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 2019

ADVANCES IN
COSMETIC SURGERY
Gregory H. Branham, MD

Jeffrey S. Dover, MD, FRCPC

Heather J. Furnas, MD, FACS

Marissa M.J. Tenenbaum, MD

Allan E. Wulc, MD, FACS

Director, Continuity Publishing: Taylor Ball
Editor: Jessica McCool
Developmental Editor: Donald Mumford

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 ADVANCES IN COSMETIC SURGERY
EDITORS
GREGORY H. BRANHAM, MD
Chief Medical Officer, Barnes-Jewish West County
Hospital, Creve Coeur, Missouri; Professor and Chief,
Facial Plastic and Reconstructive Surgery, Department
of Otolaryngology-HNS, Washington University
School of Medicine, St Louis, Missouri
JEFFREY S. DOVER, MD, FRCPC
Director, SkinCare Physicians, Chestnut Hill,
Massachusetts; Associate Clinical Professor of
Dermatology, Yale University School of Medicine,
New Haven, Connecticut; Adjunct Associate Professor
of Dermatology, Brown Medical School, Providence,
Rhode Island
HEATHER J. FURNAS, MD, FACS
Adjunct Assistant Professor, Division of Plastic and
Reconstructive Surgery, Stanford Medical School,
Stanford, California
MARISSA M.J. TENENBAUM, MD
Associate Professor and Program Director, Division of
Plastic and Reconstructive Surgery, Department of
Surgery, Washington University School of Medicine in
St. Louis, St Louis, Missouri
ALLAN E. WULC, MD, FACS
Associate Clinical Professor, Department of
Ophthalmology, University of Pennsylvania,
Philadelphia, Pennsylvania; Adjunct Associate
Professor, Department of Otolaryngology, Temple
University, Philadelphia, Pennsylvania
iii
 ADVANCES IN COSMETIC SURGERY
CONTRIBUTORS
RACHEL C. BAKER, BS
Research Assistant, Section of Plastic Surgery,
University of Michigan, North Campus Research
Complex (NCRC), Ann Arbor, Michigan, USA
DANIEL J. CALLAGHAN, MD
Mohs Micrographic Surgery Fellow, SkinCare
Physicians, Chestnut Hill, Massachusetts, USA
FRANCISCO L. CANALES, MD
Private Practice, Santa Rosa, California, USA
YUNYOUNG CLAIRE CHANG, MD
Physician, Union Square Laser Dermatology,
New York, New York, USA
ANNE CHAPAS, MD
Physician, Union Square Laser Dermatology,
New York, New York, USA
JUSTIN COHEN, MD, FACS
Glasgold Group Plastic Surgery, Princeton,
New Jersey, USA
STEVEN M. COUCH, MD, FACS
Associate Professor of Orbital and Oculofacial Plastic
Surgery, Department of Ophthalmology and Visual
Sciences, Washington University in St. Louis, St Louis,
Missouri, USA
JEFFREY S. DOVER, MD, FRCPC
Director, SkinCare Physicians, Chestnut Hill,
Massachusetts; Associate Clinical Professor of
Dermatology, Yale University School of Medicine,
New Haven, Connecticut; Adjunct Associate Professor
of Dermatology, Brown Medical School, Providence,
Rhode Island, USA
GORANA KUKA EPSTEIN, MD
Foundation for Hair Restoration, Miami, Florida, USA
JEFFREY EPSTEIN, MD, FACS
Foundation for Hair Restoration, Miami, Florida,
USA; Assistant Clinical Professor, Department of
Otolaryngology, University of Miami, Coral Gables,
Florida, USA
JILL A. FOSTER, MD, FACS
Plastic Surgery Ohio/Ophthalmic Surgeons and
Consultants of Ohio, Inc, Department of
Ophthalmology, The Ohio State University,
Columbus, Ohio, USA
HEATHER J. FURNAS, MD, FACS
Adjunct Assistant Professor, Division of Plastic and
Reconstructive Surgery, Stanford Medical School,
Stanford, California, USA
ADELE HAIMOVIC, MD
The Ronald O. Perelman Department of Dermatology,
New York University Langone Health, New York City,
New York, USA
ANDREW HARRISON, MD
Department of Ophthalmology and Visual
Neurosciences, University of Minnesota Medical
School, Minneapolis, Minnesota, USA
MORRIS E. HARTSTEIN, MD, FACS
Director, Ophthalmic Plastic Surgery, Assaf Harofeh
Medical Center, Tel Aviv University-Sackler School of
Medicine, Tel Aviv-Yafo, Israel
LARRY KEVIN HEARD, MD
Resident Physician, Department of Dermatology,
University of South Florida, Tampa, Florida, USA
SARA HOGAN, MD, MPH
Cosmetic and Laser Dermatologic Surgery Fellow,
SkinCare Physicians, Chestnut Hill, Massachusetts,
USA
OMER IBRAHIM, MD
Chicago Cosmetic Surgery and Dermatology, Chicago,
Illinois, USA
PRASANTHI KANDULA, MD
Cosmetic and Laser Dermatologic Surgery Fellow,
SkinCare Physicians, Chestnut Hill, Massachusetts,
USA
v
vi CONTRIBUTORS
RYAN C. KELM, BS
Univsersity of Oklahoma College of Medicine,
Oklahoma City, Oklahoma, USA
SHILPI KHETARPAL, MD
Department of Dermatology, Cleveland Clinic
Foundation, Cleveland, Ohio, USA
JENNIFER MACGREGOR, MD
Physician, Union Square Laser Dermatology,
New York, New York, USA
KAVITA MARIWALLA, MD
Founder, Mariwalla Dermatology, West Islip,
New York, USA
GUY MASSRY, MD
Beverly Hills Ophthalmic Plastic and Reconstructive
Surgery, Beverly Hills, California, USA; Orbital Center,
Cedars-Sinai Medical Center, Department of
Ophthalmology, Division of Oculoplastic Surgery,
Keck School of Medicine of USC, University of
Southern California, Los Angeles, California, USA
AMY PATEL, MD
Beverly Hills Ophthalmic Plastic and Reconstructive
Surgery, Beverly Hills, California, USA, USA; Orbital
Center, Cedars-Sinai Medical Center, Los Angeles,
California, USA
FORUM PATEL, MD
Physician, Union Square Laser Dermatology,
New York, New York, USA
ALI A. QURESHI, MD
Aesthetic Surgery Fellow, Marina Plastic Surgery,
Marina del Rey, California, USA
SHAWN ROMAN, BS
Bovie Vice President of Research & Development,
Safety Harbor, Florida, USA
PETER M. SCHMID, DO, FAOCOOHNS, FAACS
Private Practice, Longmont, Colorado, USA
LORELEY D. SMITH, MD
Resident Physician, Department of Ophthalmology
and Visual Sciences, Washington University in
St. Louis, St Louis, Missouri, USA
JONATHAN SOH, MD
University of Rochester Medical Center, Rochester,
New York, USA
EMILY A. SPATARO, MD
Assistant Professor, Washington University in St. Louis,
St Louis, Missouri, USA; Division of Facial Plastic and
Reconstructive Surgery, Washington University School
of Medicine, Creve Coeur, Missouri, USA
DANIEL G. STRAKA, MD
Plastic Surgery Ohio/Ophthalmic Surgeons and
Consultants of Ohio, Department of Ophthalmology,
The Ohio State University, Columbus, Ohio, USA
MARISSA M.J. TENENBAUM, MD
Associate Professor and Program Director, Division of
Plastic and Reconstructive Surgery, Department of
Surgery, Washington University School of Medicine in
St. Louis, St Louis, Missouri, USA
SAMANTHA A. THIRY, MSN, FNP-C
Dr. Jennifer Walden, PLLC, Austin, Texas
MARA WEINSTEIN VELEZ, MD
University of Rochester Medical Center, New York,
USA
JENNIFER L. WALDEN, MD, FACS
Clinical Assistant Professor, Department of Plastic
Surgery, The University of Texas Southwestern Medical
Center, Private Practice, Austin, Texas, USA
JENNIFER F. WALJEE, MD, MPH, MS
Associate Professor, Section of Plastic Surgery,
University of Michigan, North Campus Research
Complex (NCRC), Ann Arbor, Michigan, USA
YAO WANG, MD
Department of Ophthalmology and Visual
Neurosciences, University of Minnesota Medical
School, Minneapolis, Minnesota, USA
SUSAN WEINKLE, MD
Assistant Clinical Professor, Department of
Dermatology, University of South Florida, Tampa,
Florida, USA
CHRISTINA WONG, MD
Department of Dermatology, Cleveland Clinic
Foundation, Cleveland, Ohio, USA
JACK ZAMORA, MD
Medical Advisory Board of Bovie, Medical Advisory
Board of Vitro Biopharma, Limitless MD Founder,
Jack Zamora M.D. Cosmetic Surgery & Aesthetics,
Denver, Colorado, USA
 ADVANCES IN COSMETIC SURGERY

