- Four Types of Botulinum Toxin Injections
- Advantages and Disadvantages of Each Type of Botox
- What can I do if something goes wrong with my injection?
- The New Guide to Botox: Which Type Is Best for You?
- Baby Botox: Best for People Looking to Prevent Signs of Aging
- BlowTox: Best for People Looking to Stop Scalp Sweating
- BroTox: Best for Guys Who Want to Get in on the Anti-Wrinkle Treatment
- NewTox (Jeuveau): Best for Ex-Botox Users
- Budget Botox: A Dangerous Cosmetic Trend to Avoid
- Xeomin: What is it and How Xeomin Compares to BOTOX®
- Better or worse then Botox?
- What are the risks?
- How much does Xeomin cost?
- What is Botulinum toxin type A?
- What Types of Wrinkles can Botox-type Injectables Treat?
- What is the Difference Between Botox, Dysport, and Xeomin?
- Choosing a Provider for Injectable Treatments
- What to Expect During Treatment
- How Long Do the Results Last?
- What Else Can Neurotoxins Help With?
- Xeomin vs Botox vs Dysport Explained
- Get Your FREE Botox Best Practices Ebook
- Executive Summary Xeomin vs Botox vs Dysport
- Explaining Xeomin® vs. Botox®
Four Types of Botulinum Toxin Injections
The substance used in Botox procedures comes from the bacterium Clostridium botulinum. Botox works by blocking nerve signals from the nerves to muscles in a particular area of the body. Doctors inject Botox into the forehead, around the eyes and other areas for cosmetic use. Muscles don’t slouch or sag once the nerve signals are blocked, resulting in reduced appearance of wrinkles after the injection. There are medical uses of Botox as well to help with spasticity after a stroke and treat migraines or excessive underarm sweating.
Below are the four different types of botulinum toxin injections:
- Xeomin; and
Some common side effects of Botox injections include headache, bruising around the injection site and eyelid drooping.
There are also serious side effects reported in some cases like:
- trouble breathing;
- trouble talking or swallowing;
- problems with vision;
- botulism; and
- heart problems.
In rare circumstances, people have died from complications after a Botox injection.
Advantages and Disadvantages of Each Type of Botox
Dysport works slightly quicker than Botox, but Botox may last longer than Dysport. Costs may also be greater for Botox than Dysport. Both Botox and Dysport advertise results for up to four months.
Some believe Xeomin may last slightly longer than Botox, according to the American Academy of Facial Esthetics. Xeomin contains no additives and thus does not require refrigeration. Some have suggested that people are less likely to become resistant to Xeomin injections because of its purity. Botox, Dysport and Xeomin are all made from botulinum toxin type A, while Myobloc contains botulinum toxin type B. Some have suggested that Myobloc may help with people who’ve become immune to Botox and Dysport.
What can I do if something goes wrong with my injection?
People suffering from injuries because of a problem with a treatment or surgery can file a medical malpractice case against the treating medical professional. To win a malpractice lawsuit, plaintiffs need to prove that the medical professional violated the standard of care for their field.
The standard of care means the level and type of care that a reasonably competent and skilled healthcare professional with a similar background would have provided under the same or similar circumstances.Medical malpractice cases can be difficult to pursue because plaintiffs need to collect medical records and present other evidence to prove a professional violated the standard of care.
Hiring a lawyer may be the best way to build and present a strong case. Ryan, LLP is committed to helping patients seek justice after a botched procedure that leads to serious side effects and injuries. Contact our office in Cleveland, Ohio at 877-864-9495 to set up a consultation to review your case.
About the author of this article: Thomas Ryan
The New Guide to Botox: Which Type Is Best for You?
When someone says they “get Botox,” it may not exactly mean what you think. Indeed, there are four such injectables on the market: Botox, Dysport, Xeomin, and now Jeuveau, and all of these use botulinum toxin to smooth out wrinkles and lessen the signs of aging in the same way, though there are many misnomers about how that happens.
“Many people think that they’re fillers, but they’re paralyzing agents. These injectables stop the transmission of the electrical impulses from the nerve endings to the muscles, meaning the muscles cannot contract normally,” says Phillip R. Langsdon, MD, facial plastic surgeon in Germantown, Tennessee, and president of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). When you can’t move the muscle, the expressions you make with your face can’t create the fine lines and wrinkles that etch in over time to take up permanent residence on your face. (Though when done right by a trained professional, you won’t look “frozen” or expressionless.)
