Monthly ArchiveOctober 2018

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Restoring Change from Time and Childbirth

The use of radiofrequency technology for medical and cosmetic procedures has become a popular and effective choice for both medical offices and consumers. According to the American Society for Dermatologic Surgery, the non-invasive, electric current technology is proven to tighten skin, reduce wrinkles and scarring, smooth surfaces and stimulate collagen production.1

That same technology is now being used for women who suffer from stress incontinence or vaginal dryness, as well as those who simply want to rejuvenate the look of what age and childbirth may have taken away.

Created by Red Alinsod, MD, a gynecologist and reconstructive surgeon, Thermiva is a non-surgical therapy which tightens the skin and tissues on both the external labia and the internal region. Dr. Alinsod reported on The Doctors that this new technology offers an option to surgery and increases access for more women who suffer from stress urinary incontinence or post-menopausal vaginal dryness. He adds that the temperature-controlled heat creates brand new collagen that is softer and improves blood flow to the region, so the sensitivity in the area is dramatically increased as well.

How does it work?

The device used by medical professionals is a small wand (thinner than an index finger) which produces temperature-controlled heat and is gently applied to the area both externally and internally. The in-office procedure takes only a few minutes and three treatments one month apart are recommended. There is no down time and patients can resume normal activity immediately, including intercourse.

According to Alinsod and other doctors using the technology, patients see same-day results and continue to improve for up to three months as new collagen is produced. Annual touch ups are also recommended.

“We are seeing tremendous results with our patients,” says Joan Warren, MD, of Palm Desert. “Those who struggle with mild to moderate stress incontinence often experience tightening of the lower bladder wall which helps control the issue; others whose external structure has changed due to natural childbirth are feeling confident in their appearance once again.” Warren adds that the treatment is simple, efficient and very comfortable for patients.

The parent company, Thermi, states that there are no known adverse reactions or complications as the device is temperature controlled. It was also noted on The Doctors that vaginal rejuvenation and cosmetic labiaplasty are considered controversial by some doctors who feel that medical professionals should not be sending the message that there is an ideal feminine aesthetic. However, the doctors on the show were quick to state that they all support the right to choose for either medical or cosmetic purposes.

For more information on Thermiva visit www.thermi.com.

References: 1) NIH’s PubMed http://www.ncbi.nlm.nih.gov/pubmed/22913399.

Corrective Rhinoplasty

Plastic surgery results usually come out great, but there are exceptions. Unsatisfactory results occur often enough that some surgeons, like me, develop a reputation as being the go-to man to rescue a bad result.

When a surgical nose result is bad, it’s very troubling to a person. It cannot be concealed. Make up helps a little, but not enough. Another challenge for the unhappy nasal patient is that there must be a relatively long waiting period before revision surgery can be done. I rarely break my one-year rule, because for up to a year there may still be a little swelling. The problem with going in too early is that swelling may conceal an issue. Furthermore, swelling may be the entire reason for the patients’ discontent and additional surgery ends up being unnecessary.

To understand the nature of the poor result, a little anatomy lesson is in order. The upper nose is made of two bones that arise from the cheek bone. The nasal bones are connected to the middle part of the nose, which are the upper lateral cartilages. The lower part of the nose (the tip) is made of the lower lateral cartilages which arch up from the nostrils, bend inward at the tip and continue inward together forming the bit of tissue between your nostrils, called the columella. The nasal septum begins just above the columella and continues upward to right between your eyes. The lower part is cartilage and the upper part is bone. That means that cosmetically, the nose has three thirds: the upper which is bone, and the middle and lower (tip) which are cartilaginous.

One of the hardest things to do in plastic surgery is to have smooth transitions between these three parts. Specifically, the junction of the upper nose and the middle third is the most troublesome. Dissatisfaction with the tip is the second most commonly reported complaint. Lastly, it can be a concern if the resulting nose is not straight or symmetrical.

The fix for these problems is usually surgery, but surprisingly, some of them can be substantially improved with the use of injectable fillers or injectable steroids. If surgery is required, it is imperative for the surgeon to educate the patient about this anatomy and where the problem lies. A “punch list” of problems needs to be identified for the patient to fully understand the root of the dissatisfaction. Patients who understand the nature of the defect are most likely to be happy with revision surgery, even if not every single item can be corrected. Patients who are vague and say: “I just don’t like it” are not helping their surgeon establish a pre-operative plan.

