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SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: February 25, 2010
RESIDENT PHYSICIAN: Andrew Coughlin MD
FACULTY PHYSICIAN: Raghu A=
DISCUSSANT: Michael P. Underbrink, MD
SERIES EDITORS: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Qui=
material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program =
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not
intended for clinical use in its present form. It was prepared for the purp=
of stimulating group discussion in a conference setting. No warranties, eit=
express or implied, are made with respect to its accuracy, completeness, or
timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes=
diagnosis or treatment without consulting appropriate literature sources an=
d informed
professional opinion."
Since the dawn of time humans have been obsessed= with their outward appearance. From shoes to tattoos and breast lifts to brow li= fts we will do anything to look our best. When it comes to our facial appearanc= e, nothing can be harder on our image than mother nature herself. Sagging skin, scars,= and sun damage all date the years we have put on our skin and over the years we have been quite thrifty in finding ways to attempt to reverse these afflictions.
In 3000 BCE the Egyptians were using bath houses, facial tattoos, and makeup to hide their facial distortions, and by 1500 BCE they had developed an early form of dermabrasion with sandpaper to help red= uce the scars they had accumulated on their faces (1, 2). Jewish Law in 100 BCE went so far = as to say that a husband is required to provide 10 dinars per month for the cosme= tic appearance of their wives. In= 200 CE the Romans became involved with the process as Ovid, in his book The Art= of Love, wrote of a homemade facial mask that was meant to rejuvenate the skin. In 900 CE the Arabic physicians also came up with an early form of dermabrasion composed of marble, seashells, and other coarse objects that w= ere used to exfoliate and smooth the face (3).
In the recent past dermabrasion as we know it was first introduced using the wheel and rasp in 1905 by Kromayer (4). Over the past century, the techniques for rejuvenation of the face have rapidly progressed leading to the development of chemical peels in the 1940's= and 1950's, laser resurfacing in the 1990's, and most recently a bo= om in the different preparations of dermal fillers over the last decade.
In this paper we will review anatomy of the skin= and the process of skin damage, and then discuss the different options available for nonoperative facial rejuvenation and their associated complications. = p>
The Skin
The skin is composed of 3 layers including the epidermis, the dermis, and the hypodermis. The epidermis is the initial bar= rier of the body to the outside world. It is a 5 layer continuum from stratum ba= sale where cells are regenerated every 12-14 days to the stratum corneum where keratinocytes are sloughed off as dead skin cells (1). Along this continuum= are three intervening layers; stratum spinosum, stratum granulosum, and stratum lucidum (deep to superficial) which show increasing degrees of maturation a= nd keratin production as you move more superficially. Additionally found in the basal layer are melanocytes important for skin pigmentation.
The dermis is the next layer, deep to the epider= mis. It is composed of 2 layers, the papillary and reticular dermis. The papilla= ry dermis is present more superficially at the dermal epidermal junction. It houses fibroblasts that produce a meshwork of type III collagen, and anchors the epidermis down to the dermis. The reticular dermis consists of type I collagen, elastin, and glycosaminoglycans. Glycosaminoglycans interestingly= can hold up to 1000 times their weight in water thus adding to the turgor of the skin (5). In addition to connective tissue, the reticular dermis is also the host of nerve fibers, blood vessels, hair swells, and sweat/sebaceous glands which are the latter are important for re-epithelialization.
The deepest layer is the hypodermis which is com= posed of loose connective tissue, fat and elastin important for anchoring the skin down to the bone and muscle. Predominant cells include fibroblasts, adipocy= tes, and macrophages
Damage to the skin
As the skin ages and the damaging effects of the= sun and environmental toxins like tobacco smoke act on the skin several changes begin to occur. In the epidermis the stratum corneum thickens and the strat= um spinosum thins. In the dermal layer the high ratio of type I to type III collagen decreases and tissue collagenases and gelatinases increase thus facilitating the degradation of collagen and elastin in the dermal layer (6= ). Ultimately this leads to decreased elasticity and skin turgor resulting in increased sagging of the skin and deepening of wrinkles (7).
Initial Examination
When a patient first comes to the office inquiri= ng about options for facial rejuvenation a couple of things must first be elicited. Patient expectations are of vital importance. If a patient has unrealistic goals or objective it is important to make the patient aware of what you can and cannot do for them. Treatment before setting these ground rules can result in unhappy patients and lawsuits. Parallel to this idea of realistic goals is the need to look for patient with psychiatric instabilit= y or those who "doctor shop." These patients are at increased risk of having unrealistic expectati= ons and are more likely to have poor outcomes based on those expectations. Fina= lly, patients who smoke are at 12 times increased risk of scarring from facial plastic procedures. Therefore it is important to require smoking cessation before treatment and/or properly document informed consent of their increas= ed risk of scarring and treat only if the patient accepts these risks. These a= re all important components of the patient's history.
On physical exam you first want to look for skin conditions that may increase the risk of complication or undesirable outcom= e. Hyper- and hypo pigmentation increase the risk of pigmentary irregularities after treatment. Collagen vascular disease increased the risk of inappropri= ate collagen formation and scarring. Active infection also increases the risk of infection.
In order to evaluate the most appropriate form of treatment you must also decide if rhytids are dynamic or adynamic. Dynamic rhytids will resolve with manipulation of the skin in antagonistic directio= ns to the muscle causing rhytids. These rhytids are more commonly treated with botulinum toxin in order to prevent over activity of the muscle in question. Adynamic rhytids that are due to photoaging do not correct with antagonistic motion and therefore are not amenable to botulinum toxin therapy. This is an important distinction to make before beginning treatment.
Finally you want to assess skin thickness and the depth of injury that has occurred. The Glogau scale has been used to define depth of injury and will be described below in Table 1 (8).
Category<= /p> |
Damage |
Skin Find= ings |
Treatment= |
Stratum G= ranulosum or Papillary Dermis |
Fine wrin= kles |
Superfici= al skin peels or dermabrasion |
Upper Ret= icular Dermis |
Wrinkles = with facial gestures |
Medium de= pth peel or laser resurfacing |
Upper Ret= icular Dermis |
Wrinkles = at rest |
Medium de= pth peel or laser resurfacing |
Mid Retic= ular Dermis |
Wrinkles = at rest and skin discoloration |
Deep peel= or laser resurfacing |
Table 1. Table comparing the different depths of skin damage using the Glog=
scale and their associated treatment options.
As discussed earlier, dermabrasion has been arou= nd in 1 form or another since at least 1500 BCE. The purpose of dermabrasion is to injure the superficial layer of cells to promote re-epithelialization of the epidermis and collagen deposition in the dermis. Indications for dermabrasi= on are traumatic and acne scarring, adynamic rhytids, and rhinophyma. It is contraindicated in cases where patient have had hypertrophic scars or keloi= ds in the past as this increases the risk of unsatisfactory results. The key to dermabrasion is to only damage down to the papillary dermis. If you injure = deep to the papillary dermis and into the reticular dermis, you may damage pilosebaceous units and impair re-epithelialization.
It can be performed in the office with local anesthesia, but may require IV sedation. Either a brush or diamond fraise is used to perform the procedure. Mobile subunits like the malar fat pads can = be frozen prior to the procedure in order to have a rigid surface for debridem= ent. Feathering is a technique used to blend the edges of the debrided area to m= ake the skin appear more uniform.
Patients having dermabrasio= n performed my have some punctuate bleeding from the skin on the day of the procedure which can be controlled with occlusive dressings. Erythematous skin and re-epithelialization will persist for 7 to 10 days with complete healing ar= ound 2 to 3 weeks.
Microdermabrasion is= a technique that has really become popular at local beauty stores and boutiqu= es. Microdermabrasion utilizes an aluminum oxide microcrystal to remove the superficial layers of the dermis. The advantage being that it can be perfor= med at relatively short intervals, it is painless requiring no anesthesia, and = it has much less erythema as a result of superficial damage. The disadvantages, however are that it only affects the upper layer of the epidermis and cannot treat deeper rhytids that originate in the dermis
In 2001, Freedman et al. (9) looked at the just = 10 patients treated with 6 sessions of microdermabrasion. They evaluated patie= nts both with facial analysis and tissue biopsy. They found that not only were = fine rhytids improved with the procedure but also that dermal collagen had actua= lly increased post-therapy. This latter finding was paradoxical because the microdermabrasion does not penetrate to do injury in the dermis. In 2010 a review article by Karimipour (10) concluded that microdermabrasion is useful for fine or superficial rhytids, it is not useful for deeper rhytids or dyschromias, and although there are no RCTs looking at its use in acne, patients should be individually evaluated and treated on a case by case bas= is depending on the acne scarring severity.
Laser Resurfacing
Lasers work by damaging tissues via thermal heat= . In order for tissues to receive the thermal damage the laser has to be absorbe= d by a chromophore within the cell that the laser is specific to. Several differ= ent chromophores are used including water, oxyhemaglobin and even melanin. The more chromophore a cell has th= e more heat that will be absorbed. Therefore laser therapy is quite specific and c= an be more precise than other therapy choices.
The first laser to discuss would be the carbon d= ioxide (CO2) laser with a wavelength of 10,600nm. It has specificity for water and= is therefore taken up by the dermal layers. This laser has increased dispersio= n of its thermal energy and therefore redness is increased post therapy. An advantage of this dispersion however is the fact that it causes significant= ly increased collagen production, immediate tightening of the skin and therefo= re immediate cosmetic results. The laser also has hemostatic properties.
Similar to the CO2 laser is the Erbium:YAG laser= with a wavelength of 2,640nm. This laser is also specific to water however it do= es not produce the same thermal dispersion as the CO2 laser. In a study by New= man et al in 1999, 21 upper lips treated with half CO2 and half Erb:YAG were evaluated. Patients treated with the Erb:YAG laser had significantly less erythema (3.4 days vs 7.7 days) but also significantly decreased cosmesis a= t 2 months (54% compared to 63%). Given these results the study favored the use= of CO2 laser especially in patients willing to weak make-up while the erythema persisted (11).
Although the remaining lasers are not used for s= kin resurfacing it is important to mention them as they can be important for cosmesis. The Nd:YAG laser has a wavelength of 1,064nm, is infrared, and is specific for the chromophore oxyhemaglobin. It has deeper penetration than = the CO2 and Erb:YAG lasers and it is indicated for treatment of telangiectasias, capillary hemangiomas, and port-wine stains. The KTP laser with a wavelengt= h of 532nm is visible and also specific for oxyhemaglobin. It is good for cutane= ous vascular lesions. The argon l= aser is a visible blue light with a wavelength of 193nm. It has depth of penetra= tion between the Nd:YAG and CO2 laser and is used for similar indications as the Nd:YAG laser. Finally we have the flashlamp excited pulsed dye laser that i= s a yellow visible laser with a wavelength of 595 nm. Again this is useful for cutaneous vascular lesions but has the added benefit of decreased hypo pigmentation and scarring compared to the Argon and Nd:YAG lasers.
In 2002 Bisson et al= looked at the usefulness of lasers and their long term effects. They showed that a= t 6 weeks wrinkle reduction was achieved in 91% of patients and at 2 years this= effect was still seen in 87% of patients (12). Although such good results are comm= only seen, the erythema and time spent performing the procedure seems to be its limiting factor. In 2001, Trelles et al looked at patient satisfaction following laser skin resurfacing and found that although 88% of patients we= re happy with the cosmetic outcome, 77% would not have it performed again if t= hey had the chance (13). Therefore the swing seems to be moving more towards ot= her therapeutic modalities as several studies have shown similar results compar= ing dermabrasion to laser therapy (14-16). Laser therapy, however, is still very useful in the periorbital and perioral region where dermabrasion is limited=
Complications of laser therapy and dermabrasion = are similar and will be discussed together. Infection, either bacterial or fung= al, is probably one of the most common complications occurring in 4.3 to 12% and 1.8 to 2.2% of patients respectively (17). These numbers include patients treated with antibiotic prophylaxis. Herpes virus risk is also substantial = even in patients who have never had an outbreak before. In 1997 Roberts et al evaluated their experience with 907 patients and found that the incidence of post-therapy HSV infections decreased from 3% to 1% with antiviral prophyla= xis (18). Therefore patients usually treated with antivirals for 2-3 days prior= to therapy and then 2-10 days post therapy to prevent infection.
Other complications are hypo or hyperpigmentary changes commonly seen with patients with melasma, cholasma, and darker skin= ned patients (Fitzpatrick category 3-6). Melasma and cholasma are associated wi= th oral contraceptive use and pregnancy respectively. Patients should be treat= ed with sunscreen and sun avoidance both pre and post therapy to prevent pigme= ntation changes (19-20). Milia is a supepidermal cyst that can develop on the malar surfaces and eyelids. These are treated with mild abrasive cleansers or can= be deroofed with an 18 gauge needle. Occlusive dressing for 2 weeks post thera= py can decrease their occurrence. Isotretinoin preparations should not be used= within 6 to 12 months either before or after treatment as it damages pilosebaceous units and therefore inhibits re-epithelialization leading to increased scar= ring risks (21).
Another option for facial rejuvenation is chemoexfoliation known better as a chemical peel. The idea behind chemical peels is to wound the skin in a controlled manner to promote new collagen formation and re-epithelialization for a more youthful appearance. As discu= ssed earlier, photodamage increases the thickness of the stratum corneum, decrea= ses the thickness of the stratum granulosum, decreased collagen and elastin maturation and organization, and also leads to disorganized melanin deposit= ion.
There are different damaging levels that can be obtained with a chemical peel and it is important to understand the effects= of such peels at different depths of the skin. Peels that damage the stratum corneum will only smooth the skin due to debridement of the keratin layer. Peels extending down to the basement membrane also will help reorganize pig= ment and melanin since melanocytes live in the basal layer of the epidermis. Dam= age into the upper reticular dermis will smooth and lighten the skin but also increase collagen, elastin and GAG production leading to reduction in fine wrinkles. Peels down to the mid reticular dermis will produce an even more robust collagen formation reaction to help get rid of deep rhytids. Finally, peels that extend down in the deep reticular dermis or subcutaneous tissue = will often times lead to scarring due to overactive collagen formation and poor re-epithelialization.
Factors that influence the depth of penetration = of chemical peels exist and can be used to tailor each therapy for the individ= ual patient. First, with the exception of phenol, the stronger the solution concentration, the deeper the peel penetrates. Because high concentrations often lead to worse outcomes due to toxicity or overtreatment, other modali= ties are used to help increase penetration without increasing the solution concentration. Pre-peel cleansing with septisol and acetone, prolonged time= of contact, rubbing or scrubbing the chemical into the skin and even applicati= on of occlusive tapes are all examples used to increase penetration. Patient factors that may inadvertently increase solution penetration are recent electrolysis, surgery, or waxing. These events are important to tease out in the history in order to plan appropriately for the depth of therapeutic int= ent.
Given the large amount of patient factors that e= xist, each person responds to a chemical peel differently. Each patient has a different thickness of skin, collagen formation capacity, and scarring risk. Therefore, some argue that pre-treatment of the skin in an inconspicuous ar= ea is important before treating the entire face. This will help identify how e= ach patient responds to a given treatment and will help guide further therapy.<= /p>
Regardless of patient differences, each patient = is encouraged to cleanse the face regularly, use petroleum jelly as needed to promote moisturized healing, avoid sun and used sunscreen to prevent pigmentation problems, and perform proper wound care post therapy to prevent infection. Again patient selection is very important especially because fac= ial peeling can be quite disfiguring. Patients need to be psychologically ready= to cope with their post treatment appearance, be willing to follow up closely,= and be patient with the healing process as it can be prolonged with chemoexfoli= ation.
The actual process of chemoexfoliation is threef= old. First is the preparation stage where the skin is cleansed with septisol and acetone to remove the superficial layer of oil and keratin that has been bu= ilt up. Jester's solution or low concentration glycolic acid peels can al= so be used to thin the epidermis and help the main chemical peel penetrate more deeply (8).
After the skin is clean the chemical peel is app= lied in a systematic manner for uniformity. Superficial peels will produce a blo= tchy white and red skin discoloration, medium peels will produce skin with a whi= te center and peripheral erythema, and deep peels will produce a pasty white s= kin with no erythema present. Being able to identify this during therapy helps = you know if you are achieving your planned depth of treatment.
Once the patient has been treated they will usua= lly begin to exfoliate and desquamate within 2 days and this will continue for = up to a week or more depending on the depth of peel. Cool saline presses are applied to the face to prevent inflammation. Vinegar soaks are utilized eve= ry 2 hours while the patient is awake for 5-7 days to cleanse the skin and preve= nt infection. Close follow up is necessary to ensure that infection is not developing and that proper healing is occurring.
Next we will discuss the different options for chemical peeling starting with the least damaging.
A. Tretinoin
