed. Light and confocal microscopy were performed on the specimens. Results Shape change was observed in all 9 treated rabbit ears, while none of the control ears (stenting alone) showed significant change. Qualitatively, reshaped ears were stiffer after 4 weeks of splinting than after 1 or 3 weeks. None of the rabbits showed evidence of skin injury nor did they show signs of postprocedural pain. Findings from histologic analysis in the treated areas showed evidence of an expanded chondrocyte population in the region of laser irradiation, along with some perichondrial thickening and some fibrosis of the deep dermis. Confocal microscopy revealed minimal cellular death at 1 week and none thereafter. Conclusions Cartilage reshaping using laser energy can be performed safely transcutaneously using cryogen spray cooling in rabbits. This animal model has similarity to human ears with regard to skin and cartilage thickness and is a stepping stone toward developing minimally invasive laser auricle reshaping in humans. Error in Text in: Margin Reflex Distance in Different Ethnic Groups [Correction] Objective To delineate the superior (facial) extent of the platysma muscle. Methods A total of 142 facial halves were examined from 71 consecutive deep-plane rhytidectomies performed over a period of 3 months. The platysma muscle was identified and isolated during the procedure. The superior extent of the platysma was measured along the line created by the angle of the mandible to the malar eminence, also known as the malar mandibular line. Results On average, the platysma extended 3.98 cm along the malar mandibular line, superiorly from the inferior border of the mandible. The platysma was located 3.09 cm inferiorly from the malar eminence along the malar mandibular line. On average, the platysma muscle occupied 56% of the malar mandibular line. Conclusion The platysma muscle may have a more significant facial extension than previously described. Perspectives on the Evolution of Rhinoplasty [Commentary] The Legacy of Jack Anderson, MD [Commentary] Has the Pendulum Swung Too Far?: Trends in the Teaching of Endonasal Rhinoplasty [Commentary] Measuring Outcomes in Nasal Surgery: Realities and Possibilities [Commentary] Cultivating a Global Aesthetic Consciousness [Commentary] Rhinoplasty at the Global Crossroads [Commentary] Rhinoplasty: A View From the United Kingdom [Commentary] Functional Valvular Indrawing [Editor's Correspondence] Functional Valvular Indrawing--Reply [Editor's Correspondence] Abstracts: In Other Archives Journals [Abstracts: In Other Archives Journals] About This Journal [About This Journal] Highlights of Archives of Facial Plastic Surgery [Highlights of Archives of Facial Plastic Surgery] Alar Rim Grafting in Rhinoplasty: Indications, Technique, and Outcomes [Original Article] Objective To determine the potential indications for placement of cartilaginous alar rim grafts in primary and revision septorhinoplasty. Methods Retrospective medical chart analysis of all patients undergoing septorhinoplasty from March 2003 through June 2004 in a private facial plastic and reconstructive surgery center and a tertiary teaching hospital. Patients who received alar rim grafts were identified. The indications for placement of the alar rim grafts were deduced from their preoperative evaluation and intraoperative assessment as noted in their comprehensive operative notes. Preoperative and postoperative digital photographs as well as postoperative medical records were analyzed for alar contour, pertinent patient complaints, and complications. Results During the 15-month study period, 150 patients underwent septorhinoplasty performed by the senior author. Of these patients, 31 received alar rim grafts. The most frequent indications for placement of alar rim grafts were cephalic malposition of the lower lateral cartilage with inadequate alar support (9 patients [29%]), correction of alar flare (9 patients [29%]), and correction of dynamic alar margin collapse (8 patients [26%]). At a mean 6-month follow-up, there were no graft displacements or extrusion. Conclusion Alar rim grafting is a simple and versatile approach to providing additional support to the external nasal valve and for improving nasal base contour. Analysis of Patient-Determined Preoperative Computer Imaging [Original Article] Objective To compare patients' goals in aesthetic rhinoplasty with aesthetic ideals by analyzing changes requested through computer imaging during the initial consultation. Methods The frontal and lateral views of 20 consecutive female rhinoplasty patients were analyzed retrospectively before and after using image manipulation software. Indexes from the frontal view included the ratio of alar base width to dorsal length and the ratio of alar base width to interpupillary distance. On the lateral view, parameters included the nasolabial angle, nasofacial angle, and tip projection (Goode ratio). Ideal parameters were based on descriptions by Powell and Humphreys. Results The ideal and patient-determined proportions were compared using a paired 2-tailed t test. The mean nasolabial angle falls within the ideal range before and after image manipulation. However, the Goode ratio and the ratio