Over time with genetic influences and facial expression, we see changes in the appearance lower face and neck. Complaints include worsening of a crease on the chin under the lower lip, dimpling of the chin, a sad or angry appearance of the corners of the lips, jowls worsening and loss of definition of the jaw and neckline. It is common to hear patients complain that they are starting to look like their mother or father.
A non-surgical approach we offer in our clinic is treatment of these areas with a neuromodulator like Botox or Dysport. The crease between the lower lip and base of the chin is a result of strong muscles of the chin that pulls up and inward. As patients age they lose volume in the chin and dimpling is seen when the patient animates. Treatment of the mid chin with a neuromodulator can help relax the horizontal crease and reduce the appearance of the dimpling.
The down-turned corners of the mouth create a sad or angry look caused by the depressor anguli oris muscle pulling down over time. Relaxing these muscles with a neuromodulator causes relaxation of the muscles and creates a lift of the corners of the lips.
Volume loss in the mid and upper cheek causes tissue to descend and creates the jowls. The platysmal muscles of neck pull down and tension increases which results in the appearance of the vertical platysmal neckbands with animation. Patients usually grab under the chin at the angle of the neck and ask, "What can you do with this?" In addition, horizontal necklace lines and puckered crepe-like skin on the central part of the neck can develop with aging. Within a few days of treatment, neuromodulators can improve the definition of the jaw and neckline resulting in relaxation of the tensed bands, which allows the muscles to lift up. The necklace lines across the neck appear softer and the puckering of the central neck smooths out. With this simple office procedure with virtually no downtime patients can enjoy the benefits of this beauty secret for several months.
Various nutrients and antioxidants have been identified to benefit overall health. These nutrients and antioxidants are also essential for maintaining youthful skin vitality. Eating foods rich in antioxidants and supplementing with these nutrients can help protect against free radicals. Free radicals can potentially damage DNA and can lead to cancer. Topical application of these nutrients and antioxidants to the skin can help repair damage and slow the aging process and improve skin vitality. Some of the key nutrients and antioxidants include:
Alpha-Lipoic Acid improves immune function and neutralizes free radical formation. It increases collagen content in the skin. Alpha-lipoic acid diminishes fine lines and gives skin a healthy glow. It helps recycle and boosts levels of other antioxidants such as vitamin C. Because of its ability to enter all parts of a skin cell, it is believed that alpha-lipoic acid can provide more protection than other antioxidants against free radicals that can damage the skin.
Coenzyme Q-10 is an enzyme that enhances effects of other enzymes. It produces energy in the cell and enhances regeneration of vitamin E. CO Q-10 speeds up the rate of natural chemical reactions in cells to make energy needed for the cells to grow. It assists fibroblasts in producing more collagen and elastin.
Green Tea contains nutrients loaded with antioxidants and polyphenols that have been shown to fight free radicals. Applied topically, green tea may protect fibroblasts from UVB exposure and reduce the damaging effects of the sun and protect against skin cancer. Using green tea in conjunction with sunscreen can enhance sun protection.
Hyaluronic Acid is a natural substance found in the body. It is found in high concentrations in the eye and joints. In the aesthetic world, hyaluronic acid is used as tissue filler. Hyaluronic acid produces volume, fullness and helps to provide moisture. It has been used on the skin for wound healing, burns, skin ulcers and used as a moisturizer.
Vitamin E supports immunity and healthy skin. Vitamin E is also an antioxidant that protects cells from damage. It decreases skin roughness and wrinkle depth when applied topically.
Pomegranate Extract: The antioxidants in pomegranates include polyphenols such as tannins and anthocyanins. There are many reported benefits of eating the fruit or drinking the juice of pomegranate. Pomegranate extract from the peel of the fruit promotes regeneration and thickening of epidermal cells and enhances dermal repair.
The process of aging and genetics can result in
the lips losing volume and structure.