CONTENTS VOLUME 2  2019

Editorial Board, iii Surgical Site Infections in Cosmetic

Surgery, 29
Contributors, v By Emily A. Spataro
Introduction, 29
Introduction, xi Background, 29
By Gregory H. Branham, Jeffrey S. Dover, Heather J. Summary of current guidelines, 30
Furnas, Marissa M.J. Tenenbaum, and Allan E. Wulc Surgical site infections in plastic
surgery, 30
Preface, xiii Evidence-based recommendations for the
By Gregory Harris Branham prevention of surgical site infections in
plastic surgery, 31
The Latest in Cosmetic Medicine: Procedure-specific surgical site infection
Supplements, Hormones, and Evidence, 1 prevention, 32
By Samantha A. Thiry and Jennifer L. Walden Breast surgery, 32
Introduction, 1 Abdominoplasty, 32
Age-related diseases, 2 Liposuction, 33
Hormonal changes in men and women Rhytidectomy, 33
associated with age, symptoms, and Blepharoplasty, 33
treatment options, 3 Rhinoplasty, 34
Summary, 9 Facial alloplastic implantation, 34
Skin resurfacing, 34
Sculptural Aesthetic Surface Anatomy of Other dermatologic procedures, 35
the Face, 11 Risk factors, 35
By Peter M. Schmid Summary, 36
Introduction: the sculptor and surgeon, 11
Facial beauty and attractiveness, 11 Pain Control in the Age of an Opioid
Physical examination: facial shape and form, 12 Epidemic, 41
Canons, Proportions, and Shape, 13 By Rachel C. Baker and Jennifer F. Waljee
Facial Structural Platform, 13 Introduction, 41
Facial Soft Tissue Platform, 16 Pain control: opioids, 42
Summary, 19 Opioid prescribing for surgical care, 42
Alternative analgesic treatments, 43
Tricks for Patient Retention for Alternative analgesic treatments: nonsteroidal
Maintenance Care, 23 anti-inflammatory drugs, 43
By Kavita Mariwalla Alternative analgesic treatments:
Nature of the problem, 23 acetaminophen, 43
Discount programs, 25 Alternative analgesic treatments: behavioral
Bundled purchases, 25 techniques, 44
Summary, 27 Summary, 44

vii
viii CONTENTS

Microneedling, 47 Management of vasoocclusion, 74

By Shilpi Khetarpal, Jonathan Soh, Mara Weinstein Authors’ thoughts on fat versus filler, 74
Velez, and Adele Haimovic
Video content accompanies this article at Submental Fat Contouring: A Comparison
http://www.advancesincosmeticsurgery. of Deoxycholic Acid, Cryolipolysis, and
com. Liposuction, 75
Background, 47 By Sara Hogan, Prasanthi Kandula,
Mechanism of action, 47 Daniel J. Callaghan, and Jeffrey S. Dover
Microneedling instruments, 48 Introduction, 75
Procedure, 48 Anatomy of the submental area, 75
Contraindications and treatment Evaluation of the patient with submental
considerations, 48 fullness, 76
Adverse events, 49 Deoxycholic acid, 76
Microneedling and rejuvenation, 49 Deoxycholic acid patient evaluation, 76
Microneedling and scars, 51 Preprocedure, 78
Procedure, 79
New Synergistic Tricks: Fillers D Postprocedure, 79
Neuromodulators D Technology 5 More Adverse effects, 79
than the Sum, 55 Complications, 79
By Ryan C. Kelm and Omer Ibrahim Clinical results, 80
Cryolipolysis, 80
Introduction, 55
Cryolipolysis patient evaluation, 80
Combining soft tissue fillers with
Preprocedure, 80
neuromodulators, 55
Procedure, 82
Soft tissue filler combinations, 56
Postprocedure, 82
Combinations with energy-based devices, 58
Clinical results, 82
Intense pulsed light, 59
Adverse effects, 82
Lasers, 59
Submental liposuction, 82
Nonablative lasers, 59
Submental liposuction patient evaluation, 82
Ablative lasers, 60
Preprocedure, 84
Microfocused ultrasound, 62
Procedure, 84
Radiofrequency, 63
Postprocedural care, 84
Radiofrequency with microneedling, 63
Adverse effects, 84
Soft tissue filler and synthetic deoxycholic
Summary, 84
acid, 63
Summary, 64
Subcutaneous Neck Skin Plasma
Facial Rejuvenation: Fat Transfer Versus Tightening, 89
Fillers, 69 By Jack Zamora and Shawn Roman
By Ali A. Qureshi and Marissa M.J. Tenenbaum Video content accompanies this article at
The aging face, 69 http://www.advancesincosmeticsurgery.com.
Autologous fat injection, 69 Introduction, 89
Surgical technique for fat grafting, 70 Surgical technique, 90
Injection, 71 Preoperative planning, 90
Common side effects, 71 Procedural approach, 90
Filler, 72 Miniincision superficial musculoaponeurotic
Anesthesia and pain management, 73 system/platysma plication, 90
Common side effects, 74 Plasma skin tightening, 91