of alar base width to interpupillary distance were statistically similar to ideal values only after image manipulation. The nasofacial angle and the ratio of alar base width to dorsal length showed a trend toward the ideal ratio. Conclusions Patients' preferences were similar to the ideal in 3 of 5 parameters, and the remaining parameters approached the ideal. These parameters are useful in creating satisfying proportions in aesthetic rhinoplasty and reconstructive surgery within our population. Rather than population-based normative data or ideals based on fashion models or Greek statuary, these are proportions requested by patients. Computer imaging software, used by a growing number of aesthetic surgeons, holds a wealth of data regarding common patient preferences. The Treatment of Nasal Fractures: A Changing Paradigm [Original Article] Objectives To compare the efficacy of closed vs open treatment of nasal fractures, and to suggest an algorithm for nasal fracture management that includes closed and open techniques. Methods Retrospective study of 86 patients with nasal fractures who received either closed treatment (41 patients) or open treatment (45 patients) between January 1, 1997, and December 30, 2007. Fractures were classified as 1 of 5 types. Revision rates were calculated for each group. Preoperative and postoperative photographs were rated, if available, and patients were interviewed about aesthetic, functional, and quality of life issues related to surgical treatment. Results The revision rate for all fractures was 6%. The revision rate for closed vs open treatment was 2% vs 9%, respectively. Many closed treatment cases were classified as type II fractures, whereas most open treatment cases were classified as type IV fractures. There was no statistical difference in revision rate, patient satisfaction, or surgeon photographic evaluation scores between the closed and open treatment groups when fractures were treated in the recommended fashion. Conclusions Patients who undergo open or closed treatment have similar outcomes if the surgical approach is well matched to the individual fracture. Our treatment algorithm provided consistent aesthetic and functional results while minimizing the need for revision procedures. Margin Reflex Distance in Different Ethnic Groups [Original Article] Objective To determine the normal range for eyelid margin reflex distance (MRD) in adults according to their ethnicity, age, and sex. Methods A prospective study of eyelid measurements in 112 consecutive adult African American, Asian, white, and Latino patients was compared using t test analysis. Measurements of MRD were collected by a single examiner across 5 months. Patients with conditions disposing to eyelid height changes were excluded. Results The MRD showed statistically significant variance among select ethnic groups. There was no statistical significance between sexes within each ethnic group. Conclusions Variance in MRD exists among ethnic groups. This information and further data on ethnicity and sex variance of eyelid measurements can be used for both diagnostic purposes and surgical treatment of patients for optimal results. Objective To examine our outcomes with skin paddle survival using pectoralis myocutaneous flaps in reconstruction of the head and neck. The pectoralis major myocutaneous flap has been associated with a notable incidence of distal skin necrosis and flap loss. Our experience has been favorable compared with that reported in the literature. Methods Retrospective medical record review of 81 cases of pectoralis major muscle flap reconstruction performed in 78 patients from 1995 to 2008 using a flap harvest technique that is slightly different from the classic descriptions. Data were obtained regarding coexisting health conditions and perioperative complications, which were divided into major and minor categories. Major complications were defined as total flap failure or greater than 25% skin paddle loss. Minor complications and donor site complications included fistulas that were managed conservatively, wound dehiscence not requiring additional surgery, local infections, seromas, and hematomas. Results Of the 81 flaps performed, 22 complications were encountered. Total flap loss was not encountered in any patient. The overall major complication rate in myocutaneous flaps was 3 of 76 (4%), with these cases consisting of significant skin paddle loss. Minor complications occurred in 14 of 81 myofascial and myocutaneous flaps (17%). Donor site complications of the chest wall occurred in 5 of 81 flaps (6%). Conclusions Skin paddle necrosis may be minimized with modifications of the classic technique. We believe that extension of the skin flap over the rectus sheath is the cause of distal skin flap necrosis. The pectoralis major myocutaneous flap remains a valuable reconstructive option in the head and neck. Objective To discuss our experiences with the use of a supratip transposition flap to simultaneously correct pollybeak deformity and nasal tip dimpling. Design From April 1, 2007, through August 31, 2008, 10 Asian women with a contracted, short nose that exhibited nasal tip dimpling were retrospectively included in this study. By use of an open