Healing from revision surgery takes longer than healing from first-time surgery and patients need to know that ahead of time. That’s the reason revising a nose by simply injecting it has become the first choice, if the defect can be managed that way.

To determine if your unsatisfactory surgical result can be remedied, contact a board certified plastic and reconstructive surgeon.

Dr. Ordon is medical director and owner of The Plastic Surgery Institute in Rancho Mirage and co-host of The Doctors television show. The Plastic Surgery Institute can be reached at (760) 568.2211.

Face Lifts: The Real Deal

One of the nice things about a free market economy is competition, which creates the incentive to be better at what we do. In medicine, we strive to achieve our patients’ goals more predictably, with shorter recovery and less down time. The competition between health care providers, medical device companies and pharmaceutical companies encourages evolution and development at a rapid rate. It makes us better.

Unfortunately, competition also provides incentive to make claims that bend the truth in order to gain a financial advantage. Safe guards are in place, but I commonly see treatment that is described as non-surgical when it isn’t; or non-invasive when it actually is invasive.

So, what’s the real deal in face lifting? Is there a non-surgical lift? Is there an incision-less face lift? Let’s remove the smoke and mirrors and reveal the state of the art in facial rejuvenation.

I perform face lifts in four ways, including the traditional facelift, the O-lift, hybrid jawline contouring, and non-invasive techniques which require no incision. No beating around the bush, three of these are surgical; one is not. Procedures promising weekend recovery, and/or involve chin implants and liposuction are surgical, even if they claim to be non-surgical.

These are the four types of surgery I have offered for nearly 30 years. Let’s go from least to most as it pertains to expense, recovery and invasiveness.

Non-surgical

An aged, droopy face is caused by an imbalance between how much face you have and how much skin you have to cover it. So the least invasive methods address that discrepancy one of two ways: shrink the covering or fill the face.

Filling the face is easy and fast with nearly no recovery. We call it the liquid facelift. We inject fillers or collagen stimulators into the hollow areas of the face, filling out the skin and improving the contours. The result is a smoother, fuller more youthful look that can be instantaneous. There are many fillers out there, but the ones we rely upon the most are Sculptra, Voluma, and Lyft.

Shrinking the facial skin can be done two ways: ablative and non-ablative. My favorite ablative technique is Total FX laser because it offers both deep skin tightening and resurfacing of the fine wrinkles in one treatment. Even though this treatment involves a week or so of down time, it is considered non-invasive because no incisions are made. Non-ablative methods use a laser or radio waves to penetrate and stimulate the deep dermis and leave no surface changes at all. Thermage (radio wave) patients are back to work the next day and the face tightens over a 6-month period.

Hybrid Jawline Contouring

One of the first things that makes a person look older is a jowl. It is the fullness along the jaw-line next to a relatively receded chin. That is where neck and jaw line contouring come in. It is surgical, but it offers a predictably fast recovery of just a few days with a result that lasts years, not months.

We now can remove small amounts of fat in the jowl and neck while using an ultrasonic probe to stimulate tightening of the skin down the line. When this is conducted with special sutures along the neckbands and sometimes a small implant to fill in the pre-jowl sulcus (the indent just inside the jowl), the jaw line can benefit from a miraculous improvement with a single 1- or 2-centimeter incision beneath the chin. The recovery is fast and the impact is vast.

The O-Lift

The O-Lift is my personal answer to the abbreviated facelift. The O-Lift is a moderate facelift through a very short incision. We lift both the muscle and skin and yes, there is an incision. It’s hard to find, but it’s there, hidden within the natural folds of the ear and the side-burn area of the temple. I have revealed my results on our show The Doctors in only three days, but healing of ten days is more typical. We do this type of surgery on many women and men in their 40s and 50s. We often combine it with other procedures like blepharoplasty (eye lids) and forehead lifting through a scope with tiny incisions.

Traditional Facelift

When I perform a traditional face-lift, I am usually doing it for someone who has earned their lines, people in their 60s and 70s who have waited until they really needed it to correct deep furrows, heavy jowls and a collapsed neck with substantial banding. This patient is looking for improvement all the way from the Adam’s apple to the hairline. Our incision is similar to the O-Lift but extends around the ear lobe in a natural crease and runs up the back of the ear to, and along, the hairline. Both the skin and muscle are lifted in a vertical vector so that the face is lifted, not pulled. The result is a dramatic transformation that sometimes makes old friends gasp. While the improvement is dramatic, I am careful to attain a natural look that does not look “done.”