Treatments for the Aging Lip, 97
By Larry Kevin Heard and Susan Weinkle
Video content accompanies this article at
http://www.advancesincosmeticsurgery.com.
Introduction: Nature of the problem, 97
Surgical technique, 99
Preoperative planning, 99
Preparation and patient positioning, 100
Procedural approach, 101
Injecting fillers, 101
Injecting neurotoxin, 102
Immediate postprocedural care and
rehabilitation, 103
Clinical results in the literature, 103
Potential complications, risks, benefits, and
limits, 103
Summary, 104
Nonsurgical Periorbital Rejuvenation, 107
By Loreley D. Smith and Steven M. Couch
Video content accompanies this article at
http://www.advancesincosmeticsurgery.
com.
Introduction, 107
Periorbital skin resurfacing, 107
Chemical peels, 107
LASER therapy, 109
Neuromodulators, 111
Surgical technique, 112
Dermal fillers, 115
Introduction, 115
Surgical technique, 115
Update on the Treatment of
Postblepharoplasty Lower Eyelid
Retraction, 121
By Daniel G. Straka and Jill A. Foster
Introduction: the nature of the problem, 121
Anatomy, 122
Risk Factors, 123
Transcutaneous or Transconjunctival?, 124
Surgical technique, 126
Preoperative Planning, 126
Preoperative Considerations for Planning
Surgical Technique, 127
Prep and Patient Positioning, 129
Procedural Approach, 130
CONTENTS ix
Immediate Postprocedural Care and
Recovery, 133
Potential complications, 133
Management, 133
Discussion, 133
Update on the Treatment of the
Skeletonized Upper Eyelid, 135
By Morris E. Hartstein
Video content accompanies this article at
http://www.advancesincosmeticsurgery.
com.
Defining the Brow Fat Pad: The Brow Fat
Pad Suspension Suture, 143
By Yao Wang, Andrew Harrison, Amy Patel, and
Guy Massry
Video content accompanies this article at
http://www.advancesincosmeticsurgery.
com.
Introduction, 143
Surgical technique, 144
Preoperative planning, 144
Preparation and patient positioning, 144
Procedural approach, 144
Immediate postoperative care, 145
Rehabilitation and recovery, 145
Clinical results in the literature, 145
Potential complications, risks, benefits, and
limitations, 146
Complications, risks, and management, 146
Benefits, 147
Limitations, 147
Summary, 148
Platelet-rich Plasma for Hair Growth, 151
By Christina Wong and Shilpi Khetarpal
Video content accompanies this article at
http://www.advancesincosmeticsurgery.
com.
Introduction, 151
Procedural technique, 152
Preoperative planning, 152
Preparation and Patient Positioning, 157
Procedural Approach, 158
Immediate Postprocedural Care, 158
Rehabilitation and Recovery, 158
Clinical results in the literature, 158
x CONTENTS
Potential complications/risks/benefits/
limits, 159
Summary, 159
Hair Loss in Men and Women: Medical and
Surgical Therapies, 161
By Gorana Kuka Epstein, Jeffrey Epstein, and Justin
Cohen
Video content accompanies this article at
http://www.advancesincosmeticsurgery.
com.
Introduction, 161
Understanding androgenic hair loss, 161
Medical therapies, 163
Addressing underlying conditions
contributing to androgenic alopecia, 163
Minoxidil, 163
Finasteride, 164
Low-level laser light, 164
Platelet-rich plasma, 165
Microneedling, 166
Mesenchymal regenerative cells, stromal
vascular fraction, and adipose tissue
injections, 166
Surgical therapies, 166
Introduction, 166
History of surgeries used to treat androgenic
alopecia, 167
Surgical procedures other than hair
transplants, 167
Hair transplantation, 168
Surgical technique, 169
Preoperative planning, 169
Preparation and patient positioning, 169
Procedural approach, 171
Post procedure care, 173
Future therapies, 175
Subcutaneous Body Skin Tightening, 177
By Forum Patel, Jennifer MacGregor, Yunyoung Claire
Chang, and Anne Chapas
Introduction, 177
Radiofrequency, 177
Micorfocused Ultrasound, 181
Surgical technique, 181
Preoperative planning, 181
Preparation and patient positioning, 181
Procedural approach, 183
Immediate postprocedural care, 185
Rehabilitation and recovery, 185
Potential complications/risks/benefits/
limits, 185
Management, 185
Summary, 185
Hand Rejuvenation, 189
By Prasanthi Kandula, Sara Hogan,
Daniel J. Callaghan, and Jeffrey S. Dover
Introduction, 189
Aging process of the hands, 189
Treatment, 190
Topical Agents, 190
Chemical Peels, 190
Soft-tissue augmentation, 190
Hyaluronic Acid, 190
Calcium Hydroxyapatite, 191
Poly-L-Lactic Acid, 191
Autologous Fat Transfer, 191
Potential Complications, Risks, and
Limitations, 191
Vein treatments, 192
Sclerotherapy, 192
Laser/light sources and energy-based
devices, 192
Intense Pulsed Light, 192
Nonablative Resurfacing Lasers, 192
Ablative Resurfacing Lasers, 192
Q-Switched Devices, 193
Photodynamic Therapy, 193
Pulsed Dye and Pulsed Green Potassium
Titanyl Phosphate Lasers, 193
Summary, 193
Nonsurgical Vaginal Treatments, 195
By Francisco L. Canales and Heather J. Furnas
Introduction, 195
Vaginal health issues, 196
Effect on women’s lives, 196
The rise of nonsurgical options for vaginal
rejuvenation, 196
Vaginal laxity, 197
Radiofrequency devices, 197
Lasers in vaginal rejuvenation, 198
Stress urinary incontinence, 199
Food and drug administration warning, 199
 Advances in Cosmetic Surgery 2 (2019) xi–xii
ADVANCES IN COSMETIC SURGERY
Introduction
Gregory H. Branham, Jeffrey S. Dover, MD, Heather J. Furnas, MD, Marissa M.J.
MD FRCPC FACS
Editors
T
he desire for cosmetic surgery has infiltrated
corners of society never seen before and is
only expected to grow in the years ahead. As
the number of cosmetic surgery procedures continues
to rise throughout the world, so too does the number
of specialists performing these important procedures.
When working with a patient to create their ideal
image, it’s critical to have the most current resources
available to guide your practice and inform your
decisions.
Advances in Cosmetic Surgery, now in its second vol-
ume, aims to highlight the year’s latest advancements
and breakthroughs in the field of cosmetic surgery.
Experts from the four core specialties have come
together to bring you, the reader, the most important
advances in this rapidly evolving field.
Subcutaneous body skin tightening, platelet-rich
plasma for hair growth, microneedling, subcutane-
ous neck plasma skin tightening, facial rejuvenation,
and treatments for the aging lip are just a handful of
topics covered in this issue. High-quality images and
videos accompany many of the articles, helping to
further deepen the reader’s understanding of these
techniques and procedures. Whether you are plan-
ning to perform the procedures discussed here or
learning about them for the first time, we think
https://doi.org/10.1016/j.yacs.2019.02.018
2542-4327/19/ © 2019 Published by Elsevier Inc.
Allan E. Wulc, MD,
Tenenbaum, MD FACS
you will find value in what this exciting series has
to offer.
The editors would like to thank the authors for their
insightful contributions, and all the pioneers in this field
working to bring us better tools, techniques, and ways of
making the seemingly impossible possible for our patients.
We hope you will enjoy reading this issue as much as
we enjoyed putting it together. It is our sincere hope
that the articles presented here will help further break
down barriers between specialties and shed new light
on current cosmetic treatments.
Gregory H. Branham, MD
Facial Plastic and Reconstructive Surgery
Department of Otolaryngology-Head and Neck Surgery
Washington University School of Medicine
St Louis, MO, USA
Jeffrey S. Dover, MD, FRCPC
SkinCare Physicians
Chestnut Hill, MA, USA
Yale University School of Medicine
New Haven, CT, USA
Brown Medical School
Providence, RI, USA
www.advancesincosmeticsurgery.com
XI
XII Introduction
Heather J. Furnas, MD, FACS
Division of Plastic and Reconstructive Surgery
Stanford Medical School
Stanford, CA, USA
Marissa M.J. Tenenbaum, MD
Plastic and Reconstructive Surgery
Washington University School of Medicine
St Louis, MO, USA
Allan E. Wulc, MD, FACS
Department of Ophthalmology
University of Pennsylvania
Philadelphia, PA, USA
Department of Otolaryngology
Temple University
Philadelphia, PA, USA
E-mail address: branhamg@wustl.edu
 Advances in Cosmetic Surgery 2 (2019) xiii
ADVANCES IN COSMETIC SURGERY
Preface
Gregory H. Branham, MD,
Editor
W
elcome to the second volume of Advances in
Cosmetic Surgery. Our diverse editorial staff
has once again solicited contributions that
will be of interest to all those providing cosmetic sur-
gery and procedures to patients. Whether you are
engaged in a surgically oriented practice or an office-
based or minimally invasive practice, there is something
for everyone in this volume. Our learning is enhanced
immeasurably when we share and compare our tech-
niques and results. To that end, you will see several ap-
proaches to the same problem or issue that you may
encounter in your practice.
In keeping with our commitment to be at the fore-
front of esthetic practice, we have curated an excep-
tional group of topics that will allow the reader to
develop a grasp of what is new and permit the reader
to make sense of what is effective and what is not.
Topics in this volume range from cosmetic medicines
and pain control in the age of the opioid epidemic to
surgical and nonsurgical treatments for correction of
the overoperated patient.
There are so many new products and procedures be-
ing developed, and we are in a time of accelerated devel-
opment of technology and devices. As you read these
articles, please consider how they can be used to inform
https://doi.org/10.1016/j.yacs.2019.03.001
2542-4327/19/ © 2019 Published by Elsevier Inc.
you of what might be useful in your practice and also
what should require caution or at least careful consider-
ation prior to adoption.
Many thanks to all of the contributors who have taken
the time to share their expertise with us and allowed us to
share that with you. We hope that you will find this vol-
ume as engaging and stimulating as our first volume. We
seem to have an endless flow of ideas but would
welcome any suggestions for future topics that you
would like to see included in future volumes.
The editors would also like to thank Jessica McCool
and all the editorial staff at Elsevier who have made this
volume possible. Their commitment to excellence in
this endeavor is evident in the quality of the publica-
tion, and we trust that will be apparent to you as well.
Gregory H. Branham, MD
Facial Plastic and Reconstructive Surgery
Otolaryngology–Head and Neck Surgery
Washington University
1020 North Mason Road
St Louis, MO 63141, USA
E-mail address: branhamg@wustl.edu
www.advancesincosmeticsurgery.com
XIII
 Advances in Cosmetic Surgery 2 (2019) 1–10