approach, the osteocartilaginous framework was elongated first. If the pollybeak and dimpling deformities of the nasal tip were found after the closure of the transcolumellar incision, a supratip transposition flap was designed to correct the combined deformities over the supratip and nasal tip areas. Finally, bilateral marginal incisions were closed. Results The follow-up period ranged from 2 to 16 months, with an average of 5 months. No immediate complications were noted in this small series. Four of 10 patients required minor flap revisions, with satisfactory results attained thereafter. All patients were satisfied with the aesthetic result after scar maturation. Conclusions The use of the supratip transposition flap not only corrects pollybeak deformity but also resolves dimpled nasal tip depression. The techniques presented herein add to the armamentarium of revision rhinoplasty surgeons, especially those dedicated to the treatment of the Asian patient who undergoes rhinoplasty. Comparison of Incision Closures With Subcuticular and Percutaneous Staples [Original Article] Objective Incision closures should yield safe, effective healing with excellent cosmesis. Subcuticular absorbable staples may combine the advantages of subcuticular suturing with the efficiency of percutaneous stapling. This study compares absorbable subcuticular staples with percutaneous metal staples as a means of incision closure in facial rejuvenation surgery. Methods Sixteen patients undergoing endoscopic eyebrow-lift and/or rhytidectomy were studied. Each patient had 50% of their temporal and postauricular skin incisions closed with subcuticular staples oversewn with 5-0 plain gut and the remaining 50% closed with percutaneous metal staples. Incisions were evaluated intraoperatively and at regular intervals for 1 year postoperatively. Intraoperative assessments included device handling, bleeding, tension, and cosmesis. Postoperative assessments included incision integrity, inflammation, and cosmesis. Patients were also interviewed regarding incision appearance and comfort. Results During the early postoperative period, metal staples produced greater incisional erythema and crusting. Subcuticular staples produced better tissue eversion, less erythema, equivalent if not superior comfort, and shorter office visits. These differences faded over time. The need to properly engage the subcuticular stapler in the dermis was the principal impediment to optimal stapler use. Conclusions Subcuticular staples represent a safe, comfortable, and potentially more rapid alternative to percutaneous staples. Modifications of the subcuticular stapler device are required before its full potential can be realized. Meta-analysis of Surgical Techniques for Preventing Parotidectomy Sequelae [Original Article] Objective To conduct a meta-analysis of the literature on surgical methods for the prevention of Frey syndrome and concave facial deformity after parotidectomy. Methods A PubMed search through February 2008 identified more than 60 English-language studies involving surgical techniques for prevention of these parameters. Analyzed works included 15 retrospective or prospective controlled studies reporting quantitative data for all included participants for 1 or more of the measured parameters in patients who had undergone parotidectomy. Report quality was assessed by the strength of taxonomy recommendation (SORT) score. Data were directly extracted from reports and dichotomized into positive and negative outcomes. The statistical significance was then calculated. Results The mean SORT score for all studies was 2.34, and the mean SORT score for all the analyzed studies was 1.88. Meta-analysis for multiple techniques to prevent symptomatic Frey syndrome, positive starch-iodine test results, and contour deformity favored intervention with a cumulative odds ratio (OR) of 3.88 (95% confidence interval [CI], 2.81-5.34); OR, 3.66 (95% CI; 2.32-5.77); and OR, 5.25 (95% CI, 3.57-7.72), respectively. Conclusion Meta-analysis of operative techniques to prevent symptomatic Frey syndrome, positive starch-iodine test results, and facial asymmetry suggests that such methods are likely to reduce the incidence of these complications after parotidectomy. Profilometric and Morphometric Response of Murine Skin to Cosmeceutical Agents [Original Article] Objective To investigate whether topical antiaging compounds can reduce wrinkle depth as noted at replica profilometry with comparable changes in histologic findings in hairless mice. Methods Commercial retinoic acid cream, a peptide lotion, and a soy cream were applied to the dorsal skin for 4 weeks. Silicone-negative replicas of treated and untreated skin surface were photographed and evaluated for traditional features of surface roughness. Skin samples were processed using histomorphometry and immunohistochemistry of proliferating cell nuclear antigen. Quantitative light microscopic data were acquired for estimating replication of epidermal keratinocytes, epidermal thickness, and depth of dermal collagen bundles. Results Data were analyzed by comparing means with 1-way analysis of variance, and significant changes in all measurements were noted. Augmented keratinocyte