So, there you have it, the real deal in face lifting. When considering a procedure, be sure to ask questions to ensure realistic expectations, and when considering a plastic surgeon, I recommend an experienced board-certified specialist. It’s better to do it once and do it right than to attempt some half measure that may result in regret.

Dr. Ordon is medical director of The Plastic Surgery Institute in Rancho Mirage and co-host of The Doctors television show. The Plastic Surgery Institute can be reached at (760) 568.2211.

Sweeten Your Holidays

Sometimes we feel all of our efforts to stay in shape and eat healthily during the summer are slowly trumped by temptation of the holiday season’s treats and sweets.

Nutritionist Tiffany Dalton

Nutritionist Tiffany Dalton

Sugar can be the single ingredient in our diet that separates us from our skinny jeans. Since we would all like to have our cake and actually eat it too, here are some sugar alternatives that will help you alleviate the extra pounds, and better yet, may even provide a healthy dose of nutrition.

Stevia is a zero calorie, natural sweetener that can be used in anything from morning coffee to pumpkin pie. This is an ideal option for those who struggle with diabetes or blood sugar issues. Stevia comes from a plant, so is natural in origin; however, some packaged sources are not as healthy as they seem, as many commercial brands mix it with unnatural ingredients. Real stevia is a green leaf ground up into a powder which sometimes can have a bitter after taste that some don’t like. Improvements were made over the years to remove bitterness, resulting in a liquid extract. Sweet Leaf, a non-GMO brand with no additives, is my favorite and comes in different flavors to make baking even more fun.

Raw honey provides many health benefits. Used in many ancient medicinal remedies, it contains powerful antioxidants called polyphenols which help heal the body, anti-inflammatory properties, and even antimicrobial compounds that fight off bacteria, especially in the mouth.1 Take note that not all honey is the same. Manuka honey is ideal for most of the medicinal properties. If Manuka is out of budget, raw honey sweetens recipes and supplies high antioxidant content. Locally sourced, raw honey has been long thought to help with seasonal allergies and the immune system. Avoid regular store brand honey which is usually processed, as it is void of the health benefits and acts just like cane sugar.

Dates are the greatest source of nutrition of all the above-mentioned sugar alternatives. Dates supply calcium, iron, phosphorus, sodium, potassium, magnesium, and zinc. This autumnal fruit also contains vitamins such as riboflavin, thiamin, niacin, folate, and vitamins A and K. Dates have been reported to help with constipation as they also have high fiber content. Dates are not considered low in sugar by any means, but from a nutrition perspective, they beat plain sugar any day!

Coconut Sugar is the easiest replacement for white sugar in any recipe. You simply swap sugars in equal amounts. Derived from coconut water, it supplies electrolytes and is high in potassium and other nutrients. Since it also scores low on the glycemic index, you can keep blood sugar more stable and increase your nutrition at the same time.

Please know that if you are using regular sugar in your baking and cooking, the majority of today’s sugar usually comes from genetically modified beets and corn. Artificial sweeteners are no better, as they are toxic to the brain and body.

This season, create a more nutritious version of “treats you can’t say no to” by using one or a mix of these healthier options.

Tiffany is a certified nutrition consultant and functional diagnostic nutrition practitioner and can be reached at (760) 285.1221. www.GlutenFreeWithTiffany.com

Bright Eyes: More Than a Fresh Look

Interpersonal communication is such an important part of life. And we are naturally drawn to people’s eyes as the focal point. The eyes provide visual and emotional cues and other non-verbal information and are vital in communication. Thus, we naturally want our eyes to look and feel their best.

Cosmetic eyelid surgery restores your natural eyelid contour and refreshes your appearance; however, this common surgery does more than enhance your looks.

The eyelid skin is very unique, as it is the thinnest and most delicate on our body. Eyelid skin is normally smooth, but with time, the eyelid tissue stretches, the fat bulges, and the muscles weaken. These changes are most often caused by age, heredity and sun damage. Dermatochalasis, the medical term used for excess eyelid tissue, occurs in both the upper and lower eyelids. When the upper lid is affected, you may have a feeling of heaviness and the redundant tissue may interfere with your peripheral vision. You may experience forehead fatigue as your body attempts to use these muscles to lift the excess upper eyelid skin out of your field of view. Some may note the urge to tilt their chin up in order to see more clearly, or have the sensation that their eyes want to close on their own while reading. An upper eyelid blepharoplasty (eyelid lift) can help to alleviate these symptoms while also improving your appearance.