Tretinoin is a cream= that is often times used as first line therapy for photoaging. It has the advantage= of decreasing the thickness of the stratum corneum, increasing the thickness of the stratum spinosum, evening out pigmentation irregularities and smoothing= the skin. Disadvantages include pregnancy class C preparation, increased photosensitivity, and it significantly dries out the skin. It is often times used in conjunction with alpha hydroxy acids that potentiate the effects of tretinoin. Alpha hydroxy acid preparations are often found in over the coun= ter creams which can be used to also treat the drying effects of tretinoin.
B. Superficial Peels
The most common superficial peel is trichloroace= tic acid (TCA) at a 10% concentration, but Jessner's solution (lactate + = salicylate + ethanol + resorcinol) and glycolic acid can also be used. The solution is usually applied for 1-2 minutes and then washed off with water or a buffered bicarbonate solution. Patients will have a slight stinging sensation, a sli= ght flush, and smooth glowing skin. Patient should have no activity restrictions and many patients will not desquamate. Because this is a mild peel they wil= l be able to have it repeated every week, two weeks, or every month as needed. F= or peels down to the basement membrane meant to tackle pigment irregularities, slightly stronger concentrations of solutions can be used and these patients will likely desquamate for 2-3 days thus limiting their activities.
C. Medium Depth Peels
Initially clinicians were simply increasing the concentration of TCA to increase the depth of penetration into the skin, however they were finding that concentrations of over 50% lead to increased risk of scarring after therapy (22, 24). Therefore they began combining TCA= at 35% with Jessner's or glycolic acid solutions to increase depth of penetration without increasing scar formation. Patients treated with medium depth peels will have skin that turns dark brown and they will desquamate f= or 4 to 7 days leaving them socially incapacitated. As they re-epithelialize the= ir skin will be pinkish red and this will persist for about 1 month.
D. Deep Peels
The most common deep peel is the Baker-Gordon pe= el which is composed of phenol, croton oil, water and septisol. The solution is agitated prior to application and it is applied to one subunit of the face = at a time with 10 to 15 minute intervals between subunits. This application tech= nique is used to prevent over absorption systemically and phenol toxicity. The patient will have immediate frosting of the skin and post therapy occlusive dressings are placed. Constant serous exudate will occur hourly that needs = to be cleansed. The patient will have intense swelling and release of epitheli= um over the next 1-2 days with re-epithelialization taking over 1 week to occu= r. Very red skin will persist for months and hypo pigmentation is expected. = p>
Complications associated with chemical peels are possible with the most fearful being phenol toxicity. In 2007 Landau looked= at 181 patients treated with full face phenol peels and found that even after waiting 15 minutes between facial subunits, 6.6% of patients developed arrhythmias. Increased risk was seen in patients with diabetes, hypertension and depression (23). In order to prevent phenol peel complications patients= are treated with sedation, IV hydration to dilute systemically absorbed phenol,= and intraoperative EKG monitoring. Other preventative measures are preoperative LFTs and creatinine to ensure that the patient can properly metabolize and excrete the phenol.
Infections are similar to those seen in patients treated with dermabrasion and laser resurfacing. Antibiotic prophylaxis and antivirals are commonly used especially for those with deeper peels. Vinegar washes and proper skin care is vital to prevention. Any non-healing wound n= eed to be cultured.
Pigmentation irregularities are possible after therapy. As stated earlier, those with dark skin and those taking OCPs or w= ho are pregnant are at increased risk. Sun avoidance and sunscreen are importa= nt preventative as is hydroquinone. Treatment with tretinoin and alpha hydroxy acids are useful, and repeeling is an option.
Scarring is significantly increased in those tre= ated with accutane within the 12 month pre and post treatment period due to poor re-epithelialization. Post therapy skin infections significantly increase t= he risk of scarring. Other factors that play a role are previous keloids or hypertrophic scars, previously radiated skin, and skin that has been recent= ly operated on or undermined.
Soft Tissue Augmentation
The art of soft tissue augmentation began in 189= 3 when Neuber harvested arm fat and injected it into facial defects (24). In the 1900's paraffin injection was introduced but fell out of favor quickly due to adverse granulomatous reactions called paraffinomas. By the 1940R= 17;s and 1950's silicone had been introduced and was being used widely, but again due to granulomatous reactions and scarring its use fell out of favor= by the early 1990's. In 1970's Stanford began using human and anim= al collagen as an injectable filler and these are still used today (25).
Today research is booming in the area of injecta= ble fillers. Companies are looking for inert, long lasting, abundant low cost, non-carcinogenic, reversible and low immunogenic potential products. Patient demand for these products has risen dramatically as procedures are performe= d on an outpatient basis, without surgery, with recovery in 48 to 72 hours, and = are lower in short term cost than are surgical techniques. Indications for injectable fillers are traumatic and acne scars, adynamic and dynamic rhyti= ds, lip augmentation and melolabial fold augmentation. Today there are 4 differ= ent types of injectables and we will discuss each below.
A. Xenografts
Bovine collagen is the first product in this cat=
and is considered the gold standard to which all others are held. It is
dissolved in saline and lidocaine for injection and comes in three different
formulations. Zyderm I and Zyderm II (INAMED Aesthetics,
Pitfalls of bovine collagen injections are most commonly hypersensitivity reactions. Up to 3 to 4% of patients will have positive skin test to the preparation prior to therapy, and it is recommend= ed that patients be re-evaluated at 4 to 6 weeks after skin testing as up to 2= 0 to 30% of patients will have delayed hypersensitivity reactions (27, 28). In addition to hypersensitivity, tissue necrosis (29), foreign body reaction a= nd headache, nausea, and arthralgias (30) are possible after therapy.
Hyaluronic acid is t= he second form of injectable xenografts. It is a glycosaminoglycan (GAG) and c= an hold 1000 times its weight in water to increase skin turgor. Overcorrection= is not required and because its structure is identical in all species, immunogenicity is quite low. Skin testing is not required and hypersensitiv= ity is less than 1%. Correction with hyaluronic acid lasts 6 to 9 months (31). Hyaluronic acid works by attracting water molecules and fibroblasts to the = area of injection in order to increase connective tissue production. One unique property of the product is that although the hyaluronic acid is slowly degraded, the water initially absorbed does not disperse until all of the molecules are degraded. This is called isovolumetric contraction (32). Beca= use of this property, re-injection for further therapy requires less of the dru= g to obtain desired effects.
There are two preparations, Hylaform (INAMED
Aesthetics) and Restylane (Medicis Aesthetics, Inc,
Pitfalls to hyaluronic acid are based on depth of injection. If injected into the subcutaneous tissue t= hen it is rapidly absorbed, but if injected too superficially, then painful nod= ules can persist. The major advantage of hyaluronic acid is that it can be rever= sed with hyaluronidase if results are less than satisfactory.
B. Homografts
The first two homografts available are human col= lagen analogues to the bovine preparations. Cosmoderm and Cosmoplast (INAMED Aesthetics) are collagen preparations bioengineered from fibroblasts. They = have no antigenicity and therefore require no skin testing providing the major advantage over Zyderm I and Zyplast. On average they last approximately 3- 6 months (26) which is less than that seen with bovine equivalents.
Cymetra (LifeCell
C. Autografts
The major autograft = used in the past was autologous fat. The advantage was that it had no immunogenic potential and was greatly abundant. The disadvantages included a second operation for harvesting, but also the discrepancy as to how long the subst= ance actually works before being reabsorbed. Studies have shown that non-mobile areas like the malar regions have longer duration of action whereas the glabella has less duration of action given the high muscle concentration (2= 6).
The other autograft =
mentioning is call Isologen (Isolagen Technologies,
D. Synthetic Material
Silicone is the most notable synthetic material =
has a long track history of use. It requires multiple microdroplet injectio=
over 4 weeks and injections are placed in the dermis approximately 1 to 3mm
apart. No overcorrection is required because the body encapsulates the prod=
and prevents it degradation. In the 1980's Webster published a paper
looking at 235 patients and over 2800 injections (36). He found excellent
results and very few complications, but over the years others have reported
both benign and severe reactions to the material. Chronic inflammation,
migration, extrusion/ulceration, skin necrosis, granulomatous hepatitis,
pulmonary emboli, and silicosis are just a few of the documented reactions
(37-39). Because of the severity of some of these reactions, the FDA declar=
it illegal in 1991. Since then the
One of the newer and more intriguing synthetic
materials is Radiesse (BioForm Medical,
Complications of Soft Tissue Augmentation
After injection pain, redness, ecchymosis, swell= ing, nodularity, and palpability are all common findings, but should only be tra= nsient with resolution after 1 to 2 days. Persistent complaints lasting more than = two days should alert the physician to complications. There are three different times periods during which specific complications can occur. They are revie= wed below in chronological order (42).
Immediate complications occur on days 0 to 2. The first complication is overcorrection. Proper knowledge the filler propertie= s, injection sites, and reversibility is important in the prevention of this complication. Implant Visibility is the second complication in this time period. Hyaluronic acid can produce a bluish nodule and other fillers can produce a white nodule. Massage is the initial treatment to disperse the injected filler, however hyaluronidase or mechanical deroofing of the nodule are second line therapies.
The last complication consists of vascular compr= omise. Arterial embolization must be treated immediately. It is evident with inten= se pain while injecting and immediate skin blanching. This is most common in t= he glabellar region where vasculature is prominent. Treatment includes aspirat= ion, massage, warm compresses, and even 2% nitropaste to aid in vasodilation. Hyperbaric oxygen can also be used should impending skin necrosis be considered. Venous injury is more common with high volume injections. It presents as a violaceous discoloration of the skin with a dull ache. Again nitropaste and warm compresses are used but treatment is less urgent. Any s= kin breakdown identified during this time period is treated with antibiotics and gentle debridement.
Delayed complications seen on days 3 to 14 inclu= de noninflammatory and early inflammatory nodules. Non-inflammatory nodules include observation, gentle massage, and reassurance. Early inflammatory nodules are first treated with tetracycline and/or macrolide antibiotics fo= r 4 to 6 weeks as they are infected until proven otherwise. Any lesions that are fluctuant require incision and drainage and close follow up is required at = 48 hours after initiation of treatment. If patients have no response to therapy then it is important to get tissue for culture to direct antibiotic therapy= .
Late complications are found after 14 weeks post therapy. Hypersensitivity reactions are possible as in the case of bovine collagen and hyaluronic acid from rooster combs. Nodules that form late can= be treated with saline injection for dilution and aggressive massage to break = up the filler. Inflammatory nodules this late must be evaluated for infection = and treated appropriately. If there is no infection but the nodules persists despite massage and saline injection for 7 to 10 days, then intralesional steroids injection can be used to prevent granuloma formation. If still no response these lesions are biopsied and sent for culture. Finally, true granulomas are very rare (0.01 to 1%) and massage and steroid injections ar= e the mainstay of treatment.
Photoaging and adynamic facial changes are events that each of us wi=
experience. Throughout history people have tried to adopt techniques to ach=
a more youthful appearance and as of today, there are many options to achie=
that goal. Proper knowledge of the products available and consistent techn=
ique is
vital to performing high quality and complication free aesthetics. Finally
patient expectations, informed consent and proper patient
selection are paramount to the success of the facial plastic surgeon.
Duscussant's Remar= ks: Michael P. Underbrink, MD
That was a very fine talk, Dr.
Coughlin and you covered all the injectables ve=
nicely. Here are a couple of points to remember: you are injecting foreign
material; and you're always at risk for hypersensitivity reactions af=
the patient has been injected. This figures in your pre-operative assessment
when you're explaining these things to the patient. You did a good jo=
b in
letting us know the length of these procedures from the standpoint of the
patient. You've got to =
the patient know that you're going to be re-injecting and it's
important to explain what the time frame is after the injections of bovine =
collagen. You will, of course have explained=
complications which can occur with each of these injections.
It's technically demandi=
with a shallow learning curve
It does take a lot of experience to inject and not get these
complications such as nodules and consequent patient dissatisfaction, much =
some of the more serious complications.&nb=
You did a very good job in describing those. Overall it was a very good talk an=
d a
good job.
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2. J.M. Stuzin, Phenol peeling = and the history of phenol peeling, Clin Plast Surg 25 (1998), p. = 1
3. F. Blanco-Davila, Beauty and= the body: the origins of cosmetics, J Am Soc Plast Reconstruct Surg 1= 05 (3) (2000), pp. 1196–1204
4. J. Golan and N. Hai, JetPeel= : a new technology for facial rejuvenation, Ann Plast Surg 54 (4) (2005), pp. 369–374
J. Uitto, E.F. Bernstein and=
McGrath, The dermis vol. 1. In: C.R. White Jr, M. Bigby and O.P. Sangueza,
Editors, Cutaneous Medicine and Surgery: An Integrated Program in Dermat=
W.B. Saunders Company,
6. S. Brooke and J. Griffiths, Interventions for photodamaged skin, Cochrane Database Syst Rev 1= (2005) CD001782
7. Athre RS. Facial filler a= gents. Operative Techniques in Otolaryngology 2007; 18: 243-247.
8. G. Monheit, Chemical peels, = Skin Ther Lett 9 (2) (2004), pp. 6–11
9. B.M. Freedman, E. Rueda-Pedr= aza and S.P. Waddell, The epidermal and dermal changes associated with microdermabrasion, Dermatol Surg 27 (12) (2001), pp. 1031–1033
10. Karimipour DJ, Karimipour G, Orringer JS. Microdermabrasion: An Evidence-Based Review. Plast Reconstr Surg. 2010 125(1):372-377
11. J. Newman, J. Lord and K. As= h et al., Variable pulse erbium:YAG laser skin resurfacing of perioral rhyti= des and side-by-side comparison with carbon dioxide laser, Lasers Surg Med= i> 25 (2) (1999), pp. 208–214
12. Bisson MA, Grover R, Grobbelaar AO. Long-term results of facial rejuvenation by carbon dioxide laser resurfacing using a quantitative metho= d of assessment. Br J Plast Surg 2002;55(8):652–656.
13. Trelles MA, Pardo L, Ayliffe P, et al. Patients' answers to a postoperative questionnaire related to laser resurfacing. Facial Plast Surg 2001;17(3):187–192
14. J. Chew, I. Gin and K. Rau <= i>et al., Treatment of upper lip wrinkles: a comparison of 950 usec dwell ti= me carbon dioxide laser with unoccluded baker's phenol chemical peel, Derma= tol Surg 25 (4) (1999), pp. 262–266
15. J. Kitzmiller, M. Visscher a= nd D. Page et al., A controlled evaluation of dermabrasion versus CO2 laser resurfacing for the treatment of perioral wrinkles, Plast Reconstruct Su= rg 106 (6) (2000), pp. 1366–1372
16. K. Holmkvist and G. Rogers, A comparison of dermabrasion and superpulsed carbon dioxide laser, Arch Dermatol 136 (2000), pp. 725–731
17. S. Gilbert, Improving the ou= tcome of facial resurfacing—prevention of herpes simplex virus type 1 reactivation, J Antimicrob Chemother 47 (2001), pp. 29–= 34
18. T.L. Roberts, C. Weinstein a= nd J.K. Alexandidies et al., Aesthetic CO2 laser surgery: evaluation of= 907 patients, Aesthet Surg J 17 (1997), pp. 293–303 =
19. Hinman CD, Maibach H. Effect= s of air exposure and occlusion on skin wounds. Nature 1963;200:377
20. Farrior RT. Dermabrasion in = facial surgery. Laryngoscope 1985;95:534
21. Stegman SS. Avoid dermabrasi= on soon after Accutane therapy. Schoch Lett 1984;34:44
H.J. Brody, Chemical Peeling=
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23. M. Landau, Exogenous factors= in skin aging, Curr Probl Dermatol 35 (2007), pp. 1–13
Neuber F.
Fettransplantation. Chir Kongr Verhandl Dsch Gesellch Chir 22;66:1893
25. Klein A, Elson M. The histor= y of substances for soft tissue augmentation. Dermatol Surg 26(12);1096:2000
26. C.A. Murray, D. Zloty and L. Warshawski, The evolution of soft tissue fillers in clinical practice, D= ermatol Clin 23 (2005), pp. 343–363
27. Framer FM, Churukium MM. Cli= nical use of injectable collagen: a three-year retrospective review. Arch Otolary= ngol 1984;110:93–98
28. Cooperman LS, Mackinnon V, B= echler G, et al. Injectable collagen: a six-year clinical investigation. Aesthetic Plast Surg 1985;9:145–151
29. Hanke CW, Hingley HR, Jolive= tte DM, et al. Abscess formation and local necrosis after treatment with Zyderm= or Zyplast collagen implant. J Am Acad Dermatol 1991;25:319–326= p>
30. J.M. Owens, Soft tissue impl= ants and fillers, Otolaryngol Clin N Am 38 (2005), pp. 361–3= 69
31. J. Rao, G.C. Chi and M.P. Go= ldman, Clinical comparison between two hyaluronic acid-derived fillers in the treatment of nasolabial folds: Hylaform versus restylane, Dermatol Surg<= /i> 31 (2005), pp. 1587–1590
32. S.L. Matarasso, J.D. Carruth= ers, M.L. Jewell and Restylane Consensus Group, Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restyla= ne), Plast Reconstr Surg 117 (suppl) (2006), pp. 3S–34S
33. Overholt MA, Tschar JA, Font RL. Granulomatous reaction to colla= gen implant: light and electron microscopic observations. Cutis 1993;51:95̵= 1;98
34. R.S. Narins and P.H. Bowman, Injectable skin fillers, Clin Plast Surg 32 (2005), pp. 151–162
35. Watson D, Keller GS, Lacombe V, et al. Autologous fibroblasts for treatment of facial rhytids and dermal depressions. Arch Facial Plast Surg 1999;1:165–170
Webster RC,
37. Ellenbogen R, Ellenbogen R, = Rubin L. Injectable fluid silicone therapy: human morbidity and mortality. JAMA 1975;234:308–309
38. Ficarra G, Mosqueda-Taylor A, Carlos R. Silicone granuloma of the facial tissues: a report of seven cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94(1):65–73
39. Pearl RM, Laub DR, Kaplan EN. Complications following silicone injections for augmentation of the contours of the face. Plast Reconstr Surg 1978;61:888–891
40. P. Flaharty, Radiance, Fa= cial Plast Surg 20 (2004), pp. 165–169
41. Tzikas TL. Evaluation of the radiance FN soft tissue filler for facial soft tissue augmentation. Arch Fa= cial Plast Surg 2004;6:234–239
42. Sclafani AP, Fagien S. Treat= ment of Injectable Soft Tissue Filler Complications. Dermatol Surg. 2009 Oct;35 Suppl 2:1672-80