Within the “Botox” umbrella, there’s been a growing interest in specific types of treatments using these injectables, including “Baby Botox,” “BlowTox,” “BroTox,” “NewTox,” and “Budget Botox.”
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Here’s what they all mean, how to choose the right treatment for you, and must-know warnings before you go:
Baby Botox: Best for People Looking to Prevent Signs of Aging
Depending on who you ask, you’ll get differing opinions on exactly when someone would benefit from starting Botox.
“For younger patients, Botox my help prevent or slow down the progression of lines, particularly around the eyes, eyebrows, and forehead,” says Patrick J. Byrne, MD, professor and director in the division of facial plastic and reconstructive surgery at the Johns Hopkins University School of Medicine in Lutherville, Maryland. (“Younger” is subjective, but Dr. Byrne says that they see some patients in their late twenties.)
“’Baby Botox,’ is a term that often refers to the desire for subtle, rather than more dramatic changes,” says Byrne. In this event, the doctor would inject smaller amounts of Botox. “Baby Botox is really a reflection of an ongoing trend towards broadening the market to offer smaller, more subtle changes to a larger pool of interested patients,” he says. One place this can be done well is when used to lift the brows. “In younger patients, Botox can be utilized to affect the balance of muscles. We can lift the brows, shape, and give them contour,” says Byrne.
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BlowTox: Best for People Looking to Stop Scalp Sweating
Dealing with an overly sweaty scalp? Botox may be able to help. Dubbed “BlowTox,” this is the nickname for Botox injected into the scalp to prevent perspiration.
For some people, this excessive sweating is a medical condition, called hyperhidrosis, points out the International Hyperhidrosis Society. For others, it’s a matter of keeping a sweaty scalp at bay to preserve a hairstyle.
When your scalp sweats — such as in the summer heat or after a hard workout — hair can fall limp and lifeless. For women who get routine blowouts (a salon treatment where the hair is professionally blow-dried), “BloxTox” is attractive. “There’s been a growing trend to superficially inject Botox into the scalp to help your blowout last longer,” says Joshua Zeichner, MD, director of cosmetic and clinical research in dermatology at Mount Sinai Hospital in New York City.
It makes some sense: “Botox has been reported to reduce both sweating and oil production. In fact, it’s FDA-approved for the treatment of excessive underarm sweating (hyperhidrosis),” says Dr. Zeichner. Injections block the chemical messenger that triggers sweat glands, the International Hyperhidrosis Society explains. When you reduce oil and sweat in the scalp, your hair won’t be bogged down with grease and wetness, he says.
The downside? Treatments are expensive — upwards of $1,000, says Zeichner — because a lot of Botox is needed to cover such a large area. Results last three to five months, so you’ll need two to four treatments per year.
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BroTox: Best for Guys Who Want to Get in on the Anti-Wrinkle Treatment
Don’t think that botulinum toxin therapy is just for women. In fact, the most common nonsurgical procedure for men is Botox and fillers, according to a 2018 AAFPRS report. Of the plastic surgeons surveyed, they said that their male patients used rejuvenating treatments with the goal of staying “relevant and competitive at work.”
One of the most popular areas to target? The “11s.” “Many men have deep frown lines between the brows. When those lines are deep, it makes a person look older or even angry,” says Dr. Langsdon. He also says that many men may also get Botox in both the crow’s feet and frown line areas, which may have the result of lifting droopy brows — and making someone appear more awake or less serious.
RELATED: 5 Quick Facts About Treating Wrinkles With Botox
NewTox (Jeuveau): Best for Ex-Botox Users
The latest buzzword refers to the newest neurotoxin injectable on the market: Jeuveau. A press release from February 1, 2019, announced that maker Evolus secured approval from the U.S. Food and Drug Administration (FDA) for the treatment of moderate-to-severe glabellar lines, which are the lines between the brows.
Jeuveau is still new, but experts are cautiously optimistic. “Although Jeuveau is almost identical to Botox, it seems to work better for most people,” says Ben Talei, MD, owner of the Beverly Hills Center for Plastic and Laser Surgery in California. One reason: Long-time users of Botox may find that they become resistant to it over time. “We hear patients tell us all the time that Botox used to work better for them years ago, despite the fact that we’ve been weakening the muscles over time with the injections,” he says. In this case, you may want to ask your doctor if making the switch is right for you.