ADVANCES IN COSMETIC SURGERY

The Latest in Cosmetic Medicine

Supplements, Hormones, and Evidence
Samantha A. Thiry, MSN, FNP-C*, Jennifer L. Walden, MD, FACS
5656 Bee Caves Road, Suite E201, Austin, TX 78746, USA

KEYWORDS
 Age-related diseases  Antiaging  Supplements  Hormone replacement therapy  Andropause  Menopause

KEY POINTS
 Provider opinions have an effect on the use of hormone replacement therapy (HRT) within practices. It is important for
providers to be educated regarding the evidence behind HRT so they may safely prescribe HRT for specific patients who
understand the risks versus the benefits. A patient-centered approach should be used with this treatment option.
 The true risks versus benefits of HRT and disease processes, such as prostate cancer and breast cancer risks, must be
presented to patients by educated providers without bias. It has been proved that provider attitudes contribute to use of
antiaging medical methods. This can, in turn, negatively affect a patient’s quality of life by not providing them with safe,
monitored, and effective treatment.
 Supplements to help prevent age-related diseases continue to be researched for their true beneficial possibilities.
Evidence exists regarding specific supplements and their chemopreventive and antioxidant properties. Cancer is an age-
related disease and many supplements are aimed at reducing the risk of its occurrence. Supplement use is a patient-
driven demand.
 Providers must become more informed about supplements by receiving appropriate education regarding the evidence so
they can give patients appropriate feed-back when patient inquiries arise.

INTRODUCTION diseases as symptoms of aging. The concept of a foun-

Patients are seeking care to stop the effects of aging not
only from an external standpoint but also from an inter-
nal standpoint. As the demand for antiaging therapy
with hormones and supplements increases, it is imper-
ative that health care providers understand the evidence
supporting proper management and information
regarding alternative treatment options with hormones
and supplements [1].
Age-related diseases continue to be researched for
prevention and optimization [2]. Antiaging specialists
use a medical framework that targets age-associated
tain of youth has been around for centuries but now,
with modern medicine and advancements in technol-
ogy, antiaging practitioners have developed as a
specialty, with the requirements of understanding dis-
eases associated with age and how to physiologically
decrease a patient’s risk of acquiring an age-related dis-
ease. Various dietary and pharmacologic interventions
have been shown to increase lifespan [3]. Also,
although aging is considered a natural life process, opti-
mization of quality of life continues to be a focus. To
meet this demand, an increasingly popular focus has

Disclosure Statement: The authors have nothing to disclose.

*Corresponding author, E-mail address: Samantha.thiry.drwalden@gmail.com

https://doi.org/10.1016/j.yacs.2019.01.001 www.advancesincosmeticsurgery.com
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2 Thiry & Walden
been geared toward preventing existing disease pro-
cesses from worsening, as well as treating disease
processes through therapeutic management with hor-
mones or supplementation [3,4].
Patients have shifted the focus of surviving to
thriving throughout their lifetime. Improving a patient’s
quality of life is an important concept in antiaging med-
icine [2]. Hormonal shifts occur during the aging pro-
cess that cause several physiologic changes and clinical
presentation of symptoms. For women, symptoms of
menopause can severely affect overall quality of life as
radical shifts and imbalances of estrogen and testos-
terone hormones occur [5]. Andropause, defined as a
continual decline in testosterone with age, affects both
men and women [5,6]. Hormone therapies are effective
in the treatment of symptoms of age-related hormonal
changes for men and women, which makes it is impor-
tant to understand the evidence regarding risk versus
benefit of the treatment prescribed. It has been proved
that many providers’ opinions on hormone therapies
are not congruent and often misinformed, causing
bias [7]. This tends to cause a lack of credibility with
specific treatment protocols. Patients can end up
suffering with symptoms of hormonal shifts and the
physiologic changes of age due to lack of appropriately
prescribed care and information regarding the true risks
versus benefits of treatment [7,8].
This article examines the multifactorial approach to
antiaging medicine with hormone replacement therapy
(HRT) and treatment using nutraceuticals to help pa-
tients achieve an improved quality of life, as well as
decrease risk for development of disease process by
optimizing their health from a physiologic evidence-
based standpoint. It examines what symptoms of aging
can be improved, as well as how aging is defined, to
improve patients’ overall quality of life. Potential risks
and benefits of HRT, as well as nutraceutical supple-
mentation, are discussed. Assessment of providers’
knowledge and the options of these types of therapies
are examined, as well as appropriate assessment and
treatment in men and in women [4–8].
Age-related diseases
Antiaging medicine is an evolving movement with the
intent to help patients decrease the development of
age-related disease, as well as improve the quality of
the normal aging process [2]. This movement has
been in place for decades but has recently become
much more advanced through research and technology.
One way to define aging is that it is the result of
continuous interaction between an individual’s genetic
makeup and environmental factors, characterized by
lifelong damage accumulation and progressive loss of
tissue and organ functionality [9]. Aging is directly asso-
ciated with an increased risk of disease development.
Common age-related diseases include neurodegenera-
tive disorders, cardiovascular disease, diabetes, osteoar-
thritis, and cancer [9]. Hypertension, high glucose,
cholesterol, and triglyceride levels are age-related risk
factors for morbidity that increase with age. The concept
of targeting age-related diseases through prevention on
a molecular level is important to understanding which
treatment methods will decrease the effects of aging,
not only from a physiologic standpoint but also from
a symptomatic standpoint [9]. Directly targeting the ag-
ing process on a molecular level versus targeting age-
related diseases or symptoms is a viable strategy
[9,10]. To slow the aging process, therapies that are
considered nonstandard, such as blood-based thera-
pies, are being prescribed and tried [9].
As patients continue to seek out ways to diminish or
decrease the effects of aging, it is important for pro-
viders to be up-to-date on current treatment options.
Hormone therapies and supplements are becoming
increasingly popular as treatment and prevention of
age-related conditions. Age-related conditions are the
leading causes of death, not only in the United States
but also worldwide. They are also the leading cause of
health care expenditures [9]. By delaying the aging pro-
cess, the delay of age-related diseases occurs. Delaying
aging, resulting in 2.2 years of additional life expec-
tance, would yield the United States $7 trillion dollars
in savings over 50 years. The target of single pathologic
conditions, such as cancer or heart disease, yields less
savings [9].
Because antiaging science has huge potential finan-
cial benefits, it has tremendous commercial opportu-
nities. Scientific breakthroughs have led to antiaging
science having a more valid reputation [9]. Provider
opinions and approaches are often skewed when it
comes to subjects such as off-label administration of
medication management [7,8]. Therefore, presenting
the evidence behind some HRT and nutraceutical
blood-based approaches of antiaging is important
when creating a patient-centered plan of care [1]. Given
the multiple genes, processes, and pathways associated
with aging, there are many opportunities to develop
pharmaceuticals to target these pathways [9]. To under-
stand the antiaging process, one must first understand
what causes aging and the specific signs and symptoms
of the aging process [2,3]. The description of aging as a
time of decline and suffering is evident because age-
related diseases often cause the physiologic decline of
a patient, in turn causing the patient to suffer [2,3].