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This is a joint quarterly publication of ABSN and the Cooperative Extension Service developed and printed through support of the Alaska Housing Finance Corporation.
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The Sunshine Kids Ultra Mat completely protects your car upholstery against scratches and dents from a car seat with partitioned squares of high-density foam.
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We purchased this seat protector for our car last year, then we purchased two more for our son and daughter-in-law's car. They protect our leather seats and are so easy to remove if necessary.
Purchased as was about to collect brand new car, fitted to car seat and placed child seat on top in moments, easily fitted around isofix connections, appears to be helping to prevent marks in seat material. The best bit was my 20mth old was sick all over self and some went down sides of seat onto seat protector, fortunitly not too much but protector kept liquid off the seat as i had ensured material well positioned to create a fold acros back of seat. Wiped off easily straight away, and washed well following instructions.
This is great for protecting your carseat from indents and the muck created by your little ones eating in their seats ! The flap by the feet is also a great addition as it keeps those mucky footprints off your upholstery or leather. Easy to install and easy to clean.
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An ideally situated hotel just a few yards from the pedestrianised area an station.We have stayed here twice..the reception has always been friendly; the rooms clean, quite adequate if on the small side and sound proofed from the outside but not always from above! The bath/showers are in the process of being updated but still provided plenty of hot water.... More
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Don Guillermo was an excellent host. He really makes you feel at home and his conversation is very interesting. They were always prompt to help you with any questions and recommend you the best spots in town according to your needs and tastes. The terrace was a very nice spot to read and relax.
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My girlfriend and I stayed 3 nights in July 2013. The hotel's location in downtown Tulum facilitated accessing food, ATMs, taxis around Tulum, and ADO buses. The penthouse suite was clean and well-lit, with a balcony and stylishly tiled bathroom for a good value ($75/n). The owners provided good information about to-dos about Tulum, My only negative impression was from the restaurant - service was slow and food was not high quality. There are far better places to eat just outside of the hotel.
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Alexander Semin returns to Verizon Center on Tuesday night as a member of the Carolina Hurricanes to face the Capitals for the first time since he parted ways with the organization this summer as a free agent. Semin, 28, spent the first seven seasons of his NHL career in Washington. While his skill level and goal-scoring ability were never questioned, his work ethic frequently was a topic of discussion. In the summer of 2011, former Capital Matt Bradley publicly questioned Semin's drive and said that the Russian winger "just doesn't care" during a radio interview. On Monday afternoon, Troy Brouwer didn't couch his criticisms of his former teammate, either. "It was tough to lose his scoring ability when he wanted to play," Brouwer said. "But all in all, I think we've been doing well without him."