proliferation and thickening of viable epidermis were observed with all 3 compounds, although a greater effect was found in the retinoic acid and peptide treatment groups. A similar trend was noted with respect to widening of the collagen layer. Epidermal surface roughness manifested maximum smoothing after treatment with the peptide compound. Conclusion The pronounced effects noted with all 3 compounds indicate that topical agents other than retinoic acid may have comparative stimulating effects on the skin in nonirradiated mice. Use of the Remnant Ear for Reconstruction in Lobule-Type Microtia [Original Article] Objective To present in detail a reconstruction technique using the remnant ear in lobule-type microtia. Methods By comparing the location of residual ear and the contralateral normal ear, we classified 3 different types of the remnant ear. Three techniques of transposition were applied to adjust the location of the reconstructed ear. Results The reconstructed earlobes not only looked real but also were symmetrical with the contralateral normal ears. Conclusion The remnant ear is a key factor—in addition to the framework and covering skin—in ear reconstruction in microtia. The Use of Ultrasonic Shears for the Harvest of Perforator Free Flaps [Surgical Technique] A retrospective chart review was performed at a university medical center to evaluate the use of ultrasonic shears for the harvest of perforator free flaps over an 18-month period. The anterolateral thigh (ALT) was the perforator free flap site selected for the study. The site of origin and the number of musculocutaneous perforator vessels that were dissected using ultrasonic shears were recorded, and ALT flap viability and wound-healing complications were evaluated to assess safety. Seventeen patients underwent harvest of ALT perforator free flaps. Successful dissection of musculocutaneous perforators was achieved in 96% (27 of 28) of the descending branch perforators and in 100% (9 of 9) of the transverse branch perforators. Flap viability was 100% (17 of 17). We found that ultrasonic shears were effective and safe to use for harvesting perforator free flaps. According to these preliminary findings, the use of ultrasonic shears appears promising, yet further prospective analysis is needed. Facial Anthropometric Analysis of the Javanese Female [Research Letters] Abstracts: In Other Archives Journals [Abstracts: In Other Archives Journals] Edgar Degas's La Savoisienne [Beauty] About This Journal [About This Journal] Highlights of Archives of Facial Plastic Surgery [Highlights of Archives of Facial Plastic Surgery] Graduated Approach to Refinement of the Nasal Lobule [Original Article] Objective To present a graduated approach to refining the nasal lobule (a frequent complaint during consultations for rhinoplasty) based on anatomic features and to discuss the casuistics of this procedure since we began performing it. Methods A retrospective evaluation of the medical charts of 1152 patients who underwent rhinoplasty from 2003 to 2006; 641 patients fulfilled the criteria for our study (55.6%). Outcomes were assessed by comparing preoperative and last follow-up photographs and considering the width, symmetry, and contour of the nasal lobule. Cases were allocated into 7 groups: (1) no surgery on nasal tip; (2) interdomal breakup; (3) cephalic trim; (4) domal suture; (5) shield-shaped graft; (6) vertical dome division; and (7) replacement of lower lateral cartilages. Results Of the 641 patients enrolled in the study, 435 were women and 206 were men. Mean follow-up period was 1.5 years. An asymmetric tip was present in 28 patients (4.4%), and a persistent width of interdomal space in 34 (5.3%). None presented overnarrowing of interdomal space. Surgical revision rate to enhance refinement of the lobule was 5.6%. Conclusion Our graduated approach has shown excellent outcomes, a high rate of patient satisfaction, and a low rate of revision. Hand-washing Practices of Facial Plastic Surgeons [Original Article] Objectives (1) To define and characterize knowledge of effective hand hygiene and its scientific basis among practicing facial plastic surgeons; (2) to review the existing literature of, basis for, and guidelines on hand washing in clinical practice; and (3) to motivate and facilitate optimum hand hygiene among facial plastic surgeons. Methods National Web-based physician survey and literature review. Results We conducted a national Web-based survey of members of the American Academy of Facial Plastic and Reconstructive Surgery regarding general patient safety practices. A subset of the survey assessed physicians' knowledge of hand hygiene, including supporting rationale and actual practices. One hundred and twenty-two facial plastic surgeons of various demographics replied to the online survey. Of these, 65 (53%) correctly knew which hand washing agents are most effective at killing microorganisms, 88 (74%) knew the preferred hand-washing method for visibly soiled hands, and 51 (42%) correctly identified the indications for hand washing. Conclusions Adherence to hand hygiene practices is suboptimal among facial plastic surgeons. There seems to be a lack of knowledge regarding indications, methods, and