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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: pa@slu.edu 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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