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Bruce McCall Illustrates the Future That Wasn't
According to past predictions, we should be living in an era of flying cars and other marvels. But be glad that some advances haven't happened
- By Bruce McCall
- Smithsonian magazine, April 2012
(Bruce McCall)
Sure, the mile-high skyscraper offers spectacular vistas, but it takes the takeout deliveryman so long to ride the elevator to the 527th floor that your Chinese food always arrives stone cold.
Comments (5) |
C'mon, Smithsonian, do you have to break stories into such SMALL pieces? You have inspred my ire, Smithsonian.
Posted by Roger on April 16,2012 | 07:24 PM
LOL Loved the play on the futuristic concepts :)
Posted by Sivaram Velauthapillai on March 31,2012 | 03:37 PM
Wow chimps sound like Americans.
Posted by Matt on March 27,2012 | 06:48 AM
Loved it
Posted by Don on March 18,2012 | 09:53 PM
While it's still literally true that the mile-high skyscraper is part of the "future that wasn't", it's perhaps worth noting that the Burj Khalifa which opened in Dubai in 2010 is over a half-mile tall. And there are plans underway to build one even taller [one] in Saudi Arabia. But McCall's comment about cold pizza really does make an important point about the problems that have to be overcome in building very tall buildings, such as getting people to the top, getting water to the top, and so on. Sure, from a technical standpoint it can be done, but from a practical standpoint why on earth would you do it? The only reason I can think of is to be able to claim the "mine is bigger than yours" bragging rights.
Posted by Peter Tritz on March 18,2012 | 02:18 PM