appropriate agents for hand hygiene. Promotion of Centers for Disease Control and Prevention guidelines is an important step in increasing hand hygiene compliance among facial plastic surgeons. Topic Collections [Announcement] Objective To prospectively follow up patients requiring microvascular reconstruction of head and neck defects to determine preoperative factors predictive of surgical complications. Methods A prospectively collected database comprising 300 consecutive microvascular head and neck reconstructions performed by a single surgeon (D.S.A.) in a tertiary care hospital over a 6-year period was reviewed in a retrospective manner. Data collected included preoperative medical and surgical history (presence of documented cardiac disease, diabetes mellitus, and hypertension) and previous cancer treatment (surgery or radiation therapy). Postoperative data, including early or late complications, hematocrit during hospitalization, and functional status, were also collected. A multiple linear regression was used to identify predictors of surgical complications and secondarily crossed to determine the strength of the prediction. Statistical significance was set at P = .05. Results Patients were stratified into 4 groups based on (1) previous radiation therapy, (2) previous surgery, (3) no previous radiation therapy or surgery, and (4) both previous radiation therapy and previous surgery, with an increased predictability of complications with both. Diabetes also added to the predictability of complications, with a smaller effect. Cardiac disease and hypertension were not predictive. Conclusions Previous radiation therapy and surgery are positive predictors for wound complications after microvascular reconstruction. Diabetes may add further risk in this setting. The Utility of Ultrasound in the Evaluation of Submental Fullness in Aging Necks [Original Article] Objectives To evaluate the submental region of the aging neck with high-frequency ultrasound and to assess the relative contribution of its various components to the appearance of age-related soft-tissue ptosis. Methods Ten patients with submental soft-tissue excess were recruited from the senior author's (G.S.K.) private practice. The subcutaneous fat compartment, the subplatysmal fat compartment, and the anterior bellies of the digastric muscles were imaged with high-frequency ultrasound and measured in the cephalocaudal dimension. Pseudoherniation of subplatysmal fat, judged in relation to the inferior surface of the digastric muscles, was also assessed from acquired images. Results A clear delineation of submental anatomy was obtained with ultrasound in all patients (N = 10, 100%). Hypertrophied digastric muscles (n = 1, 10%) and excessive subplatysmal fat (n = 5, 50%) adversely contributed to the appearance of submental fullness in 6 patients (60%). These findings would not have been predicted with the same degree of accuracy from the physical examination alone. Conclusions High-frequency ultrasound provides useful imaging of the submental region and its components. Deeply situated subplatysmal fat and anterior bellies of the digastric muscles, both of which may be difficult to assess on physical examination, can be readily evaluated with ultrasound. When sufficiently enlarged and ptotic, deep tissues of the submental space necessitate an open submentoplasty to restore a youthful neck contour. Preoperative ultrasonography can assist with anatomical imaging of the submental space and help in planning a targeted operative intervention in patients with submental soft-tissue excess. Send to a Friend [Announcement] Background Reconstruction in the head and neck can be difficult owing to the size of the defect or characteristics of the tissue that needs to be replaced. Facial wounds or reconstruction sites can be subject to contamination, thereby risking infection of any implanted material even under ideal circumstances. Particular areas of concern are sites where minimizing the bacterial contamination prior to placing an implant is difficult (eg, the oral cavity and internal nose). Reconstruction involves the facial subcutaneous soft tissue and/or bone, and the ideal implant provides support and natural feel, as well as a low risk of infection. The biocompatibility of alloplastic implants depends on the tissue inertness of the implant and the porosity, allowing connective tissue ingrowth, which in turn decreases the susceptibility to infection. Scalafani et al demonstrated that alloplastic implants contaminated prior to fibrovascular ingrowth had a much higher incidence of infection and rejection. Objective To examine the effectiveness of several techniques for infiltrating antibiotics into alloplastic implants of different porosity using 2 commonly used alloplastic implants, expanded polytetrafluoroethylene (e-PTFE, or GORE-TEX) and porous high-density polyethylene (Medpor). Results Using an in vitro bacterial growth inhibition model, we found that suction infiltration of the implant with antibiotics was the most effective technique, with a statistically significant advantage over other techniques used. The advantages of the suction impregnation were seen to be most effective using alloplasts with a