Hormonal changes in men and women
associated with age, symptoms, and
treatment options
Age-related hormonal changes in women
A significant age-related hormonal change for women is
menopause. Menopause is used to define the natural,
systemic decrease of endogenous estrogen production
from the ovaries, caused by physiologic depletion of a
woman’s ovarian reserve [11]. This process occurs in
the aging woman and manifests as the cessation of
menses and subsequent end of fertility. In many women,
vasomotor symptoms occur, as well as other physiologic
issues. Vasomotor symptoms commonly experienced
during menopause include vaginal dryness, hot flashes,
and irregular menstrual pattern. Menopausal symptoms
can greatly affect a woman’s overall quality of life and pa-
tients will bring these to a provider’s attention in search
of relief [11,12]. A progressive decline in androgen levels
also occurs as a woman increases in age. Serum concen-
trations of testosterone in women older than the age of
50 years are approximately half of that of women in
aged 20 to 30 years [13,14]. There are several symptoms
of andropause in women, including unexplained fatigue,
low libido, and decreased sense of wellness. Testosterone
therapy has been administered to women for decades to
improve sexual dysfunction [11,15]. Female sexual
dysfunction is an issue for approximately 43% of women
18 to 59 years of age [14].
Menopause is characterized by a decreased produc-
tion of both estrogen and androgen [5,11]. It is impor-
tant to understand the process of aromatization, which
is the conversion of the body’s excess testosterone into
estrogen. Expression of aromatase is important to the
adipose tissue, skin, and bone because it slows the
rate of postmenopausal bone and collagen loss [5].
Testosterone levels decline gradually with age, rather
than showing a precipitous decrease at the menopause
transition [13]. Different typical HRT plans of care are
used in premenopausal, perimenopausal, and post-
menopausal women due to hormone shifts during
each phase of her sexual maturation [11]. Each phase
is assessed differently for risks and benefits associated
with HRT, therefore making it increasingly difficult for
a provider to manage a patient’s symptoms to improve
quality of life through HRT [11].
Female sexual dysfunction and hyposexual desire are
diagnoses that are reviewed as issues that can occur in the
premenopausal, perimenopausal, or postmenopausal
phases [12]. Some studies have shown that up to 50%
of women suffer from female sexual dysfunction. Female
sexual dysfunction is characterized by low sexual desire,
The Latest in Cosmetic Medicine 3
diminished sexual arousal, vaginal dryness, and difficulty
achieving orgasm. Some women enter into menopause
naturally, whereas others enter into menopause via surgi-
cal means such as a hysterectomy [11]. In the United
States, a national survey concluded that nearly half of
women aged 57 to 85 years experience at least 1 sexual
problem, the most common issue being low sexual
desire. There has been a landmark study performed by
Laumann and colleagues [12] that found that 32% of
women ages 30 to 39 years had low sexual desire. There-
fore, it is not only perimenopausal and menopausal
women who are seeking a solution for a decreased qual-
ity of life likely due to hormonal disruption. Understand-
ing the mechanism of action of androgens in relation to
the female body is important when considering the over-
all benefit for patients seeking relief of androgen defi-
ciency symptoms [12].
Androgen deficiency in women
The organs directly responsible for production of testos-
terone in women are the ovaries and adrenal glands,
although testosterone is also converted peripherally
from androstenedione, which is also produced in the
ovaries and adrenals [11]. Androgen deficiency in women
causes decreased lean body mass, increased body fat, thin-
ning or loss of hair, osteopenia, or osteoporosis, which
present as clinical signs. Symptoms of androgen defi-
ciency include low libido, fatigue, lack of a sense of well-
being, orgasmic dysfunction, arousal disorder, vasomotor
symptoms, insomnia, and depression [11,16].
Beta endorphins increase with testosterone levels,
causing mood-enhancing effects [5]. A woman’s quality
of life is greatly affected by a decrease in androgens, not
simply because of sex hormones. Multiple organs rely
on androgens for action such as increasing bone mass,
causing erythropoiesis, augmenting certain cognitive
behaviors, stimulating muscle growth, stimulating kid-
ney growth, and modifying the pattern of adipose tissue
deposit [5]. Interestingly, the thyroid, breast, endome-
trium, colon, lung, skin, and adrenals are all affected
because androgens have a direct effect on the tissue of
each organ [5]. Androgens may affect sexual desire,
bone mineral density, muscle mass, and strength, as
well as adipose tissue. The addition of testosterone ther-
apy in testosterone-deficient women has an effect on es-
trogen production in the brain, bone, and skin
fibroblasts, among other tissues [5].
Assessment of female androgen deficiency
Female androgen deficiency is assessed through subjec-
tive questionnaires and, therefore, a lack of objective in-
formation can cause lack of consistency between
4 Thiry & Walden
provider assessment and the treatment plan. The idea
that androgen deficiency is assessed through subjective
means causes controversy among providers [8,12]. There
have been several tools designed to screen women for
hyposexual desire disorder (HSDD) [12]. The Decreased
Sexual Desire Screener (DSDS) is a validated diagnostic
tool for generalized, acquired HSDD. The DSDS is
meant to be approximately sensitive and specific for
diagnosis of HSDD in women, independent of meno-
pausal status. The Diagnostic and Statistical Manual of
Mental Disorders, 5th edition, lists specific criteria for the
diagnosis of female sexual interest or arousal disorder;
3 out of 6 symptomatic screening assessments must be
answered with a yes for diagnosis [11].
Interpretation of laboratory data associated with
decreased available androgens for women include the
review of free and total testosterone, as well as sex
hormone-binding globulin (SHBG) [13]. Free testos-
terone is biologically available testosterone, whereas
the bioavailability of testosterone for the conversion
into estrogens depends on the levels of SHBG. In a
normal scenario, only 1% to 2% of total testosterone cir-
culates unbound. SHBG binds about 66% of total circu-
lating testosterone. The rest of testosterone circulating is
bound by albumin. It is assumed that the non–SHBG-
bound circulating testosterone is biologically active
[13]. Estrogen and thyroxine increase SHBG. Testos-
terone and glucocorticoids, growth hormone, and insu-
lin suppress SHBG. It is difficult to measure testosterone
levels in women when they are at very low levels [13].
Testosterone therapy in the aging woman
Data from several studies suggest that combined HRT-
androgen therapy may be beneficial to women who
are postmenopausal who complain of low libido
despite estrogen therapy or as monotherapy in women
who are postmenopausal with female sexual dysfunc-
tion. Studies have concluded that no significant increase
of liver enzymes or cardiovascular risk factors occurred
with the administration of testosterone therapy [11].
There are multiple forms of testosterone therapy in
various routes of administration available to women
[5]. Subcutaneous hormone implants; intramuscular
injection; and transdermal, oral, and vaginal adminis-
tration of hormone replacement are among those
offered to women in search of androgen deficiency
symptom relief [5].
Safe administration of hormone replacement
therapy for women
It is extremely important for the patient and prescriber
to understand the risks versus benefits of HRT for
women. Each individual, due to family and personal
history, have variables that are important for a provider
to consider when developing a tailored treatment plan
for the patient’s needs. Women must have an active rela-
tionship with their obstetrician-gynecologist, and docu-
mented history must be reviewed by the treating
physician [11].
Abnormal menses, hirsutism, elevated blood pres-
sure, and mood swings are some of the associated
issues that may occur during androgen therapy for
women [11].
Women, hormone replacement therapy, and
cardiovascular evidence
Notably, estrogen has antiatherosclerotic and antiin-
flammatory properties that may protect women from
cardiovascular disease development through modifica-
tion of the lipid profile [17]. It is noted that women
who are premenopausal have higher high-density lipo-
protein cholesterol and lower low-density lipoprotein
cholesterol levels compared with men, which signifi-
cantly reverses after menopause [17]. Testosterone is
known to be produced by the ovaries and some of the
female body’s testosterone is converted into estrogen,
primarily when androgen levels are higher during the
premenopausal state [5,17]. The converted estrogen
has beneficial effects on vascular endothelium and
smooth muscle tissue. Menopause and the postmeno-
pausal period may be risk factors for developing coro-
nary heart disease. Directly following menopause,
there is a hormonally related risk for the development
of hypertension, coronary artery disease, congestive
heart failure, and cerebrovascular disease, which are
also age-related diseases [2,17]. The Danish Osteopo-
rosis Prevention Study recently noted in a controlled
randomized trial that menopausal hormone therapy
can have the beneficial effect of a reduced rate of coro-
nary artery disease. Hormonal therapy may be harmful
and is not advised in the setting of preexisting coronary
disease, cerebrovascular disease, or a history of throm-
boembolic disease [11]. Hormonal therapy must be
observed for risks and benefits by the administering
provider using a patient-centered approach and individ-
ualized discussion [11,17].
Hormone replacement therapy and breast
cancer concerns
It has been reviewed that there are no valid randomized
or observational clinical studies to provide appropriate
evidence that testosterone has an influence on breast
cancer risk when added to conventional postmeno-
pausal hormone therapy [14]. This is a significant point