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MONTGOMERY COUNTY NYGenealogy & HistoryIf you've arrived here from somewhere else, such as a pay or subscription site, and are trapped in a frame, click here http://montgomery.nygenweb.net/index.html to break free of the frame. If you found our site caught in a frame, please report where you came from to the site coordinator. IMPORTANT!!!!! please read this next paragraph!!! We've completed moving this site to a new server, and splitting Herkimer and Montgomery files up into two sites. You'll have "files not found" - they're not lost but are being carefully put back into new locations, so please don't email us that a link's not working for you. We must change links and cross-links to files throughout the new site to their new locations, re-install links to other websites, move files around, move files from another server to this one, and create a new main entry page and interface. During this rebuilding process some of the back links at page bottoms won't work, so please use your back-button. We appreciate your patience as we must most carefully make these changes. Hello there! You've discovered the Montgomery County NY GenWeb page, part of the New York GenWeb and the US GenWeb Project! My name is Martha and, together with Asst. County Coordinator Lisa Slaski, Glen Town Coordinator Pete Simmonds, and St. Johnsville Town Coordinator Allyn Hess Perry, we are all your hosts and wish you a great time researching your ancestors. We are all volunteers and fellow family researchers and don't live in the Mohawk Valley. ABOUT US! This deep and detailed site was formerly one half of Herkimer/Montgomery NYGenWeb, a county site of the USGenWeb Project that came on line in September 1996. The depth of our resources after 15+ years is due to the time, effort and caring given by our many typing volunteers to help their fellow researchers. Dozens of generous contributors have sent us information, tips and pointers to superb historical resources, and great feedback. Our genealogical offerings are only as good as our visitors' input. If you'd like to contribute some copyright-free resources, volunteer to assist in typing up or coding more material, or are interested in becoming a town editor, please contact the Site Coordinators. Don't let the 1996 design entry page fool you - this is a deep GenWeb site, offering hundreds files of great articles as well as many photos. Enjoy exploring our free resources, and happy ancestral hunting! MORE ABOUT US! The site coordinator and assistant coordinators aren't county residents or historians, and can't help with your personal research in any way. Due to the time involved in maintaining this large site, we DELETE ALL inquiries about your family, directions, items you don't see on this site, or specific historical questions. Many of your questions can be answered if you use a search engine such as google or yahoo, or our site's search feature. We thank you in advance for directing ALL questions of this type to the local societies, libraries, or other organizations, or subscribe to a genealogy mailing list. We're a group of volunteers, not professional genealogists, and are not affiliated with any society. All email regarding a need for corrections to a file, or to donate items to this site, should be directed to us, not to the societies. 6/25/13 WHAT'S NEW THIS MONTH New to This Site? Please Read Before You Email Us
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HISTORICAL SOCIETIES, LIBRARIES, COURT HOUSE AND HISTORIANS: Names and Addresses MONTGOMERY'S ILLUSTRIOUS HISTORY: general history of the county. MEET YOUR ANCESTORS...UP CLOSE AND PERSONAL: local ancestral tributes, biographies, family histories & sketches, and short books, all contributed by site visitors and volunteers. VITAL RECORDS AND OTHER LISTS: what you see is what we have on hand. MILITARY HISTORY: our military section is HUGE! And it's taking a while to link it all back into this new site! But we have tons of Revolutionary War, Civil War and other regimental rosters, area Military Honor Rolls, lots of articles of local interest, and well-chosen links to sites of historical military interest. CENSUS: transcriptions of early county censuses OBITS BULLETIN BOARD: Part 1 Part 2 Part 3 Part 4 Part 5 Part 6 Part 7 Part 8 ASK YOUR COUSINS: books we own, look-ups and special assistance from other researchers. THE OAK-PANELED LIBRARY: books we don't own but your library may have, including Family History Center books and microfilms, and several links to commercial resources and sites. LINKS WE LIKE: our large links list contains general research aids, current and historical county links, great military history links, maps, commercial and tourism resources - and some fun stuff. Most of your non-genealogy questions can be answered in this section! WILLS AND DEEDS BULLETIN BOARD: Part 6 Success Stories from our Queries Board: It could happen to you! Those Who Sit and Wait: The Mascots of the Herkimer/Montgomery Counties GenWeb Page Memorial for Rex Stevenson, Founder of the Herkimer/Montgomery Counties NY GenWeb County Coordinator: Martha S. Magill Montgomery Town Coordinators
Founded in August 1996 by: Rex Stevenson - a great genealogist. He is missed. Copyright © 1996 - 2013 |