Another potential perk: Jeuveau is thought to work quickly, says Dr. Talei. In one study published in March 2019 in the journal Dermatologic Surgery, the researchers reported that people using Jeuveau saw a “marked difference” in aesthetic improvements during the first post-treatment visit on day two, compared with the placebo group.
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Budget Botox: A Dangerous Cosmetic Trend to Avoid
In a disturbing trend, people may turn to DIY Botox, learning how to inject the toxin into their face via online videos. A study published in August 2018 in the journal Plastic Surgery outlined the problem. Researchers looked at four online discussion forums on the topic and noted that prospective patients were buying unregulated Botox kits online, watching YouTube tutorials, and downloading “Botox injection maps” from the internet. More worrisome, the authors pointed out that people knew that doing so wasn’t safe, but justified that risk with an explanation that they have agency over their own bodies and decisions.
It goes without saying that this isn’t safe; Botox requires a properly trained doctor. There’s also the concern that formulations purchased online are counterfeit. “Injecting may look easy, but to inject it safely requires in-depth medical knowledge of how the body works,” notes the American Academy of Dermatology (AAD). For your health and safety — and best outcome — seek out an appropriately trained and licensed physician, says Byrne. To find out if the healthcare professional administering your Botox is legit, take advantage of the free “Is My Doctor Board Certified?” search tool offered on CertificationMatters.org.
Xeomin: What is it and How Xeomin Compares to BOTOX®
Xeomin (incobotulinumtoxinA), made by Merz Pharmaceuticals, is approved by the US FDA for the treatment of adults with cervical dystonia or blepharospasm and Moderate to severe frown lines between the eyebrows. IncobotulinumtoxinA is made from the bacteria that causes botulism. Botulinum toxin blocks nerve activity in the muscles, causing a temporary reduction in muscle activity.
FDA approval of XEOMIN, was based on the results of two U.S. clinical trials. A study cited in the Journal of Neurological Sciences on the efficacy and safety of XEOMIN found it showed “non-inferiority” to Botox when used in the same doses to treat cervical dystonia. It concluded that XEOMIN is a safe and effective treatment for the disorder.
Xeomin has now been approved for some cosmetic indications – Moderate to severe frown lines between the eyebrows. Similiar to other drugs in this category, including Botox and Dysport, that also have FDA approval for the treatment of facial wrinkles. Now that Xeomin is available and FDA approved, doctors can use it both on-label and off-label to treat the same facial lines treated by Botox and Dysport, including frown lines, crow’s feet and forehead wrinkles.
Worldwide, more than 84,000 people have been treated with Xeomin injections. The U.S. is actually the 20th country to approve this new drug. It is available in 50-unit and 100-unit vials.
Better or worse then Botox?
Xeomin is the first one that does not need to be refrigerated before use, which may simplify distribution. Xeomin is also has no additives, just botulinum toxin type A. This may mean that there is less risk of developing antibodies against Xeomin than other available neurotoxins. The body develops antibodies in response to a foreign invader and attacks. In theory, antibodies could prevent a neurotoxin from having its desired effects. The effects of Xeomin occur within one week, and the results last from three to six months, making it comparable to Botox in terms of both onset and duration of action. Xeomin should not be used interchangeably with other botulinum products.
What are the risks?
There is a risk that all botulinum toxin products may spread from the area where they were injected to other parts of the body, causing potentially life-threatening swallowing and breathing problems. This was predominantly seen in children treated with Botox off-label for cerebral palsy. These issues have not been reported among people who received botulinum products for cosmetic uses or to treat blepharospasm.
Other risks may include bleeding and bruising at the injection site and allergic reactions such as itching, swelling or shortness of breath. Your doctor should discuss all the potential risks of this procedure with you during your consultation.
When Xeomin is used to treat cervical dystonia, side effects include neck pain, muscle weakness, injection site pain and musculoskeletal pain. When used to treat blepharospasm, the most common side effects of Xeomin were eyelid sagging, dry eye, dry mouth, diarrhea, headache, visual impairment, shortness of breath (dyspnea), and upper respiratory infections.