of information to provide to patients inquiring about
HRT [14]. Breast cancer diagnosis represents about
23% of all cancers in women. It is no surprise that it
is an important subject because it is typically an age-
related disease and is a common concern for patients
considering HRT [18]. Breast cancer incidence is
increasing worldwide. Weight gain in adulthood is asso-
ciated with an increased risk of breast cancer in post-
menopausal women. Studies suggest that weight gain
before and around menopausal age may be a
determinant for the development of breast cancer in
postmenopausal women [18]. Increasing a woman’s
testosterone level to a more optimal level has the
benefit of decreasing central visceral fat, increasing
metabolic rate, and decreasing or even treating obesity.
Testosterone also has the benefit of increasing the beta
endorphins responsible for sense of wellbeing [13]. If a
woman is feeling a better sense of wellbeing she is more
likely to be physically and sexually active [13].
Decreasing obesity risk for women before and during
menopause via testosterone therapy decreases a risk fac-
tor for the development of breast cancer [18,19]. Recent
clinical data support a role for testosterone in breast
cancer prevention [19]. Women with symptoms of hor-
mone deficiency who are treated with doses of testos-
terone alone or in combination with anastrazole via
subcutaneous implants have shown a reduced inci-
dence of breast cancer. In addition, testosterone therapy
along with anastrazole has been studied to alleviate
symptoms of hormone-deficient breast cancer survivors
and was not associated recurrent disease [19].
Studies have shown that testosterone and anastra-
zole subcutaneous implants placed in tissue surround-
ing malignant tumors significantly reduces breast
cancer tumor size. Testosterone therapy has been
reviewed and there are several supporting data that
note the direct antiproliferative, protective, and thera-
peutic effects [19].
Provider opinions of hormone replacement
therapy despite evidence
There are differing opinions regarding hormone
replacement therapies that affect not only a physician’s
willingness to prescribe but also a patient’s willingness
to use hormone replacement as a therapy. Part of this
disarray is due to a lack of protocol and continued con-
troversy about normal androgen levels in women. It is
also difficult to assess for androgen deficiency in
women because the symptomology overlaps with
several other medical diagnoses [8,11]. The provider
must rule out other complications that could be pre-
senting as risks to patient’s health. Providers’ opinions
The Latest in Cosmetic Medicine 5
have been observed via survey and it has been noted
that respondents correctly identified the risks of HRT
only 28% of the time, and 67% of providers overesti-
mated the risks and benefits of HRT.
Multiple sources of valid data suggest that combined
HRT-androgen therapy may be beneficial to women
[11]. Providers need to be educated regarding studies
that concluded that no significant increase of liver en-
zymes or cardiovascular risk factors occurred with the
administration of testosterone therapy [16].
Men and testosterone supplementation
Testosterone supplementation in the United States has
increased substantially over the years. Testosterone pre-
scriptions increased by 1700% from 1994 to 2003 and
do not show any signs of decreasing in popularity [4].
As this patient-driven popularity of testosterone supple-
mentation increases, it is important for providers to un-
derstand the signs and symptoms associated with the
decline of testosterone in the male body, as well as
appropriate treatment options and risk factors [4]. To
ignore the increased patient demand for treatment of
the associated symptoms of andropause causes skewed
perspectives regarding the true risks and benefits of HRT
for men throughout the aging process [4].
Men and andropause
Men undergoing the aging process, especially andro-
pause or the progressive decline of testosterone, often
search for symptom relief. Decreased testosterone levels
are also referred to as hypogonadism [20]. Low libido is
the symptom most associated with hypogonadism,
although erectile dysfunction, decreased muscle mass
and strength, increased total body fat, decreased bone
mineral density, anemia, gynecomastia, decreased
mental capacity, and skin and hair alterations also occur
[20]. Decreased quality of life, a diminished sense of
wellbeing, and insomnia are additional symptoms pre-
sent in androgen-deficient men. On clinical presenta-
tion, decreased muscle mass and strength, decrease in
bone mass, osteoporosis, and increased central body
fat may be noted in a patient with testosterone defi-
ciency [20,21]. When assessing for testosterone defi-
ciency, it is important for the provider to use an
approach that considers other age-related diseases by
using objective information, such as laboratory work,
to assess the patient for issues that may be present in
addition to androgen deficiency.
Testosterone deficiency is also associated with
increased cardiometabolic risk. For example, total
testosterone levels are inversely associated with risk of
cardiovascular events. Testosterone deficiency is
6 Thiry & Walden
associated with endothelium damage and testosterone
therapy enhances endothelial repair and function, and
increases synthesis and release of endothelial nitric ox-
ide in the body’s vascular system [20]. Testosterone
deficiency is associated with increased systolic blood
pressure and increased arterial stiffness, which are risk
factors that can lead to further development of age-
related diseases, such as coronary artery disease, hyper-
tension, and hypercholesterolemia [2,4,20].
Diagnosing low testosterone in men
The decline of testosterone for men is about 1% per year
after the age of 30 years and reaches a 30% decline by
the eighth decade of life [4]. The Androgen Deficiency
in the Aging Male (ADAM) questionnaire is an impor-
tant assessment tool when assessing for male androgen
deficiency. Testosterone declines as men age and the
symptoms associated with this decline cause an abun-
dance of unwanted patient symptoms that affect their
overall wellbeing [4]. Assessment regarding the subjec-
tive presence of the most commonly reported androgen
deficiency–associated symptoms must be performed by
a diagnosing provider. The symptoms associated with
this decline cause an abundance of unwanted patient
symptoms, such as fatigue and depression, and a
decreased sense of wellbeing [4]. When assessing for
the reasons for existing symptoms of hypogonadism,
it is important to check patient’s serum total testos-
terone, free testosterone, and SHBG, as well as the total
prostate-specific antigen (PSA) if appropriate for pa-
tient’s age range, when considering prescribing testos-
terone therapy [21].
Testosterone therapy benefits reported
Benefits of testosterone therapy in men include
increased libido, sexual function, bone density, muscle
mass, body composition, mood, erythropoiesis, cogni-
tion, quality of life, and decreased cardiovascular
disease. Improved sexual desire, function, and perfor-
mance are reported by men receiving testosterone
replacement therapy (TRT) [4,6,20].
The cognitive effects of androgen deficiency are asso-
ciated with decline in visual and verbal memory. Men
with higher ratios of testosterone to SHBG show a
decreased risk of Alzheimer disease. This was found in
the Baltimore Longitudinal Study of Aging, a prospec-
tive longitudinal study. It was noted that risk for Alz-
heimer disease was reduced by 26% for each 10 unit
(mmol/mmol) increase in free testosterone at 2, 5,
and 10 years. There are also well-reported data for a
strong correlation between serum levels of testosterone
and cognitive performance in mathematical reasoning
and spatial abilities [6]. Testosterone therapy in hypo-
gonadal men may have some benefit for cognitive per-
formance, especially in older men who are at an
additional risk of developing dementia or Alzheimer
because these are typically age-related diseases [6].
Glycometabolic and cardiometabolic functions, as
well as body compositions, are negatively affected by
testosterone deficiency or hypogonadism [20]. Testos-
terone and its metabolite, 5 alpha-dihydrotestosterone,
regulate energy metabolism, muscle growth, and main-
tenance and inhibit adipogenesis. An inverse relation-
ship between testosterone and insulin resistance has
been postulated and higher physiologic levels of testos-
terone seem to be protective against the development of
type II diabetes mellitus [20,21]. The prevalence of type
II diabetes mellitus and men with hypogonadism is as
high as 33% [21]. It has been shown that TRT causes
an improvement in glycemic control, as well as insulin
resistance, in men with type 2 diabetes [21]. Subcutane-
ous hormone implants, intramuscular injection, trans-
dermal, and sublingual administration of hormone
replacement are among those offered to men in search
of androgen deficiency symptom relief [6].
Safe administration: prostate cancer risk and
other testosterone replacement therapy
considerations
Prostate cancer and the role of testosterone in the disease
often results in confusion. It has not been assessed that
testosterone replacement directly causes prostate cancer,
although its administration in the presence of a carci-
noma can enhance the carcinoma present [4]. Prostate
cancer is a common, androgen-dependent cancer. There-
fore, testosterone administration is absolutely contrain-
dicated in men with clinical prostate cancer. Some men
are diagnosed with prostate cancer less than 4, therefore
establishing a baseline is important [4]. Assessing for
prostate cancer risk is important when assessing the risks
versus benefits of testosterone therapy in symptomatic,
androgen-deficient men. Data have shown that suggest
administration of testosterone in androgen-deficient
men can produce modest incremental increase in serum
PSA levels. These increments should generally be less
than 0.5 ng/mL; increases exceeding 1.0 ng/mL over 3
to 6 months are unusual. Recommendations for moni-
toring prostate-related adverse experiences during TRT
in older men include a baseline evaluation of a digital
rectal examination, serum PSA, and an AUA symptom
score for benign prostatic hypertrophy. Also, follow-up
evaluations should occur at 3, 6, and 12 months, then
annually, with review of the previously mentioned
monitoring tools [4].