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As other reviews mention, Alvaro's effusive welcome is one of many great personal touches staying in Case dos Guindais. We stayed in the Douro room for 3 nights in late October, with a small balcony overlooking the well-kept garden below and the Ponta Luiz. The room was clean and well-appointed, with a fantastic wet room shower overlooking the bridge. The... More
- Official Description (provided by the hotel):
- Casa dos Guindais is a XVIII century house, located in the historic center of Oporto, world heritage protected by Unesco near by the Ferdinand Wall, the Cathedral and funicular elevator. The materials used are noble and respect the rules of conservation of historic buildings in the city - Wood, Glass, Iron and Granite. It is composed of 5 independent studio apartments equipped with everything that is essential to make guests feel at home. Details like extra thick doors and windows guarantee both comfort and safety. The rooms have two twin beds, bathroom, kitchenette and access to a romantic garden. ... more less
- Reservation Options:
- TripAdvisor is proud to partner with HostelBookers so you can book your Casa dos Guindais reservations with confidence. We help millions of travellers each month to find the perfect hotel for both holiday and business trips, always with the best discounts and special offers.


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Part three of a series that illustrates using WCF to communicate between a Windows service and client application.
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Tray Notify - Part I (Getting Started)
Part one of a series that illustrates using WCF to communicate between a Windows service and client application.
The Practical Guide to Multithreading - Part 1
Understand from this guide how and when - as well as when not - to use multithreading.
Extending Microsoft's Concurrency and Coordination Runtime with MSMQ
Join Microsoft's Concurrency and Coordination Runtime and MSMQ to coordinate work across processes on multiple computers.
Using the Task Parallel Library and PLINQ to Go Parallel
With more and more computers using a multi-core processor, the free lunch of increased clock speeds and the inherent performance gains are over. Software developers must instead make sure their applications take use of all the cores available in an efficient manner. New features in .NET 4.0 mean that managed code developers too can join the party.
Create Your Own Thread Pool
By Chris Bennett - Need a thread pool with a customized level of control? Learn how to create your own thread pool in .NET.
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MFC Integration with the Windows Transactional File System (TxF)
The Transactional File System (TxF), which allows access to an NTFS file system to be conducted in a transacted manner through extensions to the Windows SDK API. MFC 10, has been extended to support TxF and related technologies. This support allows existing MFC applications to be easily extended to support kernel transactions.
.NET Framework: Collections and Generics
The original release of the .NET Framework included collections as .NET was introduced to the Microsoft programming world. The .NET Framework 2.0 introduced generics to complement the System.Collections namespace and provide a more efficient and well performing option. Read on to learn more...
Bypassing the Registry in Windows Store Apps and VB
Learn how to use ApplicationDataContainer and ApplicationDataContainerSettings in your Windows 8.1 Store apps.
Using AutoMapper in Your ASP.Net MVC Applications
AutoMapper is an external component that helps in creating a mapping between a source and destination model types. Read on to learn about the AutoMapper component and how to use it in an Asp.Net MVC application.


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"A tiger doesn't loose sleep over the opinion of a sheep." - Zag
if you can read this you're too close to my box logo
What's good with this All Black Pack? It's Black Friday here (at least in East Coast time) and nothing's on the shop.
yo i just got a $25 surprise pack, and forgot to add my info (sizes) and sent it back to the confirmation email address, you think they'll catch?
At least check out the page, thanks. https://www.facebook.com/DiamondSupplyCoTradeSell?ref=hl
fukasignature.com ... glad we have these back tho
What's you guys weight say on the tracking info? Mines only 1 lb.


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The Federal Government will Become America's Model Employer for the 21st Century.
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Bring IT to the user: Lernstatt Paderborn uses #Zarafa now since 3 years for 1.500 teachers and 17.000 pupils cc @lpinl
The Best Open Source Email & Collaboration Software
When the data from LDAP is used for Zarafa, only the value of the unique LDAP attribute is stored in the Zarafa database. When other user data is needed, Zarafa retrieves this from LDAP by searching on the value of the unique LDAP attribute. When a user is removed from LDAP, that value of the unique LDAP attribute will also be removed from LDAP. To make sure that the users which are removed from LDAP will also be removed from Zarafa, Zarafa will look to the existing values of the unique LDAP attribute. When one of those values is removed from LDAP the user will also be removed from Zarafa. When there is a new value, a new user would be created in Zarafa.
When the value of the unique attribute is changed, for Zarafa this means that the user is deleted and a new user is created. This will result in deleting the 'old' store of the user and creating a new store. The old store will move to the Admin folder in the public store.
In the LDAP documentation you can find the solution to change the unique attribute for groups, as well as for users.
Zarafa, the leading European provider of open source groupware and collaboration software, is pleased to announce its eighth presence at the CeBIT. The world's largest trade fair, showcasing digital IT and telecommunications solutions, will take place in Hanover, Germany from March 5-9, 2013.


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According to the below info I found, the new 'Fresh Paint' application could be a total revamp rather than just upgrade a few features, considering how basic previous Paint versions were. I am just comparing to previous versions of Paint & not other software. Read below links for further info, it seems to have great features for the artistic types: Microsoft Reimagines Paint(blog) Fresh Paint app page has anybody tried it yet? Also, in other news Microsoft has updated its logo/typeface
Decent beta drivers for Nvidia. Supports OpenGl 4.3 (even tho I don't need/have it) for Windows 8. for notebooks* I've just installed it on my working laptop, works pretty good. Have no idea about desktop version. Everyone can try it, here it is: for desktops* * If you need 32 bit just remove 64bit_ from url.
It seems there's a new Windows 8 build 6.2.9200.20500.This new build is either the next version of Windows or simply a service pack, time will tell. http://www.windows8core.com/image-microsoft-windows-8-delta-build-9200-20500-is-this-the-next-sp/
I have two questions about Windows 8, and more specifically, the user account. 1. You now require a Live account. Is it possible to set up a software profile linked to it? Like when you install Windows 8 on a new machine, and you put in an account and it download your apps automatically (from the Store)? 2. It has a built in reinstall function. Can you customize that to include apps as well? I just woke up and thought that would be awesome.
1. It does not require you to have a Live account. Its an option to associate your sign in windows name with your live email. When I messed with Win 8 on my virtual machine and did the install I was able to choose to have a normal windows account like Windows 7. 2. At this rate, customization in Windows 8 is pretty high. You probably could.
Yeah I know but I ment can you tie apps to a Live account that you can use on different machines? Or new installs?
Here's some info about SmartScreen how and what it reports and so on. And here are new nvidia 306.02 beta drivers for Windows 8 Desktop Notebook
I'm not 100% sure on this, but I believe that when you sign in using a Live account, anything you download is tied to it at least in the form of "purchases" (even if it's a free app). If you log into a Win8 machine with a Live account and download/install a bunch of apps from the Store, then go to another Win8 machine, sign in with Live account, you can go to the Store and it will show which apps you "purchased" using your account that are not installed on that machine, and it gives you the option to install it. I recently went through this when I installed Windows 8 on my tablet. I've already been using my laptop with Windows 8 and downloaded a bunch of stuff from the Store. When I signed in with my Live account on my tablet and went to the Store, it showed me everything that was and wasn't installed on my tablet that I had downloaded before. Then I just selected all and installed! Wonder if there's a built in kill switch like Apple has with the App Store? Also, I'm planning on writing a review of Windows 8 on a tablet, so here's a little teaser of Windows 8 on an Acer Iconia W500
I haven't gone thru 4 pages of posts here on W8, I am sure somebody would have answered. My question is Can I change the look of Windows 8 Enterprise to Windows 7 style (lot of people at work miss the Start button) and get rid of the stupid Tiles?
It'll become some kind of killswitch ... sooner or later. Maybe in windows 9. Time will show. That'd be interesting.
Thumbs up....for the most part (minor issues with using touch in the desktop environment). Hopefully have it finished this weekend maybe. Yup. The install on my tablet was a fresh install. All I did was sign in with my Live account that I used on my laptop and it knew all the apps I downloaded and what needed to still be installed on the tablet
Just got this in my mailbox,Microsoft's new agreement for Windwos8 Services.http://windows.microsoft.com/en-US/windows-live/microsoft-services-agreement Just started reading it and your Widows Live account needs to be logged into every 720 days or they cancel it auto....But can reset the password to log in.Forgot it says it goes into effect October 19 2012.
I found this interesting article: Hate Win8 Already? Waiting for Win9 Won't Help It's a nice read. In a nutshell: 9 won't bring any drastic changes (they won't change metro UI) , so people who now hate Win8 (and want to stay on 7) will have to skip Win9 too. Hm Win7 is a new XP? How do you think will 7 run for a decade like XP did?
Win 7 is supported until 2020... and I have decided to not do Win 8... so yeah. I can outlast Win 9 easy, hell GPU's still support XP and that is the only support I really care about.