Some patients completely lose the appearance of their lips when they
smile. With most patients, injection of
hyaluronic acid fillers like Restylane, Perlane or Juvederm can replace volume
that was lost over time and improve the appearance of their smile. Unfortunately, this is not successful 100% of
had a few challenging patients that due to the structure of their upper lip and
elongation of the skin from the base of the nose to the upper lip did not
result in the desired effect. These
patients had no improvement in lip show when they smiled.
approach I have taken with these challenging lips is using micro-pigmentation (permanent
makeup) to give the illusion of lip tissue above their natural lip line. Full lip color can be applied and blended
into the lips to give a natural fuller lip appearance.
are sometimes reluctant to do permanent makeup, because they may have seen unsightly
dramatic eyebrows or dark lip liner without lip color. Fear of pain may be a factor. I do a dental block so patients are
comfortable during the procedure and I am able to do several passes to work the
color into the lips evenly. The shape of
the lips can be drawn prior to procedure so the patient knows what it will look
like after the procedure. A variety of
colors are available ranging from nearly nude to a mauve or merlot. Skin type is taken into consideration and
adjusted for depending on the tone of their skin. The same lip color can be applied to10 people
and look slightly different.
(permanent makeup) requires touch ups.
The pigment does fade over time.
Colors can be changed. The color
is much brighter the first five days.
Swelling, scabbing and peeling is expected. Prophylactic antivirals are recommended
starting the day before treatment and for 3 days after the procedure, because
HSV – cold sores can occur post procedure.
with lips that disappear when they smile usually say they wished they did
permanent makeup years ago. Most
patients just apply a clear gloss of chap stick with SPF instead of
lipstick. Patient satisfaction is extremely
Frequently, women present to our clinic with melasma. Patches of dark pigmentation that often present symmetrically on the cheeks, upper lip and/or forehead characterize melasma. Excessive melanin production is stimulated by excessive sun exposure, heat or hormonal changes. The onset of melasma is often associated with hormonal shifts such as use of birth control pills, pregnancy or menopause.
Worsening of melasma can occur with overstimulation of melanocytes. Excessive sun exposure is the most common cause. Some patients who seek treatment with some laser treatment, chemical peel or waxing find that they have increased pigmentation after these procedures. Physical exposure to heat is reported to play a role in worsening symptoms as well. Women who report avoiding sun exposure but are exposed to environmental heat such that found in the workplace present with worsening melasma.
At this year's American Society of Laser Medicine & Science, many experts discussed their success with laser toning. Laser toning utilizes a 1064-nm wavelength laser that targets the melanin in the cells and breaks it up gradually. Multiple passes are required to target the amount of pigment in the tissue. Laser toning reduces the appearance of melasma and evens out skin tone without downtime. Patients will experience heating of the skin with light, prickly, snapping sensation. It is a comfortable procedure and is safe for most skin types.
Long-lasting results are obtained with multiple treatments. Patients need to be informed that improvement is gradual. The number of treatments needed depends on the severity of their condition.
Laser toning does provide long-lasting results but cannot be claimed as a cure for melasma. A tailored skin care regimen, sun protection and minimizing heat exposure are essential factors leading to the success of treatment and maintenance of results.
Are financial reasons keeping some of your patients from proceeding with an aesthetic procedure? Many patients may be unaware of great options that are out there that could aid in obtaining the aesthetic treatments they desire.
CareCredit is a financing option for health, beauty and wellness expenses. CareCredit is a great option for patients and can make treatments otherwise not possible very possible.
As the website states, CareCredit is a credit card. As with all credit cards, if you do not make your monthly payment on time, or miss a payment, you will incur a much higher interest rate and potential fees. Therefore, in order to use CareCredit efficiently, and to avoid high interest rates, it is important that you make your minimum monthly payment and pay off your balance by the agreed upon due date.
The CareCredit website is easy to navigate and can be used to find participating providers and learn about how the credit card works. They offer financing options such as "no interest if paid in full within 6, 12, 18 or 24 months (on qualifying purchases of $200 or more)." So for many people this could be a great option for having a treatment done now and paying it off over time without accruing any interest.
To learn more visit: http://www.carecredit.com/
Brilliant Distinctions is a rewards program offered by Allergan. It is not a credit card. Think of this as similar to the many rewards cards we are offered at practically every retail store we go to. I think it makes great sense for patients who use Allergan products, especially fillers (such as Juvederm and Juvederm Voluma), Botox and skin care, because you gain points to use toward future purchases. There is no fee -- you get rewarded with points to use for later purchases.
Our patients really love this rewards program and their App that works on all mobile devices.
To learn more visit: https://www.brilliantdistinctionsprogram.com/
In Office Promotions
Many offices offer specials or introductory rates for new patients. Some offices also reward patients for referring new patients. Not sure? Ask! It can't hurt to see if the office wants to accommodate you and work with you to achieve your aesthetic goals.