Some clinicians practice safe administration of TRT
in men by performing a prostate biopsy when there is
a clinical presentation of prostate cancer risk before pre-
scription of TRT. High-grade prostatic intraepithelial
neoplasia (PIN) has been postulated to be a precancer-
ous condition [21]. An examination of prostates
removed at radical prostatectomy for prostate cancer
revealed high-grade PIN in 86% of cases. It has been
shown that there was no increased risk of prostate can-
cer in hypogonadal men with PIN treated with testos-
terone for 1 year [21]. Continued studies must be
performed for long-term analysis. To date, no study
has definitively shown a relationship between TRT
and prostate cancer. Many providers are hesitant to treat
patients for androgen deficiency owing to fear of
increasing the risk for prostate cancer, whereas evidence
does not support this clinical precaution [21]. There-
fore, prescribers refrain from prescribing TRT to men
who suffer androgen deficiency symptoms and side ef-
fects owing to presumptions that are not evidence-
based [21].
PSA levels increase with age in men regardless of
prostate cancer status, which is why proper thorough ex-
amination and evaluation with established baselines
are such important components when considering
TRT risks versus benefits of therapy [21].
Lack of consistency regarding the prescription of TRT
for men with hypogonadism leads to provider confu-
sion. During the assessment, the provider must under-
stand the process of deciding what specific symptoms
of aging need to be addressed. Androgen deficiency
symptoms commonly affect an individual’s quality of
life and vital physiologic functions [4,6]. To restore
overall wellbeing, balancing these hormones to the
levels of a younger, more youthful, and more well self
is often the goal of HRT [4,6]. It is thought that a consis-
tent decline in testosterone occurs as a direct cause of
age; therefore, restoring testosterone levels to that of a
younger age is thought to help reduce certain age-
related signs and symptoms [4,6,12,20,21]. This has
been evident because patients have had positive physi-
ologic and psychological outcomes associated with TRT.
Because of a recent paradigm shift, it is important for
providers to be educated about the true risks of therapy
and to understand when referral to a gynecologist or
urologist is an appropriate and vital component for
safe administration of TRT [13,22].
Potential risks of TRT must be discussed with the pa-
tient and informed consent of receiving this knowledge
should be documented [13]. TRT can cause erythrocyto-
sis, which in turn can have adverse cardiovascular or
neurologic events. TRT can also cause testicular atrophy
The Latest in Cosmetic Medicine 7
and infertility. Symptoms of BPH may worsen with
therapy, although they could also improve. Acne and
other skin disorders, such as hirsutism, as well as exac-
erbation of sleep apnea, may occur with TRT [20].
Nutraceuticals and antiaging
An extensive amount of research is still required to
explore the profiles and extents of the benefits that nat-
ural compounds provide, although there is increasing
evidence that a nutritional approach provides a tool
to combat age-related diseases. Senescent cells have
been identified as the cause of organismal aging. Both
natural and synthetic compounds have been suggested
to have antisenescence activities, otherwise known as
senolytics [9]. Understanding proinflammatory signals
and prooxidant signals is important to develop man-
agement with antioxidants and antiinflammatory com-
pounds for healthier aging [9]. Polyphenol-rich foods
are one of nature’s antisenescent compounds [9]. Spe-
cific types of polyphenols have properties that not
only promote cell death of aging cells but also delay
the death of healthy tissue. Many supplements use poly-
phenol extract to produce concentrated polyphenol
with the intent of health promotion for the consumer.
Antioxidant and antiinflammatory properties of poly-
phenols reduce the risk of developing age-related dis-
ease [9].
There is evidence that polyphenols contain cardio-
protective and neuroprotective functions such as the
reduction of postprandial hyperlipemia and insulin
resistance. A reduction in glucose uptake in tumor cells
induced by certain polyphenols suggests an anticancer
effect in several human cancers [9]. Although
polyphenol-rich nutrients are a source of chemopreven-
tive, antioxidant, and antiaging properties, there are
other nutrients that have been observed and are viewed
as having similar effects on the human body. The
following descriptions explore popular forms of supple-
mentation widely available and sometimes marketed
with antiaging properties. Chemopreventive and antise-
nescent properties are the focus of properties of each
nutraceutical or supplement described [9].
Curcumin
Curcumin is a polyphenol-rich source often used in the
form of a spice. Curcumin is a root also known as
turmeric or Curcuma longa. It is an ingredient that is
often used in cooking and is one of the ingredients in
curry powder. Curcuminoids are the bioactive compo-
nents of curcumin [1,9,23]. These have been of interest
for years in chemoprevention because they can inhibit
carcinogen activation by way of cytochrome enzymes.
Another random document with
no related content on Scribd:
 The candidates being seated on the gunners’ seats, an officer of
the battery commands, for example:
1. Aiming point, the chimney on that white house.
2. Deflection, 440.
3. On No. 2 close 10.
At the last word of command for the deflection each man sets off
the deflection; applies the correction for deflection difference
appropriate for his piece; causes the trail to be shifted until the sight
is directed upon the aiming point; corrects for difference of level of
the wheels; raises or lowers the panoramic sight until the field of
view will include the aiming point; traverses the piece until the
vertical hair is on the aiming point; calls “Ready” and steps clear.
The trial being completed and the men again being seated, the
officer commands for example, in continuance of the assumed
situation:
1. Right, 120.
2. On No. 4, close 5.
At the last word of command for the deflection, each man operates
the sight and, if necessary, the trail as before; traverses the piece
until the vertical hair is on the aiming point; calls “Ready” and steps
clear.
The third and fourth trial is similarly conducted.
No credits will be given in the following cases:
1. If the sight is incorrectly set for the deflection or deflection
difference.
2. If, when the bubble of the cross level is accurately centered, the
vertical cross hair is found not to be on the aiming point.
3. If, at any time during the trial, the man has operated the
elevating device.
If the piece is found to be correctly laid within the limits prescribed,
credits will be given as follows:
 Time in seconds, exactly, or less than18 20 21 22 23 24
Credits 2.0 1.9 1.7 1.5 1.4 1.3

Laying for Range.