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Published: 2/12/2013 10:54 PM | Last update: 2/12/2013 11:49 PM Crusaders click, squeak by WildcatsBuhler's buzzer-beater basket gets boys a win in overtime against El Dorado.BUHLER - It hasn't been an easy season for coach Denny Wahlgren and his team.But Buhler, all of the sudden, is starting to find itself with a core of up-and-comers.
"As you go through a season, you're trying to find chemistry, combinations and how that all fits together," Wahlgren said. "We just are finding ourselves a bit better now down the stretch to where we're able to get the chemistry rolling better. Basically, the bottom line is we've shot the ball better." That started with guards Quentin Henricks and Ryan Norquist, who hit the game-winning shot - a right-side, pull-up jumper - with two seconds left in overtime, and freshman post Jace Williams. The trio combined for 43 points on a night where the Crusaders hit 19 of 40 shots from the floor, including a 6-for-11 clip from beyond the arc. The junior was in a rhythm all night and when he hit the game-winner - which redeemed him from a missed opportunity on a one-and-one less than 10 seconds beforehand - he found himself in the right place at the right time. "It just happens, you know," said Norquist, who led Buhler with 17 points and four 3s. He opened overtime by taking a tip from Williams and swishing a three-pointer from the left side. The Crusaders made their next six free throws to pull ahead 50-46 with 49 seconds to play. But Travis House, who was nearly unstoppable after halftime for El Dorado (11-5), answered with an easy layup to cap his 26-point scoring effort. Norquist was fouled with less than 30 seconds left but missed the front end of his one-and-one. El Dorado snagged the rebound, drove the floor and got a tough layup from John Scott, who earned a foul on his way to the score. He missed his free throw with 11. 4 seconds left and Buhler snagged the ball and took a timeout to set up Norquist's bucket. Wahlgren's play call was intended for Williams but when Norquist was all alone inside the arc on the right side, he pulled the trigger. Williams had his own heroics, hitting the shot that forced overtime. Bransyn Felty missed a three-point try with the clock winding down in regulation and El Dorado grabbed the rebound. But when a foul set up an inbounds pass, Williams hopped in and stole the ball. Then on the Crusaders' final possession of regulation, the 6-foot-3 freshman hit a left-side layup to knot the game at 41-all. Buhler then survived three missed shots - a three-point try for House and tip-ins by Jared Haury and Scott - to force overtime. "We planned on going to me," Williams said of the fourth-quarter play. "I was hoping that (Brandon) Keeler's guy would come over so I could make an easy pass to him but he didn't so I just shot the open layup and my teammates got up for me." Buhler's late-game success erased House's outstanding performance. He scored 21 of his points after intermission, including 17 between the third and fourth quarters. For all of the see-saw moments late in the game, it hardly looked like it would turn into an action-packed contest. A listless 6-6 first quarter kept either team from finding a rhythm - something the Buhler boys have dealt with for much of the season. "Early on, in the first quarter, it was like déjà vu and we were getting decent shots and they weren't falling in, you know, they were rolling out," Wahlgren said. "Yet the players hung in there and we got some things to go our way in the second quarter and at least put ourselves in a position to have a chance to win the game at halftime." Buhler ironed out its struggles by getting Henricks, who matched Williams with 13 points, transition opportunities. He scored seven of his points in the second quarter. Buhler has a little history with the Wildcats. Last year, they defeated El Dorado in a pair of double overtime games. Earlier this year, in El Dorado, Buhler lost on a last-second shot. But now, the hard-luck Crusaders are on the winning side.
"It's great," said Williams, who also had nine rebounds. "We've been working hard all year. We've put quarters and halves together but now we're starting to put games together and it's really fun."
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Imiss you
By Keairisford on Sep 16, 2012 at 1:18 PM
By Keairisford on Sep 16, 2012 at 1:18 PM
Both of us are 63 babies. Yesterday, would have been her 49th birthday. I played her music all day long. It still seems like a bad dream that we are yet to wake up from. My thoughts and prayers are with Ms.Cissy, Pat, Gary, Michael and her beloved daughter Bobbi. She will forever be in my heart.
By Ressy on Aug 10, 2012 at 9:40 AM


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HAGERSTOWN, Md.—Maryland State Police are urging motorists to avoid Interstate 81 near Hagerstown due to backups caused by bridge work at the Potomac River.
Police said Friday that a lane closure associated with resurfacing project was causing heavy congestion. They urged drivers to find other routes, such as U.S. 11.
Police say they expect the bridge work to continue at least through the weekend.


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The board denied the rezoning request from Pell City-Tifton Properties LLC, a subsidiary of Thunder Enterprises of Chattanooga, which has owned the property since 2006. The board voted 4-1 Thursday night against the rezoning proposal.
John Hoffman was the only board member who voted in favor of the request. Board members Dot Wood, Mike Sewell, Doug Carden and Pat Wrigley voted against the rezoning.
Thunder Enterprises requested the 28-acre commercial tract, currently zoned M-1 for manufacturing, be rezoned B-2 for general business and R-4, which would allow developers to build apartments or town homes.
Chris Eckroate, a civil engineer for Goodwyn, Mills and Caywood of Birmingham who represented Thunder Enterprises, told the board Thursday night that the company wanted about 20 acres of the property rezoned R-4, and the remaining eight acres rezoned for general business.
Eckroate said the R-4 zoning for multi-family dwellings was good transitional use of the property located adjacent to the Mill Village community, and would provide a buffer between residential and the commercial development.
He said the same board approved similar rezoning plans in February 2011, but the City Council rejected the request last year.
Eckroate said the proposed development of apartments on the former Avondale Mills plant site is an estimated $26 million construction investment that would bring tax dollars, fees and jobs to Pell City.
Residents spoke both for and against the proposed zoning of the former Avondale Mills property, which borders U.S. 231, Comer Avenue, U.S. 78 and the Mill Village.
John Thornton, president of Thunder Enterprises, told the board the company tried to get the property rezoned last year for a $13 million, 64-unit apartment complex, which would have brought more than $300,000 to the city in taxes alone.
"This body approved that plan," he said.
Thornton said a proposed apartment development could provide a $25 million investment and another $4 million for the commercial development of the former Avondale Mills plant site.
"Experts tell us this is the right plan," Thornton said, adding that he knows it is in the best interest of the city to approve the rezoning request.
He said some city officials were concerned about increased crime rates that some people believe come with high-density developments, but Thornton said he had a study that disproves that notion, saying the crime rate is dependent on socio-economic status, not the number of residents living in a certain area.
Eckroate said the numbers he provided to the board were based on a 320-unit apartment complex, and he assured the board that this is going to be a high-caliber development "well-suited for this property."
"It could be a 64-unit development," he said.
Eckroate said the company must get the proper zoning for the property before moving forward with concrete development plans, which the same board would also have to approve.
Resident and former Pell City Mayor Lawrence Fields, who is in the real estate business, said he was against building more apartments in the city.
"I don't oppose the B-2 zoning," Fields said. "But guys, we are running over with apartments."
He said the majority of the former Avondale Mills property needs to be used for commercial retail.
Some residents suggested building homes or garden homes instead of apartments, but Thornton said the company also has home lots in Pell City that have not sold in the past year.
He said there is a market for apartments.
Avondale Mills resident Darrell Howell said the city approved the zoning so a church could be build in front of his home, so he asked the board why it would not approve the rezoning that would improve the vacant Avondale Mills property.
Howell said not everyone can afford to buy a home.
"I hear every day about people looking for a place to rent," he said.
Another man speaking on behalf of a church in the Mill Village community said he was opposed to the construction of apartments on the Avondale Mills property.
"I'm not against garden homes," he said, adding that apartment owners are not selective about renters, if there is a struggle to rent apartments.
Pell City resident Gene Newman, who is a retired policeman, said he did not believe the apartment complex would bring more crime.
He said the additional revenue from the development would help the city pay for needed road repairs and water line leaks.
"I'm for it," Newman said.
Ben Weaver said the proposed apartment complex would be at his back door.
"I am 110 percent opposed to apartments," he said. "I'm not opposed to other structures."
Weaver said he would prefer the construction of homes, not apartments, on the former Avondale Mills property.
Before the board's vote Thursday night, Larry Riggins, the city's building inspector, recommended that the board approve the requested rezoning.
"We feel like with the right development and density, it will be a plus for the area," Riggins said.
Wood said her biggest problem is the impact on traffic along 29th Street.
"Especially with 320 units," she said.
But city engineer Essam Ahmad said the city could require the developer to improve road entrances for future development.
Thornton said his company will appeal to the council with its rezoning request.
"What would you like to see there?" Thornton asked the board.
Bill Phillips, who was acting as the board chairman, said that was an issue that needed to be discussed with city leaders and the board at another time.
Contact David Atchison at email@example.com.


