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R E G I S T R AT I O N FORM AN INTENSIVE HANDS-ON CADAVER WORKSHOP F COURSE DIRECTOR LAB FACULTY NON-PROFIT ORG. 1455 Contemporary Surgery of the Aging Face CONTEMPORARY ST. LOUIS, MO Laxmeesh Mike Nayak, MD Gregory H. Branham, MD, FACS U.S. POSTAGE PAID PERMIT NO. Chief, Facial Plastic and Reconstructive Surgery Chief, Division of Facial Plastic Surgery November 18-20, 2005 Department of Otolaryngology Washington University School of Medicine Please print A Saint Louis University School of Medicine St. Louis, Missouri Name ________________________________________________________________________ Degree ______________________________ Specialty __________________________________ C St. Louis, Missouri FEATURED SPEAKER Jeannie Chung, MD Associate Staff, Department of Otolaryngology Head and Neck Surgery SURGERY Oscar M. Ramirez, MD, FACS Massachusetts Eye and Ear Infirmary OF THE Mailing Address ________________________________________________________________ Assistant Clinical Professor Boston, Massachusetts City ________________________________________________________________________ U Johns Hopkins University School of Medicine Baltimore, Maryland Robert Glasgold, MD Glasgold Group Plastic Surgery AGING FACE State ____________________ Postal Code __________________ Country ________________ FACULTY and Assistant Clinical Professor of Surgery Includes Contour Threads Certification Phone __________________________________ Fax __________________________________ L William J. Binder, MD, FACS Associate Clinical Professor UMDNJ-Robert Wood Johnson Medical School Highland Park, NJ Course Director: Laxmeesh Mike Nayak, MD Department of Head & Neck Surgery E-mail ______________________________________________________________________ Samuel M. Lam, MD Tuition Fees: Course # P111805 T UCLA School of Medicine, Los Angeles, California Lisa M. Donofrio, MD The Lam Facial Plastic Surgery Center Plano, Texas K $2195 Physician Fee Associate Clinical Professor, Dermatology Brock D. Ridenour, MD, FACS K $1495 Residents/Fellow/PA (Letter of verification required) Y Yale University School of Medicine New Haven, Connecticut Ridenour Plastic Surgery K $0 Special Event Dinner - November 18, 2005 (Check if you will attend) St. Louis, Missouri Mark Glasgold, MD, FACS Frank Simo, MD Practical Anatomy & Surgical Education Glasgold Group Plastic Surgery Special Needs: Please indicate any special needs (i.e. dietary, etc.) Facial Plastic & Cosmetic Surgery Center and Assistant Clinical Professor of Surgery UMDNJ-Robert Wood Johnson Medical School St. Louis, Missouri ______________________________________________________________________________________ Highland Park, New Jersey ______________________________________________________________________________________________ Method of Payment: Make check payable to Saint Louis University. St. Louis, MO 63108-3413 An Intensive Hands-On Cadaver Workshop CONTEMPORARY K Check Enclosed 3839 Lindell Boulevard Includes Contour Threads Certification November 18-20, 2005 OR AGING FACE Charge K K K K SURGERY November 18-20, 2005 - St. Louis, MO USA OF THE Account Number __________________________________________ Exp. Date ____________ Cardholder’s Name ______________________________________________________________ Cardholder’s Address (if different than participant) __________________________________________ PRESENTED BY City ________________________________________________________________________ State ____________________ Postal Code __________________ Country ________________ Signature______________________________________________________________________ Mail completed registration to: Practical Anatomy & Surgical Education, Attn: Tammi Mooshegian, 3839 Lindell Blvd., St. Louis, MO 63108 USA Phone: 314-535-4000 Fax: 314-535-8214 E-mail: firstname.lastname@example.org Website: http://pa.slu.edu SCHEDULE and LECTURES GENERAL I N F O R M AT I O N E D U C AT I O N A L OBJECTIVES FRIDAY, NOVEMBER 18, 2005 SATURDAY, NOVEMBER 19, 2005 This workshop has been designed to provide plastic surgeons, facial plastic surgeons, and WORKSHOP LOCATION cosmetic surgeons with an overview of contemporary surgical rejuvenation of the aging face. 7:00 am Registration & Continental Breakfast 7:00 am Sign-in & Continental Breakfast This workshop will be conducted at The Practical Anatomy & Surgical Education Center located at 3839 Special attention has been directed toward restoring youthful volumes and contours to the aging Lindell Boulevard, St. Louis, Missouri 63108-3413. midface, jawline, and neck. The participants will have the opportunity to learn and enhance their 7:45 am Welcome & Introductions L. M. Nayak 7:30 am Alloplastic Implants in Aesthetic Contouring of the Face W. Binder CANCELLATION POLICY skills in a variety of procedures on the brow, midface, lower face, and neck. By completing this 8:00 am Three-Dimensional Brow and Forehead Rejuvenation O. Ramirez 8:15 am Alloplastic Implants Video Demonstration W. Binder workshop, participants will learn state of the art techniques in the following procedures: Cancellations received by November 4, 2005 will be refunded in full; those received after that date are 8:30 am Endoscopic Browlift Video Demonstration O. Ramirez 9:00 am Hands-On Implantology Lab All Faculty subject to a $100 administrative fee. No refunds will be issued for cancellations received after November G endoscopic brow and midface lifting 10:15 am Break and Exhibits 11, 2005. The conference is not responsible for travel expenses incurred. In the event the conference is G restoring facial balance through facial implants 9:15 am Hands-On Endobrow Lab - Group A Percutaneous Cheeklift/Browlift - Group B L. M. Nayak 10:30 am Fat Rebalancing and Autologous Fat Transfer L. Donofrio cancelled, the tuition fee and flight transfer fee (original receipt required) are reimbursable. G restoring facial balance through autologous fat transfer G open facelifting 10:30 am Break & Exhibits 11:15 am Fat Transfer/Microliposuction Video Demonstration L. Donofrio PLEASE NOTE G percutaneous brow and midface lifting, with and without Contour Threads 12:00 pm Lunch Lecture: Harvesting Autologous Fat: Technical Aspects L. M. Nayak If you have NOT received confirmation of registration prior to your departure, contact Practical 10:45 am Hands-On Endobrow Lab - Group B Anatomy. Registration cannot be processed until full payment is received. Practical Anatomy is not The objectives will be met in part by performing the procedures on specially prepared cadavers. Percutaneous Cheeklift/Browlift - Group A L. M. Nayak 12:45 pm Hands-On Fat Rebalancing Lab All Faculty responsible for expenses incurred by individuals who are not confirmed and paid-in-full. The cadavers used are extremely flexible and “life-like”. 