Intense pulsed light (IPL), broadband light (BBL), photorejuvenation and fotofacial are all terms that refer to a technology that has been available for several years to rejuvenate the skin. Most laser companies have their own version of this technology incorporating a broad band of non-coherent light waves that range from 560 nm to 1200 nm. Various targets in the skin absorb different wavelengths. Due to the range of wavelengths, a decrease in the appearance of fine lines, pore size, hyperpigmentation and erythema are observed, along with improved elasticity. The American Society of Aesthetic Plastic Surgery reported in 2009 that more than $215 million was spent in the US for these procedures. Today it is still one of the most popular nonablative procedures.
Photorejuvenation is not without complications. Earlier devices that pioneered the procedure were called Photo-Derm and became known as "Photo-Burn" due to the complications that occurred. With advanced technology, use of cut-off filters and cooling mechanisms within devices, the incidence of burns has significantly reduced, but still occur.
The patient's skin type and a clear history of recent sun exposure are critical factors to consider before treating patients with photorejuvenation. Patients who have had photorejuvenation in the past using the same device and settings can be burned on a subsequent treatment if they had significantly more sun exposure since the previous treatment.
Off-the-face treatments on the neck, chest, back or extremities require extreme caution. Usually, parameters used on the face are too high for off-the-face areas. Patients are usually frantic and upset when they see footprint burns a few hours later, followed by blistering and dyspigmentation. The areas of burn appear much lighter than skipped areas. This is disfiguring and creates prolonged social downtime.
The décolleté and upper back are the most common areas of dyspigmentation that present to our clinic. The décolleté is usually treated for extensive sun damage and upper back is usually treated for hyperpigmented scars from acne.
Fortunately, continued treatment with photorejuvenation usually helps resolve the complications. After the skin has re-epithelialized I have patients use a compound of a combination tretinoin and bleaching agents as well as sun block and continue with photorejuvenation treatments 3 to 4 weeks apart, with intermittent microdermabrasion and/or chemical peels Understandably, most patients are very reluctant to try this approach, but in the long run patients are very pleased with the results.
We are each unique in that we are different. One thing or feature that bothers you may truly set you apart from others … in a very good way.
I don’t believe in changing your looks to achieve something that another wants wants in you or to please someone else’s vision of you. If we are happy with ourselves, we will set the foundation to also be happier and strengthen our relationships with others.
I think looking beautiful and feeling beautiful are two entirely different things. Many people can look beautiful but only few ever actually feel beautiful. Working on our outside appearance can improve what we and other see visually, but working on the inside is what can make us shine.
We must learn to see beauty in what makes us unique. Call them imperfections if you will -- we all have them. Our unique traits, be them features or talents, and personality are what make us who we are. Embrace what you have! While things could always be “better,” they could also be much worse. Work with what you have and love what you have, and worry less about what you want. Accepting ourselves and the beauty others may see in us -- this is what makes us uniquely beautiful creatures.
With new aesthetic products being introduced every year, new advanced techniques to deliver these products are also introduced. Tissue filler injection techniques have evolved from filling fine lines to liquid facelifts utilizing more volume, which in some cases resulted in the unwanted appearance of a "pillow face" appearance.
When a patient looks at her face in a mirror, she usual sees nasolabial folds, marionette lines or dark undereye circles from volume loss. Volume replacement in the mid- to lower face to address these folds can result in changing the face to a more aged rectangular shape. The aesthetic goal is to regain the so-called triangle of youth, with a narrow chin and jawline.
The introduction of Voluma and its associated techniques has allowed us to recreate the triangle of youth and renew the "Oggi" curve of the cheek. Voluma has more cohesiveness than other fillers and creates an anchor for the skin when injected over the zygomatic arch. By using this approach first, I have found that I can provide a better correction with less product. Anchoring the filler over the zygomatic arch allows for a lift of the nasolabial folds, jowls and also improvement of the marionette lines. I then proceed to treat these areas (if still needed) with fillers that are less cohesive. I end up using significantly less product.