Some patients may also have ptosis (“toe-sis”), or a drooping eyelid. The muscle used to lift the upper eyelid is very delicate. With time, its attachment may become loose, causing the lid to droop. This drooping can be addressed with a ptosis repair. The repair can be performed with an incision on the inside of the upper eyelid, or through a skin incision. Your surgeon will help you determine if you have ptosis, and if so, which approach is most appropriate for you. At times, upper lid blepharoplasty or ptosis repair may be medically indicated if the patient meets certain criteria. A visual field test must be performed in the office to determine medical necessity.

A blepharoplasty may also be performed to reduce excess fat and skin in the lower eyelids. The surgeon makes incisions (either on the inside or on the skin of the lower lid) and excess tissue is removed. Incisions made inside the eyelid are not visible; incisions on the skin are barely visible and generally fade over time. The goal of surgery is to provide a more rested but natural appearance. Your surgeon will help you determine which approach is most appropriate for your surgery.

Eyelid surgery is performed on an outpatient basis. Patients may have the surgery with local anesthetic only, or they may receive intravenous sedation (twilight sleep) as well. Pre-operative preparation includes a thorough review of your medical and ophthalmic (eye) history as well as a review of your medication and over-the-counter supplements. After surgery, swelling and bruising are alleviated with ice packs. Most patients experience minimal down time and are able to return to many activities within a week. The results of surgery are generally long lasting, leaving patients looking refreshed, seeing clearly and feeling lighter and vibrant.

Dr. Hui is the founder of The Eyelid Institute in Palm Desert. She is an Oculoplastic surgeon and has a special interest in helping patients with eyelid, lacrimal and orbital conditions and can be reached at (760) 610.2677.

Beauty Tips to Remember

Are you often confused when buying beauty products? Do you reach for that product which advertises the most therefore capturing your attention? Or, do you head to the counters to buy the secret potion that a friend recommended while sharing that her wrinkles had disappeared overnight?

Whatever reason motivates your beauty purchase or anti-aging investment, here are some simple things to remember:

  • The most expensive on the market is not always the best. Many times products can be extremely close in formulation but just packaged differently. Some products have cleaner ingredients and a better delivery system.
  • Buy your skincare when there are free gift promotions so you can try free samples first to make sure you have no allergic reactions.
  • A facial once a month not only forces you to sit still; it gets the blood moving which is very good for your skin.
  • Our diet shows up on our faces, unfortunately! Watch what you eat and avoid diet drinks and fast foods. Think about the old saying, “You are what you eat.” It’s true!
  • Sleep is the cheapest form of an anti-aging product! Make sure you get your 8 hours of sleep if you can.
  • Alcohol, medication and cigarette smoking can promote early signs of aging as well.
  • Our Moms used items from the kitchen before there were fancy products available at the cosmetic counter. Sometimes just a little olive oil or coconut oil can ease the pain of dry hands or feet.

My favorite “go to” resource for beauty information is euromonitor.com. Below are some consumer industry trends I’d like to share. The beauty survey referred to in this article can be found on their website in its entirety.

The beauty space is turning green, and smart companies are taking part. Green features are secondary only to efficacy, suitability, and a quality-price balance in consumers’ decision-making, and are actually more important than low prices and strong brand names, according to the 2016 beauty survey results. So what are the best “shades” of green? In particular, “all natural” product claims matter to 50% or more of green-minded buyers in all markets, while other factors, like water efficiency, 100% organic, or botanically-derived ingredients exhibit regional appeal. 

It’s all about me! Consumer demand is moving from ‘suitable for me’ towards a ‘made for me’ level of customization. This is achieved through individual product formulations, digital consultation on brands’ and retailers’ websites and smart devices and applications that provide near constant feedback on efficacy. At the same time, consumers’ expectations for a healthy and extended youthful appearance continue to hold strong across many age groups.