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Twitter takes you everywhere online via @anywhere
Tue, 16/03/2010 - 13:37 by Natalie James
Twitter Inc. announced Monday a new service that will integrate its service into other partner sites and media outlets. The new tech tool empowers Web sites to link Web content to Twitter accounts that users can follow without leaving the site. |


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One of the factors in my switch to Apple products was the level of customer service afforded, both online and via my local Apple retail store. I've had only one hardware related issue to date with the myriad devices (and there have been quite a few) I've purchased, but a short visit to my local retail outlet resulted in my faulty device being swapped out by the manager. No questions, no hassle, just friendly and quick help- something few retailers have been able to provide at all, much less to the level I was afforded.
To continue this positive relationship with their customers MacRumors reported recently that Apple's online store will be expanding their support via chat (traditional text chat, screen sharing sessions, and online sessions to help set up new devices) to include the UK, Germany, Spain, and Brazil. US customers have already been able to access these advanced online support features, helping those that lived in a market area without an Apple retail store.
Unfortunately MacRumors also brought us news of changes at Apple retail stores that could have a negative impact on customer relations. The report reflected news of reductions of part time staff and cutbacks in staff hours on the heels of an admission by Apple that they had "messed up" in adjusting their staffing formulas for retail outlets that would have resulted in significant cuts to staff.
The changes are thought to be the result of the departure of former retail head John Browett who had campaigned for the focus of the stores to be customer satisfaction, while new CEO Tim Cook is thought to favor a more financially-focused approach for the retail operations. While the retail outlets should undoubtedly produce a profit, I've always felt that an organization that specializes in premium products such as Apple should provide an overall atmosphere to reflect that commitment. Much as BMW uses their comprehensive maintenance program to reinforce their brand image as a quality product, Apple should (even at the risk of losing out on some profit) focus on providing the best possible customer experience. The shift to using profit as the primary statistic to evaluate store performance is in my opinion a mistake, but I'll defer to Mr. Cook's business acumen. Time will tell if the change in strategy will be successful.


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Note: This message is displayed if (1) your browser is not standards-compliant or (2) you have you disabled CSS. Read our Policies for more information.
Note: The start date of the next Partners in Policymaking class has not been determined and therefore applications are not currently being accepted.
Every other year the Partners in Policymaking Academy offers eight weekends of intensive training to a new class of 35 people with disabilities and family members. Partners is designed to educate participants to be active partners with those who make policy. Partners curriculum utilizes national and state presenters and promotes the values of integration/ inclusion. Partners believe that all people with disabilities should be respected and contributing members of their communities.
Class begins in October of even numbered years and runs for eight months ending with graduation in May. The next Partners class will be held in 2012.
If you answered yes to these questions, you might be interested in becoming one of a growing number of more than 500 Hoosiers who are graduates of Indiana's Partners in Policymaking Academy
The Partners in Policymaking Academy is a leadership training program for adults with disabilities and parents of children with disabilities. The program teaches leadership skills and techniques to develop positive partnerships with elected officials, school personnel and other individuals who make policy decisions about services that you and/or your family use.
In monthly sessions, you will have the opportunity to practice new skills in a comfortable and safe environment, build a network of people from diverse cultural backgrounds and life experiences, and learn from national experts.
Partners in Policymaking is about systems change –creating, working toward and achieving a vision of shared values about people with disabilities. This program is based on the belief that the most effective and enduring public policy decisions are made by the people who need and use services in partnership with policymakers.
It's about becoming confident in yourself, competent in the knowledge and information you'll receive, and comfortable in sharing the life experiences and expertise you bring to the program.
The Academy is presented every other year by the Indiana Governor's Council for People with Disabilities.
In general, session topics may include:
Partners in Policymaking is a commitment to:
Partners in Policymaking is based on a program developed by the Minnesota Governor's Council on Developmental Disabilities. Partners are widely recognized throughout the United States and overseas. The program is open to a limited number of people. Every other year, 35 Hoosiers with disabilities and family members are selected to participate in this Academy. If selected, hotel, travel, childcare and other related expenses are covered by the program.
Academy graduates agree that the commitment is well worth the life changes that result from the training program. If you are someone who can make this level of commitment, we invite you to apply to be a member of the next class by contacting the Council's office for an application form:
Click on the links below for more details about the program or to apply:
Partners Application: PDF | MS Word | Online Form
This application is an Adobe interactive PDF, an electronic form that allows you to complete the form and submit the data via email.
Partners Brochure: PDF
Partner Fact Sheet: MS Word
National Partner's In Policymaking website
Partners Flyer: MS Word
Partners Flyer with Contact Info: MS Word
If you need more information, an article for a newsletter, a fact sheet or brochure to distribute, call Partners in Policymaking at 317-232-7770 or e-mail firstname.lastname@example.com


text:
400 S Zinn
Blair, OK 73526
Take your pick of the prime rib, steaks, shrimp or catfish – each is fantastic, as is the friendly service. Even ... read more...
American, Steakhouse, Local Flavor
2080 E 2nd St
Edmond, OK 73034
Kang's Sushi Bar & Bistro in Edmond is a modern Asian restaurant and sushi bar serving up fusions of Chinese, ... read more...
205 S Main St
Broken Arrow, OK 74012
Nouveau Chocolates, in the heart of Broken Arrow, is reminiscent of a small European store and is the ultimate ... read more...
Coffee Shop, Sweet Treats
6030 S Yale Ave
Tulsa, OK 74135
Camille's Sidewalk Cafe in Tulsa offers a wide range of menu items, including sandwiches, wraps, salads, flatbread ... read more...
Bistro/Gourmet Cafe, Deli
311 E Hall of Fame
Stillwater, OK 74075
Part of the Eskimo Joe's family, Mexico Joe's is Stillwater's hole-in-the-wall cantina. Offering a vast array of ... read more...
101 S Chouteau Ave
Chouteau, OK 74337
This 7,200-square-foot building houses a family-owned restaurant featuring delicious sandwiches made from freshly baked ... read more...
Bakery, Deli
1324 S Main St
Tulsa, OK 74119
A quiet, classy European-style bistro nestled in the historic Hotel Ambassador, the Chalkboard is the perfect spot for ... read more...
Bistro/Gourmet Cafe, Fine Dining
150 S EK Gaylord Blvd
Oklahoma City, OK 73102
Pinkitzel Cupcakes & Candy, located in downtown Oklahoma City, is an unbelievably unique and extravagant cupcake ... read more...
Bakery, Sweet Treats
821 W Broadway
Muskogee, OK 74401
Formerly a bed and breakfast, this cafe and pub-style restaurant now offers lunch and dinner in private dining rooms on ... read more...
Bistro/Gourmet Cafe, Fine Dining
6600 N Olie Ave
Nichols Hills, OK 73116
Kang's Sushi Bar & Bistro in Oklahoma City is a modern Asian restaurant and sushi bar serving up fusions of Chinese, ... read more...