Take the time to assess the patient using photographs at various angles and review the photos together as you discuss your plan for treatment. This helps the patient understand your approach. Limitations to this technique include restricted patient budget; you may be able to provide only one syringe of product and end up focused on the nasolabial folds. Patient education about the need for progressive treatment to achieve their desired results is extremely helpful to achieving patient understanding and satisfaction.
Hair loss can be devastating to both men and women. Various genetic and environmental factors can cause hair loss. Environmental factors may include chemotherapy, diet, nutrition, stress, hormonal shifts, autoimmune disorders and various illnesses due to imbalances
Treatment options for hair loss include magical topical lotions and potions, prescription medication and surgical procedures. A revolutionary procedure gaining popularity utilizes a patient’s own rejuvenating properties. It applies the patient’s own platelet-rich plasma (PRP) to the scalp after the process of microneedling. Microneedling is much less traumatic to the skin than dermal rolling or injecting the PRP directly into the scalp.
The patient’s blood is drawn directly into a special blood collection tube similar to that used for laboratory tests. The tube of blood is then placed into a centrifuge to allow separation of the red blood cells from the plasma. Multiple channels are created into the scalp during the microneedling process. Immediately after the microneedling, the patient’s plasma is applied onto the scalp. The microchannels allow absorption of the PRP into the scalp.
The plasma contains the platelets that are rich in growth factors that stimulate stem cells to promote a natural process of wound healing, resulting in repair and regeneration of cells. PRP can generate new hair growth and enhance hair transplant results for thicker, healthier hair growth. Unfortunately, for patients with absence of hair follicles, PRP will not likely stimulate new hair growth. Healthy hair follicles need to be present.
PRP to the scalp for hair loss is well-tolerated. A topical anesthetic is applied prior to the microneedling. A mild “sunburn” feel can be expected following the procedure. There may be minor pinpoint bleeding during the procedure, prior to the PRP application. Anti-inflammatories are not recommended since they may interfere with the natural healing process stimulated by the PRP. Multiple treatments may be needed before results are seen.
Combination therapies with PRP are being performed in various clinics, and we will continue to learn more about effective treatments for hair restoration.
If our eyes are the windows to our soul, then our eyebrows are most certainly the curtains. And it has been studied to be true - eyes are the first thing another person notices about our appearance.
With all the care that goes into taking care of our eyes, I find that eyebrows are often overlooked. The shape of our brows is very specific to our face and with a little professional tweeking we can really (and easily) improve our appearances. Full brows are en vogue while thin, over plucked brows can really age us.
Tweezing is a great way to keep up with unruly brows but I caution you to seek professional attention for dramatic shaping. I only tweeze outliers and leave the artwork to the professionals. My biggest pet peeve is young girls who over pluck their brows. What! No! Stop! Just say no to over plucking. P.S. Invest in really good tweezers and you'll never regret it.
Waxing is the old standby for brow shaping and definitely works wonders. Pay extra attention to not using any products with retinol or retinoidic acid the week of your treatment as the skin could more easily lift (and result in burns and potentially scarring).
Threading has been gaining popularity in eyebrow shaping - we have malls in Miami that offer threading only services. I find it more painful than waxing but it also seems to negatively affect the skin less (score!) and give a manicured arch. Careful not to overdo it with threading and have too much hair removed.
As we age, brow hair becomes more sparse (think of all the years of abuse adding up too) so for women who truly have no brow hair, permanent makeup could be a great option. We have a particular artist and salon that we recommend, and most importantly trust, for this unique service. I would caution anyone to go very conservative in this department or hold off all together and use brow makeup which is non-permanent. If you are trying to improve sparse brows, also consider Latisse!
The popular product for eyelashes can be used, off label, to help hair in the brow region grow. I decided I wanted to grow my brows out to change their shape and Latisse has helped me get there much faster. This stuff works. Not to mention your fabulous brows will look even better accompanied by gorgeous lashes.
Some of my favorites in this category include powders, pencils and gels. Going a shade lighter than your color tends to give the best results, depending on the look you are going for. I love thin brow pencils and using very small strokes to mimic the look of real hairs. Clear brow gel is an essential for me so hairs (not to mention all your hard work) stay in place. There are also colored versions that are fun if you want to mix things up or to match your brows to a new hair color. Don't have brow specific products on hand? No worries, eye shadows can also be used with an angled brush to fill in brows.
Moral of the story - don't forget those beautiful brows! Everyone is looking at your eyes, whether you like it or not. Keep your look fresh, rejuvenated and the Wow Factor going with proper care of your brows.