Michele McDonough is a Strategic Consultant and Executive Recruiter in the field of health and beauty. She is also co-founder of Women’s Power Circle and can be reached at [email protected]

Guidelines to Your “Perfect Diet”

We would all love to find a convenient way to follow the “perfect diet,” after we figure out what that actually looks like. Many studies agreed on the same healthy diet philosophy. The most popular was published in 2014 by Yale University and identified ‘the best human diet for health’ was to simply eat whole foods.1 This traditional nutrient-dense approach to diet has proven to be effective for those who follow it. However, due to information overload in our society and lack of clear guidelines, implementing a whole food approach on a day-to-day basis can feel overwhelming and unattainable for many.

Here are some easy guidelines to simplify the process of mastering your optimal diet, despite your lifestyle:

Lower carb meals. Aside from some athletes, many health professionals suggest approximately 80% of your meals should lean towards having a lower, or ‘slower’ carbohydrate content.2,3 Slow means the carbohydrates have high fiber content which slow blood sugar spikes. A typical low carb lunch may consist of a large salad, chopped vegetables and beans or chicken. Tip: Don’t skip the healthy fats like olive oil-based dressing or added nuts and seeds.

1/2 plate full of vegetables. Your carbohydrates should come from mostly vegetables. This means replacing your bun and fries with lettuce wrap and a double side of sautéed broccoli. Easy!

Protein. The absolute best appetite suppressant known to date is protein. It also repairs tissues and sustains energy like nothing else. Prioritize and budget for high-quality of protein, especially if from an animal source. Plant-based proteins like beans, lentils, and seeds count too!

Nothing from a bag or a box. Probably not new advice to you, but track how many snacks you consume that are pre-packaged…replace those with veggies and dip, boiled eggs, homemade low-sugar trail mix…real food.

Limit alcohol to 2 days per week. Especially for fat loss; 1-2 drinks max. Nothing thwarts fat loss like alcohol. As a sugary additive to our diet at an average 7 calories per gram, it can easily put your body into fat-storing mode.

The secret behind the above guidelines is not so much that it is offering you the “perfect diet” (still worth following since perfect doesn’t exist!), but it is actually setting your body up for better digestion, increased metabolism for fat burning, and enhanced detoxification. When we provide the body with the optimal nutrition from real food, along with healthy lifestyle habits like exercise and well-managed stress, we can make it easy to manage detoxification, blood sugar and even an occasional ‘off the diet’ splurge.

Diet is at the root of health, so it must be a priority. Thankfully, unlike some life situations and environmental toxins, it is something we can control. Keep these simple guidelines in mind to easily improve and maintain your health.

Tiffany is a certified nutrition consultant and functional diagnostic nutrition practitioner and can be reached at (760) 285.1221.

1)http://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-032013-182351 2) http://lowcarbdoctors.blogspot.com/ 3) http://drhyman.com/blog/2015/08/20/slow-carbs-not-low-carbs-the-truth-about-low-carb-diets/

Summer Beauty Tips

Use non-comedogenic products. Non-comedogenic beauty products are designed not to clog pores which can lead to irritation and blemishes. This is important to remember for sunscreens, but may impact you more if you moisturize often and are prone to acne – especially in the summer. Hot and humid weather leads to sweat which takes a longer time to evaporate off your skin. Combining that with oily products isn’t exactly a party for your pores. Go the oil-free or non-comedogenic route to ward off pimples.

Stay moisturized with good clean/organic products. A faithful moisturizing routine can do so many beneficial things for your complexion. Your skin is a barrier that protects you from environmental factors like pollution, bacteria and moisture loss, and keeping it moisturized helps keep that barrier working properly. Dry skin is unhappy, damage-prone skin, so apply a light moisturizer to protect it from summertime drying agents like sunburn, salt and chlorine.

Exfoliate at the right times – and don’t overdo it! Not only will it help you maintain a fresh fake tan (when your dead skin cells flake off, the old tan will come off with it), but gentle facial exfoliation will help keep your skin free of clogged pores and create a better canvas for makeup application. However, keep in mind that exfoliation reveals new, sensitive skin that can be more prone to burning in the sun. Reserve your exfoliating habits for the evening (and not right before a special occasion), or for days when you aren’t heading straight from the shower to the pool.

Aloe can be your new best friend during the summer. It is a known anti-inflammatory that also provides moisturizing relief. Applying products containing aloe vera after sun exposure will calm and soothe your skin, leaving you far less likely to experience that awful scaly dryness that comes with summer. It’s also said to contain antioxidants that can help repair damaged skin and prevent free radicals from doing their undesirable work. Keep an aloe plant in your backyard or even your kitchen and use when needed!