How much does Xeomin cost?
Xeomin costs will likely be comparable to Botox if not slightly lower. Exact price points are not yet available since Xeomin was so recently approved for use in the U.S. If your doctor suggests Xeomin, make sure to get accurate pricing information before booking your appointment.
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What is Botulinum toxin type A?
Botulinum toxin type A is an injectable neurotoxin, better known under brand names such as Botox Cosmetic®, Dysport®, and Xeomin®. Neurotoxin treatments are the most popular single cosmetic procedure in the U.S. and are mainly used to smooth dynamic wrinkles, or those wrinkles that form as a result of facial movements like frowning, squinting, smiling, and other expressions we tend to make day after day. Treatment works by blocking nerve impulses to the muscles, causing them to relax. As a result, your expressions soften and the dynamic wrinkles are greatly reduced.
What Types of Wrinkles can Botox-type Injectables Treat?
Botox-type injectables can help an adult patient of any age improve his or her appearance, not only imparting a more youthful look, but also alleviating an overly concerned look, helping you look better refreshed or even more pleasant. The most commonly treated areas are those where muscle activity influences facial features, such as the following:
- Glabellar lines (a.k.a. “elevens” or frown lines)
- Wrinkles around the eyes, such as crow’s feet
- Forehead creases
- Corners of the mouth
- A “cobblestoned” appearance to the chin
What is the Difference Between Botox, Dysport, and Xeomin?
Now you know that each of these products contain the same active ingredient: botulinum toxin type A, and are designed to address the same types of wrinkles and other cosmetic concerns. So how are they different? The main distinction lies in their formulation, which influences the dosage used, how much the product spreads, and how quickly a patient might see the results. For example, Botox Cosmetic is formulated with an accompanying protein. Dysport contains a smaller version of a similar protein, while Xeomin doesn’t contain an accompanying protein at all. All three products are FDA approved and have been used safely and effectively for years. Which of these products is best for you will depend on your unique anatomy, your goals, and your cosmetic surgeon’s recommendations.
Choosing a Provider for Injectable Treatments
Many people think that because Botox is advertised in day spas and other non-medical offices, botulinum injections are on the same level as a manicure, facial or haircut. We cannot stress enough that this is not the case! Though non-surgical, injections are a medical procedure that requires specific training, knowledge and skill to administer safely and effectively.
When selecting a provider for injectable treatments, give your decision the same level of care and scrutiny that you would for a surgical procedure. While many doctors begin advertising Botox treatments after attending a weekend course in injectables, ABCS board certified cosmetic surgeons receive specific training performing neurotoxin injections during their year-long cosmetic surgery fellowship. Choosing a board certified cosmetic surgeon means choosing a Botox provider with an extensive knowledge of facial anatomy, a well-developed aesthetic eye, and a surgeon’s skill and precision.
Whomever you choose, make sure your provider has a proven background in cosmetic medicine as well as training and substantial experience administering botulinum toxin injections. Ask to see before & after photos of that provider’s patients. If an R.N. or physician’s assistant will be performing your injections, that person should be working closely under the supervision of a board certified cosmetic surgeon or other qualified physician.
What to Expect During Treatment
Botulinum toxin injections are non-surgical and typically completed during an office visit. Your initial treatment will begin with a consultation, during which you will meet with your cosmetic surgeon to discuss your concerns and goals.
During your consultation, your cosmetic surgeon will evaluate your area of concern and go over your medical history. Even though there is little risk of major complications for most patients, it is still imperative that you share your medical history fully and openly with your provider before treatment, as certain allergies, skin and neurological conditions, or medications can make treatment unsuitable for a patient. For instance, you need to tell your cosmetic surgeon if you have been taking NSAIDs (e.g., aspirin, ibuprofen, naproxen) or blood thinners.
Your Botox-type injectable treatment
Just before the actual treatment, you may be given a topical anesthetic to numb the area prior to injection, though many patients find this unnecessary, as the needles used to inject botulinum toxins are very thin and the injections are not very deep. Your provider will reconstitute the botulinum toxin into a solution, and inject this solution into the muscle at strategic points. Most patients describe a pinching feeling during the injection, though not much pain.