One of the biggest skin challenges we encounter on a daily
basis is melasma. Melasma appears to be most prevalent with darker skinned
women, primarily Asians and Hispanics.
I have seen a few Fitzpatrick II-III patients that present
with it as well. Melasma usually presents somewhat in a symmetrical pattern
involving one or a few areas such as the forehead, cheeks, jawline, upper lip
The pigment can involve the epidermis, dermis or a
combination. Most women report a seasonal pattern with complaints of pigment
worsening at the end of the summer.
We have learned to keep our patients' expectations low as
far as treatment results and counsel them that maintenance treatment may be
required. We recommend sun protection on a daily basis, even on a rainy, cloudy
day. Prescription and nonprescription topical creams may include one or more of
Various Botanical Ingredients
Various modalities can be used to treat the symptoms. In our
clinic, we use a combination of laser or light type devices, such as IPL and
laser toning, microdermabrasion and chemical peels. Micro-needling and conservative
fractional CO2 laser resurfacing alone, or enhanced with Platelet Rich Plasma
(PRP), also known as the "Vampire Facelift", aid in treatment.
PRP utilizes the patient's own repair-response to be
activated. Their plasma, rich in growth factors, is applied after micro-channels
are created in the skin to stimulate the stem cells to repair. Great caution is
taken with these patients, because melanocytes can be over-stimulated. When too
much inflammation is created, symptoms can worsen.
Fraxel was one of the first laser type technologies that had
FDA approval to treat Melasma. Unfortunately some patients developed more
hyperpigmentation post procedure.
I like explaining to patients that the development of
melasma is not fully understood. Genetic factors can play a role in the
formation of melasma and can be affected by hormone fluctuations and
Estrogen receptors on melanocytes have been found to
stimulate the production of more melanin in some studies. I think we will learn
more about the hormonal activity in the very near future.
In summary, I set their expectations low, recommend a
variety of modalities, and emphasize the importance of home care regimen, sun
protection and possible need for maintenance treatment.
I tell patients that we can't "cure" this condition because
it is chronic, but we can help them control the symptoms and get them to the
point where it may appear completely resolved. However, even one hour without
sun protection can bring all the symptoms back.
It's a rare occasion that a product gets me so excited that I
would literally jump up and down in excitement talking about it. SkinMedica's TNS Essential Serum is
one such product.
personal addiction to this product aside, TNS Essential Serum opened my eyes
years ago to the world of growth factors and antioxidants. If you are not
using growth factors, you should be. Growth
factors, such as TNS (or Tissue Nutrient Solution), rejuvenate the skin by
stimulating collagen and improving the appearance of fine lines, skin tone,
texture and resiliency of the skin. TNS
Essential Serum in particular combines growth factors, antioxidants, soluble
collagen, cytokines and matrix proteins. Simply put, growth factors are game
changers in skin care.
growth factor in particular consists of two chambers separating the two
components which cannot be mixed until you put them on the skin. The two components of this product are
TNS Recovery Complex and APS Corrective Complex. Think of this as recovery and
regeneration of your skin.
TNS Recovery Complex is formulated from naturally occurring growth
factors, antioxidants, soluble collagen, cytokines and matrix proteins. TNS Recovery Complex has been
clinically proven to reduce the appearance of fine lines and age spots, and
improve skin texture, tone and elasticity.
APS Corrective Complex is a potent mixture of antioxidants, peptides
and other innovative anti-aging ingredients which promote the skin's natural
regenerative process. This works
to strengthen the skin's natural ability to regenerate itself, fights against
environmental damage as well as smooths and tightens skin. Together the
products truly work synergistically to rejuvenate the skin.
I'm a big believer in great products with scientific backing that
yield amazing results. There are
also several other growth factor products that also work very well. If you aren't already on board with
growth factors, I encourage you to get your feet wet and see what great things
they can do for your patients' skin.
Juvederm Voluma with Lidocaine is the hot new filler for 2014. With the
natural aging process we lose facial volume. Voluma was developed to provide
more volume and lift in areas such as the cheeks, cheekbones and chin which are areas of larger-scale volume
Voluma is hyaluronic acid that is smoother than
other hyaluronic acids which makes it easier to inject during the treatment and
results look and feel smooth and natural. Voluma is developed using Vycross
technology, which is responsible for these results. It has been proven to last
up to 18 months.