Invest in moisturizers that work on wet skin when best absorbed. Don’t skip the after-bathing rehydration! Many brands now make body washes that provide hydration via their oil ingredients with many that you apply even before you towel off.

Buy quality sunscreens. Look beyond the SPF and buy quality sunscreens with safe ingredients. Reapply every hour or so, and if you take a dip in the water, reapply when you get out. Water attracts the sun (like snow), creating a glare that can cause sunburns.

Michele McDonough is a strategic consultant and executive recruiter in the field of health and beauty. She is also co-founder of Women’s Power Circle and can be reached at [email protected]

Benefits of Collagen: More than Skin Deep

The word “collagen” is derived from the Greek “kolla,” meaning glue. It is the most abundant protein in our body forming the musculoskeletal system and all connective tissue. Experts often refer to it as the fountain of youth. As we age, our body’s ability to make collagen begins to slow down. Consequently, our skin, hair, tendons, cartilage, bones, joints, organs, and intestines start losing their structure, causing signs of aging and poor health.

Collagen is made of primarily amino acids, many of which need to be obtained through diet. There are delicious foods that help replenish collagen, but supplementation may benefit you more efficiently and in more ways than just beauty.

Research shows our skin is made of approximately 70% collagen. In some studies, consumption of collagen peptides was seen to significantly reduce eye wrinkle volume by up to 20 percent and this effect was long-lasting.1 Other studies show how after 6 months of use, collagen led to a clear improvement of the skin appearance in women suffering from moderate cellulite2 and stretchmarks.

About 33% of collagen is made from the amino acids proline and glycine. Today, it can be difficult to obtain therapeutic amounts from diet alone. Hydrolyzed collagen protein (powder) is arguably the easiest way to increase collagen levels. Hydrolyzed simply means the proteins are broken down into easy-to-use molecules. Two highly reputable brands are Great Lakes and Vital Proteins (I have no affiliation with either). Taking 2 tablespoons at breakfast and at night have shown to be enough to experience benefits. There is virtually no taste or smell.

Bone broth, commonly used centuries ago and popular again today, is abundant in collagen, minerals, and other special anti-inflammatory properties. From your kitchen or health food store, it’s easy to sip on broth like tea, or use in soups and stir fry. Bone broth is high in protein and supports the immune system. It is particularly useful for gastrointestinal health and in reduction of inflammation.3

In our daily diet, fish, meat, bones, and organs are the best sources of collagen. Vegetarians can depend on beans, cheese, eggs and wheat germ. Here’s a great tip: Adding vitamin C from berries and greens will increase the utilization and production of collagen, in addition to the mineral copper, and sterols derived from aloe vera.4 You can get copper from sources such as sesame seeds and cashews.5

Aside from the beauty benefits, collagen’s amino acid profile can be life changing for everyone. It supports mood, gut health, joint6 and post-exercise pain.7 Its high content of proline, shown to be significantly present in wound healing,8 and glycine, an important inhibitory neurotransmitter as well as a natural anti-inflammatory9 are of significant interest in research today.

With consistent use, anti-aging, improved digestion, detoxification, restful sleep7, brain function, as well as weight loss are all benefits of collagen consumption you can look forward to experiencing. For those of us who want to beat the clock, stay pain-free and look younger, collagen may just be your secret weapon.

Tiffany is a certified nutrition consultant and functional diagnostic nutrition practitioner and can be reached at (760) 285.1221. www.GlutenFreeWithTiffany.com

References: 1) https://www.ncbi.nlm.nih.gov/pubmed/23949208, 2) https://www.ncbi.nlm.nih.gov/pubmed/26561784, 3) https://www.ncbi.nlm.nih.gov/m/pubmed/11035691/, 4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4345938/, 5) https://www.ncbi.nlm.nih.gov/pubmed/6110524, 6)http://www.scielo.br/pdf/rbgg/v19n1/1809-9823-rbgg-19-01-00153.pdf, 7)https://www.ncbi.nlm.nih.gov/pubmed/18416885, 8) https://www.ncbi.nlm.nih.gov/pubmed/23508578, 9)https://www.ncbi.nlm.nih.gov/pubmed/12589194