12:00 pm Lunch 2:00 pm Break & Exhibits ACCOMMODATIONS 1:00 pm Endoscopic Midface Rejuvenation O. Ramirez 2:15 pm Complementary Fat Grafting M. Glasgold For the convenience of our attendees, a block of discounted rooms has been set aside at three hotels 1:30 pm Endoscopic Midface Rejuvenation Video Demonstration O. Ramirez 2:45 pm SMAS Facelifting L. M. Nayak within 5 miles from the workshop location. MISSION STATEMENT: Practical 2:15 pm Hands-On Endoscopic Midface Lift Lab - Group B 3:15 pm SMAS Facelift Video Demonstration L. M. Nayak Chase Park Plaza $149 - 1 Bedroom Suite Anatomy and Surgical Education, Hands-On Percutaneous Techniques - Group A All Faculty 4:00 pm Hands-On SMAS Facelifting Lab All Faculty 212 N. Kingshighway, St. Louis, MO 63108 Center for Anatomical Science and Phone: (877) 587-2427 Fax: (314) 633-3003 Website: http://www.chaseparkplaza.com Education, Saint Louis University 5:15 pm Adjourn School of Medicine, is dedicated to Water Tower Inn at Saint Louis University $75 - Please be sure to mention Booking #800 the development and presentation of 3545 Lafayette Ave., St. Louis, MO 63104 innovative medical health and SUNDAY, NOVEMBER 20, 2005 science workshops. Practical Phone: (314) 977-7500 Fax: (314) 977-7505 Website: http://www.slu.edu/events/wti.html Anatomy strives to promote the 7:00 am Sign-in & Continental Breakfast The Parkway Hotel $109 - Please be sure to mention the name of the workshop for group rate. concept of lifelong learning by 4550 Parkway Blvd., St. Louis, MO 63108 utilizing the latest technology to 7:30 am The Ramirez Facial Threadlifting O. Ramirez Phone: (314) 256-7777 or (866) 314-7700 Fax: (314) 256-7710 Website: http://www.theparkwayhotel.com connect young people, residents, healthcare professionals and 8:15 am CME Workshop Adjourns For information on alternative hotels, contact the Course Manager. surgeons, to world-class experts and Make reservations directly with the hotel. Room reservations are NOT made through the Practical faculty. 8:15 am Contour Threads Certification Course (CME credit will not be awarded for this activity) Anatomy office. Do not make airline reservations until you have received written confirmation of 12:00 pm Lunch placement in the workshop. 12:30 pm Contour Threads Certification Course (cont.) SPECIAL EVENT DINNER 1:45 pm Course Adjourns A special dinner is planned for Friday, November 18, 2005, at a popular St. Louis restaurant. Participants are welcome to enjoy this special evening at no additional cost. If you wish to bring a guest, there will be an additional charge of $65 per guest. Transportation will be provided from the conference hotels. 3:30 pm Break and Exhibits 3:45 pm Hands-On Endoscopic Midface Lift Lab - Group A CONTINUING FACULTY DISCLOSURE POLICY E D U C AT I O N VALIDATION OF CONTENT CONTINUING EDUCATION F or information on our upcoming Hands-On Percutaneous Techniques - Group B It is the policy of Saint Louis University School of Medicine to Saint Louis University School of Medicine follows the ACCME Saint Louis University School of Medicine designates this workshops, please educational activity for a maximum of 17.25 category 1 credits All Faculty insure balance, independence, objectivity and scientific rigor in policy on Validation of Content for CME activities which toward the AMA Physician's Recognition Award. Each visit our website at: its continuing medical education program. Faculty participating requires that: physician should claim only those credits that he/she actually ACCREDITATION 5:00 pm Adjourn in these activities are required to disclose to the audiences prior G All recommendations involving clinical medicine must be spent in the activity. Saint Louis University School of Medicine is accredited by to the activity the following: based on evidence that is accepted within the profession of This course has been designated as Level 1 (Verification of the Accreditation Council for Continuing Medical Education to 7:00 pm Optional Special Event Dinner (1) The existence of any significant financial or other relationship medicine as adequate justification for their indications and provide continuing medical education for physicians. Attendance) of the AMA’s Credit Designation for New with the manufacturer of any commercial product or provider of contraindications in the care of patients. Procedures and Skills. Completion of this course does not any commercial service discussed. (2) Their intention to discuss a product that is not labeled for the use under discussion. (3) G All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation certify the participant in their proficiency of the skills. http://pa.slu.edu The American Medical Association has determined that Their intention to discuss preliminary research data. must conform to the generally accepted standards of physicians not licensed in the US who participate in this CME experimental design, data collection and analysis. activity are eligible for AMA PRA category 1 credit.
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