smaller pore size (20-30 µm) (P < .001), but there was a statistically significant difference even with implants with a larger pore size (150-200 µm) (P < .001). Conclusions Suction infiltration of antibiotics into porous implants seems to be the most effective method identified using an in vitro testing protocol. Further experiments will be needed to confirm the effectiveness in reducing the perioperative risk of infection in vivo. Citation Manager [Announcement] Objective To determine the efficacy of an over-the-counter topical skin adhesive pad for reducing central forehead and glabellar rhytids over a 4-week period. Design Prospective series involving 30 healthy volunteers with central forehead and glabellar rhytids at a tertiary care academic medical center. The participants used topical skin adhesive pads over the central forehead area and the glabella for 4 weeks in an effort to reduce rhytids. Before and after treatment, the participants had facial photographs taken and completed a questionnaire assessing the severity of their rhytids. Blinded to the timing of the photographs, 2 independent facial plastic surgeons scored the pretreatment and posttreatment rhytid severity using the Glogau scale (1-4) and a wrinkle severity scale (1-10) to evaluate treatment effect. Results Twenty-six participants (87%) completed follow-up with an average of 7.4 hours of use of the topical adhesive pads per night. The independent evaluators found minimal improvements in the Glogau scores (mean [SD], 0.12 [0.33] [P = .08] and 0.06 [0.22] [P = .18] for the central forehead area and the glabella, respectively). The same evaluators also found minimal change in the wrinkle severity scores (mean [SD], 0.21 [1.28] [P = .41] and 0.25 [0.75] [P = .10] out of 10 for central forehead rhytids and glabellar rhytids, respectively). None of these measures were statistically significant. The study participants' self-evaluations demonstrated changes in the wrinkle severity scores of 0.35 (2.10) (P = .41) in the central forehead area and 0.73 (1.7) (P = .04) in the glabella. Conclusions Subjective self-evaluation of topical adhesive pads demonstrates improvement in glabellar rhytids but may be affected by bias. Independent, blinded evaluation by facial plastic surgeons showed no statistical benefit in the reduction of rhytids in the central forehead area or the glabella. Objective To demonstrate that a classic temporal cheek rhytidectomy results in substantial and acceptable rejuvenation of the so-called midface and that additional surgery is not necessary to improve a sagging cheek, the melolabial fold, and the position of the corner of the mouth and the lateral corner of the eye. Design A retrospective observational study of 53 patients seen at the McCollough Plastic Surgery Clinic between 2005 and 2007. Each patient underwent temporal and cheek face-lifting surgery for various indications. All procedures were performed by the same surgeon, and the surgical technique was identical in all cases. Patient photographs were evaluated by 3 unbiased plastic surgeons who were asked to compare preoperative and postoperative elevation of the cheek mound, melolabial fold, oral commissure, and lateral canthus. Each anatomic area was appraised for improvement by each reviewer using a 4-point scale. Results The average patient age was 57 years, and the average patient follow-up was 11 months. Patients achieved excellent or significant improvement in a sagging cheek, melolabial fold, oral commissure, and lateral canthus in 79% (n = 42), 70% (n = 37), 72% (n = 38), and 65% (n = 34) of cases, respectively. Conclusions It has been written often that standard face-lifting techniques fail to address many of the aging changes seen in the cheeks. Many authors argue that a separate, unique procedure is required to effectively rejuvenate the cheek, nasolabial fold, and corner of the mouth. Our experience is contrary to this notion. The middle third facial rejuvenation can be achieved by our standard temporal cheek face-lift, and the term midface-lift may be a misnomer. Full-text Online Access [Announcement] Sculpting Resection of Rhinophyma Using the Shaw Scalpel [Surgical Technique] Background Rhinophyma is a disfiguring disorder of the nasal skin characterized by hypervascularity, sebaceous gland hyperplasia, occluded sebaceous ducts, and dermal fibrosis. It has no known effective medical treatment; however, a myriad of surgical treatments have been reported. We report an effective, efficient, and safe approach to treat this disorder using the Shaw scalpel to surgically sculpt the nose. Objective To evaluate the efficacy and safety of using the Shaw scalpel to treat rhinophyma. Methods We performed a retrospective review of 7 male patients (age range, 58-81 years) who underwent primary surgical treatment of rhinophyma with the Shaw scalpel. Results A good to excellent outcome was noted in all 7 patients. No perioperative complications occurred. Essentially no blood loss was noted during or after the procedures. Conclusion Use of the Shaw scalpel as the sole surgical instrument and method is a safe, efficient, and effective means to treat rhinophyma. Special Theme Issue: Cancer and the Face [Call for Papers] A modified Freer elevator was created to aid the safe placement of alloplasts in a subcutaneous dissection pocket. We believe that this innovation represents a better way to insert nonrigid facial alloplasts and grafts and that it contributes to the reduced technique-related complications of migration, kinking, and asymmetry; it also minimizes tissue trauma and unnecessary surgical explorations. Microbiologic Assessment of Multidose Restylane for Facial Augmentation [Research Letters] Error in Legend in: A Novel Bioabsorbable Device for Facial Suspension and Rejuvenation [Correction] Abstracts: In Other Archives Journals [Abstracts: In Other Archives Journals] Childe Hassam's Portrait of Adelaide Christina Meyer, 1913 [Beauty]