You will be able to go back to your normal activities right after treatment, but your cosmetic surgeon may ask you to take the day off from exercise or other strenuous activity, and to keep your head upright for the rest of the day. Mild redness, swelling at the injection site, and bruising are the most common side effects.
Following treatment, you will not see results immediately. This is expected, so do not worry that treatment hasn’t worked. Depending on the patient, product used, and area treated, final results are typically reached 3 to 7 days after initial treatments. If this is your first botulinum toxin treatment, your cosmetic surgeon may initially inject a more conservative amount and touch up the results during a follow up treatment. This helps to ensure natural, optimal results without the risk of over-treating an area.
How Long Do the Results Last?
The wrinkle-reducing effects from botulinum treatments will vary depending on the patient, the area treated, and the product used, but results will typically last anywhere from 3 to 6 months. To maintain your results, your cosmetic surgeon will simply repeat treatment, adjusting dosage and techniques as necessary to ensure optimal results.
What Else Can Neurotoxins Help With?
While botulinum toxin type A is most commonly used to treat facial wrinkles, cosmetic surgeons can also use neurotoxins to address other aesthetic concerns that are associated with nerve and muscle activity:
- Reduce excessive sweating. Botulinum type A injections can be used to interrupt the nerve impulses that activate the sweat glands, helping alleviate embarrassment from excessive sweating on the armpits, hands or feet.
- Soften vertical neck bands. If you are bothered by prominent vertical bands on your neck, botulinum toxins can be used to relax the responsible muscles and give your neck a smoother, softer appearance.
With an experienced, qualified provider, Botox-type injectables provide natural-looking rejuvenation with a safe, convenient procedure with virtually no downtime. The best way to learn whether you are a good candidate for botulinum toxin injections is to meet with a board certified cosmetic surgeon for a consultation. Use our ABCS Find-a-Surgeon tool to locate a cosmetic surgeon near you.
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Xeomin vs Botox vs Dysport Explained
Xeomin is an incobotulinumtoxinA product and is a competitor to the more recognized Botox Cosmetic and also Dysport. The IAPAM queried its faculty for an overview of the differences between the 3 products. All the experts we queried agreed that the key to using any of these products: Botox vs Dysport vs Xeomin is to first engage in a comprehensive injectables training program that includes all three as part of the didactic.
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Executive Summary Xeomin vs Botox vs Dysport
- The main difference between Xeomin and Botox or Dysport, is that Xeomin contains just one ingredient: botulinum toxin A.
- The manufacturing process is slightly different with all 3, which leads to some potential, subtle differences in clinical practice.
- Xeomin is a “naked injectable,” meaning that it does not contain any additives. A benefit of a pure-form injectable is that the human body is less likely to become resistant to it. Some patients have developed antibodies to Botox and Dysport.
- Xeomin is the only one of the three (Xeomin, Botox and Dysport) injectables that does not need to be refrigerated before use, due to its lack of additives.
- The cost of Xeomin is roughly the same as for Botox at $5.00-5.40 per unit. Dysport is about $3.99 per unit.
- Patients average 20 units of Xeomin per visit, vs. 20 units of Botox and 40 units of Dysport.
- The average retail cost to a patient in the US, for a Xeomin treatment, is between $300.00 – $400.00 every 3 months based on the recommended dose of 20 Units per treatment session.
- Xeomin might have the slowest “onset” of action of the 3 (Dysport onset in 24 hours, Botox onset in 72 hours, and Xeomin onset in 4 days.)
- Xeomin may be “mildly more convenient” than Botox or Dysport, as the “product’s lack of complex proteins will help prevent antibody formation, or resistance to neuromuscular treatment with botulinum type A toxin, in patients being treated for neuromuscular conditions.”
- Neurotoxins diffuse differently, in part because Botox and Dysport have protective proteins clustered around the active part of the molecule, while Xeomin has no protective proteins.
- Botox has a full complement of protective proteins and weighs about 900 kD. Dysport is a mixture of 500 kD and 300 kD complexes of protective proteins and botulinum toxin A. Being heavier, these complexes migrate more slowly than Xeomin/NT-201, which is BTX-A without protective proteins. Conversely, you will have less precision.
- Dysport has been shown to “drift” or diffuse more than Botox, increasing the chances of an accidental droopy eyelid or unintentional relaxation of a neighboring muscle due to diffusion of the product.
- Botox and Dysport are not interchangeable because the products are dosed and injected differently.