A youthful face has round contours, high
cheekbones and definition of lower face, chin and jawline. With Voluma
injections, cheeks can appear higher and firmer. It can also support the chin,
replacing some structural integrity due to volume loss partially due to bone
loss. Patients can regain the youthful curve and angles that they once had in
Because Voluma is made with Lidocaine, patients
tolerate the procedure well. A topical anesthetic can be used to minimize discomfort
from the needle puncture. Although Voluma is considered to provide more lift
and seems “thicker”, it passes smoothly though a small guage (27gauage) needle.
I feel it is easier to inject than Juvederm Ultra.
Caution must be taken with injections because
less pressure is needed to inject this product. Routine aspiration prior to
each injection is critical to avoid intravascular injections when using
Optimum results in some areas require injecting
just above the periosteum, and patients should be prepared for tenderness post-procedure
when the anesthetic wears off. Due to the depth of injection in most sites,
patients seem to experience less swelling post-procedure.
For years patients have been asking for
something to provide more volume and last longer. With the safety profile of
hyaluronic acid and Voluma’s volumizing and lifting properties, patients will
have a higher satisfaction with their liquid facelift results.
Over half of the US population is overweight. Most of us
are considering again our old resolution for the New Year - losing weight. Fad
diets that require severe calorie restriction have historically failed us
long-term. Many of us lose weight with these diets temporarily, but then
the weight comes on again, and is usually much more difficult to take off. The
body goes into survival mode with severe calorie and fat restriction. When this
happens, the body holds onto fat and burns muscle tissue, reducing the body's
ability to burn fuel in the future.
vicious cycle of calorie restriction has allowed many to give up. Patients need more
structured guidance on what types of food to consume, how much to eat for their
size and how often. We need to think of food as medicine or poison to our
system. What we put in our mouths triggers certain responses.
most successful programs recommend the following:
meals (typically five throughout the day)
healthy fats such as nuts and avocados
Unlimited leafy greens
simple carbohydrates - sugars and high glycemic foods
amount of protein and fat
in moderate exercise that is enjoyable
hormone imbalances in conjunction to diet and exercise is critical to improving
the body's metabolism. Hormones that play a role in weight control include:
healthcare provider you may not have time to address this in detail with your
patients but you can have resources available. You can still play a part
in the success for a healthier year.
The art of tattooing has been performed since ancient times
and will continue to be performed for years to come all over the world. People
get tattoos for a variety of reasons. Tattoos may be a loved-one's name,
identify an individual belonging to a group, a symbol of a significant event in
someone's life or something that seemed like a good idea during a rebellious
time in someone's life.
Laser technology for tattoo removal has advanced over the
last decade, however many of the latest lasers continue to have a challenge
with removing certain colors like aqua green or blue. Some tattoos can be
significantly reduced in one to three treatments. However, multiple treatments
are usually required.
Toxic acids have been used as an alternative to lasers for
removing tattoos, and unfortunately tattoos had been replaced with scars. Some
permanent makeup artists have been successful with removal of unwanted cosmetic
tattooing with some acid solutions without scarring, however this is dangerous
practice. Fortunately, the face is very vascular and allows for faster healing.
When toxic acids are used for tattoo removal from the neck down, the risk of
A safe all-natural non-acid saline solution can now be used
as an alternative to laser tattoo removal. After a specific technique is used,
using a tattoo machine with a specific needle configuration, the solution is applied
directly over the area. Over time a scab forms.
Patients have to take extreme care during the healing
process. The longer the scab stays on, the better the results. Once the scab
falls off the process is interrupted. The scab must be kept dry. Patients experience
more pain at the site of tattoo removal after 4-5 days. An average of 3-5
treatments are required, spaced 6-8 weeks apart. The biggest advantage to this
procedure is that all tattoo colors can be removed.
Non-laser, all natural solution tattoo removal has risks
just like laser tattoo removal. Pain,
swelling, infection, scarring and skin discoloration can occur. There is a
higher risk of hypo and hyperpigmentation with darker skin types.
A technician performing non-laser, all natural solution
tattoo removal must not only be trained in proper techniques of performing the
procedure, but must know how to minimize risk of complications as well as know
how to treat complications from the procedure.