|
Health Insurance
Your health insurance policy lists a package of medical benefits such as tests, drugs and treatment services. The insurance company agrees to cover the cost of certain benefits listed in your policy.
Everyone’s different. That's why Online-Insurance-Advisor has a huge range of health cover options – you’ll find the right level of hospital, extras or package cover for you, your partner and family here. Worlds Best PharmacyThe name says it all. This is the best online pharmacy on the web. The index page is set to show the most polular ED products, while the menu and quicksearch allow to find products in other categories. Indian MedsA most recent indian-themed, ethnic site. Includes generic and original (brand) products. al our standard navigational tools and support options are available. This site converts nicely on general pharmaceutical traffic as it has products for vurtually any need. Health Insurance Quote health insurance quote california health insurance quote free health insurance quote health insurance online quote individual health insurance quote health insurance quote texas florida health insurance quote instant online health insurance quote family health insurance quote health care insurance quote instant health insurance quote arizona health insurance quote cheap health insurance quote small business health insurance quote affordable health insurance quote illinois health insurance quote arizona free health insurance quote health and medical insurance quote california health insurance online quote affordable individual health insurance quote private health insurance quote health insurance quote wisconsin california group health insurance quote california individual health insurance quote health insurance quote georgia missouri health insurance quote individual health insurance quote online self employed health insurance quote health insurance ohio quote free health insurance quote texas california life and health insurance quote health and life insurance quote online health insurance quote for child colorado health insurance quote affordable family health insurance quote health insurance life quote health insurance low cost health insurance family health insurance health insurance quote affordable health insurance texas health insurance california health insurance individual health insurance health insurance company florida health insurance short term health insurance health and dental insurance health insurance illinois health insurance houston cheap health insurance health insurance coverage student health insurance health insurance dallas temporary health insurance child health insurance health insurance chicago health insurance lead private health insurance free health insurance arizona health insurance health insurance indianapolis health insurance las vegas health insurance jacksonville health insurance in california health insurance nashville health insurance miami health insurance philadelphia affordable california health insurance health insurance new york long term care health insurance health insurance provider health insurance cincinnati medical health insurance california individual health insurance north carolina health insurance health insurance atlanta health insurance pittsburgh health insurance dayton health insurance greenville health insurance orlando oxford health insurance health insurance new orleans health insurance online health insurance denver michigan health insurance ohio health insurance personal health insurance health insurance indiana free health insurance quote online health individual insurance quote texas california family health insurance quote affordable health insurance quote online florida health insurance instant quote indiana health insurance quote free instant health insurance quote california free health insurance quote student health insurance quote health insurance quote short term michigan health insurance quote minnesota health insurance quote dental health insurance quote health insurance quote virginia best health insurance quote california cheap health insurance quote north carolina health insurance quote california care health insurance quote southern california individual health insurance quote health insurance quote new jersey personal health insurance quote low cost health insurance quote illinois affordable health insurance quote oregon health insurance quote instant health insurance quote california health insurance quote tennessee |
All rights reserved.