For a complete overview on Xeomin: Instructions for Preparation, Dosage and Administration, please visit https://iapam.com/xeomin-incobotulinumtoxina
Explaining Xeomin® vs. Botox®
Aesthetic medicine now uses botulinum toxin regularly in treating a variety of skin and muscle problems. Xeomin and Botox are two commonly used preparations, and in this article, we will review the similarities and differences between these two preparations.
There are a number of similarities between Xeomin and Botox. These are listed below –
1. Both Xeomin and Botox consist of the same basic ingredient – Botulinum toxin A, a toxin that this produced by the Clostridium botulinum bacteria. This neurotoxin acts by blocking the neuromuscular junction and has an effect on the skin and muscles it is injected into.
2. Both Xeomin and Botox exert their effect in around 7 days after it has been injected, with the effects lasting up to 6 months. The overall effect that results from Xeomin and Botox are the same.
3. Both Xeomin and Botox are measured in the same units, making it easy for the treating physician to measure up the required dose.
4. The cost of Xeomin and Botox are comparable, making the administration of either drug a choice that can lie with the physician or the patient.
There are only a few differences between Xeomin and Botox. These have been listed below –
1. The basic structure of Xeomin and Botox are different, even though the toxin is the same. Botox is encased within a protein structure, while Xeomin lacks this protein covering and is, in fact, the ‘naked’ botulinum toxin. This protein casing on Botox can cause immune reactions that can eventually block the actions on botulinum toxin when injected. It is believed that this is an advantage that Xeomin bears over Botox as it results in no antibody formation with repeated injections of Xeomin.
2. Botox is stored in a freezer or at temperatures between 2 to 8°C. It, therefore, requires it to be transported in a freezer. On the other hand, Xeomin does not necessarily need to be stored in a freezer or refrigerator, making transporting the product a lot easier and even cheaper.
3. is manufactured by Merz Pharma while Botox is manufactured by Allergan.
In most cases, Xeomin can be offered if patients develop antibodies to Botox.
For more information on the IAPAM Aesthetic Medicine Symposium with Botox Training, please call 1-800-219-5108 x704 or e-mail us at: [email protected]
Please note: Botox, Allergan Botox Cosmetic and Juvederm are registered trademarks of Allergan, Inc. Dysport, Restylane and Perlane are registered trademarks of Galderma. Xeomin is a registered trademark of Merz Pharmaceuticals, LLC.
DISCLOSURE OF UNLABELED USE
This document contains a discussion of agents that are not indicated by the U.S. Food and Drug Administration. The International Association for Physicians in Aesthetic Medicine (IAPAM), Allergan, Inc., and Medicis, Inc., do not recommend the use of any agent outside of the labeled indications. The opinions expressed in this document are those of the contributors and do not necessarily represent the views of the IAPAM, Allergan, Inc. or Medicis, Inc. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Copyright, Legal Notice and Disclaimer
The information presented in this document is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used without evaluation of their patients’ conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. This publication is protected under the US Copyright Act of 1976 and all other applicable international, federal, state and local laws, and all rights are reserved, including resale rights: you are not allowed to give or sell this e-book to anyone else. No part of this e_report may be reproduced in any form by any means (including electronic, photocopying, recording, scanning, or otherwise) without prior written permission of the publisher.
Please note that much of this publication is based on personal experience and anecdotal evidence. Although the author(s) and publisher have made every reasonable attempt to achieve complete accuracy of the content in this text, they assume no responsibility for errors or omissions. Also, you should use this information as you see fit, and at your own risk. Your particular situation may not be exactly suited to the examples illustrated here; in fact, it’s likely that they won’t be the same, and you should adjust your use of the information and recommendations accordingly.
Any trademarks, service marks, product names or named features are assumed to be the property of their respective owners and are used only for reference. There is no implied endorsement if we use one of these terms. Please note that the information presented on these pages is for informational purposes only. The IAPAM (or its affiliates), shall not be liable to anyone for any loss or injury caused in whole or in part by your use of this information, or for any decision you make or action you take in reliance on information you received from this text. This text is not intended to replace legal, medical, accounting or other professional advice, and is only meant to be used as a guideline for the reader. Any information in this publication should not be considered a substitute for consultation with a physician to address individual medical needs.