Six trials, using the range quadrant.
The man being seated on the seat on the right side of the trail, an
officer of the battery commands, for example:
1. Site, 280.
2. 3400.
At the last word of the command, the man sets off the angle of
site; sets the quadrant for range; corrects for difference of level of
wheels; turns the elevating crank so as to center the range bubble;
calls “Ready” and steps clear.
No credits will be given in the following cases:
1. If the quadrant is incorrectly set for angle of site or range.
2. If no part of the bubble of the cross level is between the middle
two lines on the glass tube.
3. If there be found to be an error of more than 50 yards in laying
for any range less than 1,500 yards or more than 25 yards for any
equal range to or exceeding 1,500 yards.
If the piece is found to be correctly laid within the limits prescribed,
credits will be given as follows:
Time in seconds, exactly, or less than14 16 18 19 20 21
Credits 3.0 2.3 2.6 2.4 2.2 2

Fuse Setting.
 12 Trials: 6 with the bracket fuse setter, 6 with the hand fuse
setter.
Drill cartridges with fuses in good order set at safety are placed as
in service. An officer of the battery commands, for example:
1. Corrector, 24.
2. 2700.
At the last word of the command for the corrector, in trials with the
bracket fuse setter, the man sets the fuse setter at the corrector, and,
as the data are received, at the range ordered, receives the cartridge
from an assistant, inserts its head in the instrument, sets the fuse
and calls “Ready.”
At the last word of the command for the corrector, in trials with
the hand fuse setter, the candidate sets the fuse setter at the
corrector, and, as the data are received at the range, ordered; with
the aid of an assistant, sets the fuse, and calls “Ready.”
No credits are given in the following cases:
1. If the fuse setter is incorrectly set for corrector or range.
2. If the candidate fails to obtain a correct fuse setting within one-
fifth of a second.
If the fuse setter is found to be correctly set and is properly
operated, credits are given as follows:
Time in seconds, exactly, or less than8 9 10 11 12 13
Credits 1.5 1.4 1.3 1.2 1.1 1.0

Drill of the Gun Squad.

The subjects will embrace such parts of the following exercises (D.
and S. R. F. A.) as will thoroughly test the candidate’s familiarity with
the service of the piece: Formation of the gun squad (135, 138); to
form the gun squad (170-173); to tell off the gun squad (174); post of
the gun squads (175-177); to post the gun squad (178-179); posts of
the cannoneers, carriages limbered (180-182); to mount the
cannoneers (183-185); to dismount the cannoneers (186-187); to
change posts (189-190); to move by hand the carriages limbered
(191-192); to leave the park (204); action front (199); posts of the
cannoneers, carriages unlimbered but not prepared for action (188);
limber front and rear (202); action rear (200); limber rear (203); to
move by hand the carriages unlimbered (937); prepare for action
(938); march order (942); posts of the cannoneers, carriages
unlimbered and prepared for action (941); duties in detail of the
gunner (845-869); duties in detail of No. 1 (870-891); duties in detail
of No. 2 (892-901); duties in detail of No. 3 (902-911); duties in detail
of No. 4 (913-918); duties in detail of No. 5 (919-924); methods of
laying (985-988); and methods of fire (995-1008).
The questions will only cover the important parts covered in the
paragraphs above.

Materiel.
The examination of each candidate will be sufficiently extended to
test his familiarity with the use and care of the materiel of his
organization, and will be theoretical. The examination will be
conducted by questions on the following subjects: Nomenclature of
harness and of the parts and accessories of the wheeled materiel;
use of oils; method of cleaning and lubricating parts and
mechanisms; method of cleaning cylinder oil and of emptying and
filling cylinders; use of tools; the kinds of projectiles, of fuses, and of
powder actually issued for use, and their projectiles, of fuses, and of
powder actually issued for use, and their general purpose and effect,
omitting questions as to construction, weight, manufacture, and
technical description; the care and preservation of saddle and
harness equipment in use. Description of: breech mechanism, to
mount, to assemble; elevating screws, to dismount, to assemble;
hub liner, to remove, to assemble; brakes, piece and caisson, to
adjust; wheel, to remove, to replace.
Chevrons will be issued to those candidates who qualify and will
be worn as prescribed in orders.
 DON’TS FOR CANNONEERS.
Don’ts for All Cannoneers:
—Sacrifice accuracy for speed.
—Guess at the data.
—Expose yourself.
—Let your attention be distracted.
—Make unnecessary moves.
—Talk.
Don’ts for Chief of Section:
—Forget that you are responsible for the work of your
squad.
—Fail to assist the gunner in laying on the aiming point.
—Say “Muzzle Right (left),” merely move your hand in
the direction you desire the trail shifted.
—Write down the data.
—Forget your proper pose, covering No. 3 opposite the
float.
—Forget to extend your arm vertically, fingers joined,
after the gunner has announced “Ready.”
—Fail to caution “With the Lanyard” for the first shot.
—Fail to look at both gunner and executive.
—Command “Fire;” merely drop your arm.
—Fail to designate who shall assist No. 2 when he is
unable to shift the trail.
—Forget to announce “Volley Complete.”
—Forget to select the individual Aiming Points for the
gunner.
 —Forget to announce “No. (so & so) on Aiming Point,”
in reciprocal laying.
—Ever say “Range 3000,” merely “3000.”
Dont’s for Gunner:
—Forget to place the sight bracket cover in the left axle
seat.
—Forget to put the sight shank cover in the trail box.
—Forget to close the panoramic sight box, and fasten it
with your left hand.
—Forget to clamp the panoramic sight in its seat.
—Forget to close the ports in the shield.
—Forget to put your weight against the shoulder guard
while laying.
—Touch any adjustment after calling “Ready.”
—Forget to move your head from the panoramic sight
after calling “Ready.”
—Lean against the wheel.
—Fail to take up lost motion in the proper direction.
—Fail to watch the executive after calling “Ready.”
—Signal with your hand for movements of the trail.
—Fail to identify Aiming Points or Targets.
—Fail to secure hood on sight bracket.
—Say “Whoa” to No. 2 while the trail is being shifted.
Say “Trail Down.”
—Fail to lower the top shield at once at the command
“March Order.”
—Forget to relay vertical hair on A. P. at completion of
sweeping volley.
 —Forget to set range 1000, deflection zero in “Fire at
Will.”
—Forget to say “Ready” just loud enough for the chief of
section to hear.
—Forget to chalk up the deflection on the main shield in
reciprocal laying.
—Forget to set site and level bubble (British).
—Forget to release the brake in trail shifts (British).
—Forget to count “1001, 1002” to preserve proper firing
interval.
Dont’s for Number 1:
—Touch the firing handle until you announce “Set.”
—Fire the piece with the right hand.
—Try to throw the drill cartridge over the float by jerking
the breech open.
—Slam the breech.
—Fail to level bubbles.
—Fail to set and release brake in trail shifts.
—Fail to look squarely at the scales of the quadrant.
—Fail to take up lost motion properly.
—Forget to close the quadrant box.
—Fire the piece until the command is given.
—Lean against the wheel.
—Forget to keep up with the range in direct laying.
—Forget to lower the top shield immediately at “March
Order.”
—Talk.
Dont’s for Number 2:
 —Throw the breech cover on the ground.
—Fail to engage the handspike.
—Slam the apron.
—Put feet on the float.
—Wait for the command in shifts of 50 mils or more.
—Move the trail in a series of shifts.
—Fail to mark off 11 lines 50 mils apart at once on
taking your post.
—Fail to secure the breech cover.
—Fail to secure the handspike in “March Order.”
—Run between carriages.
—Fail to throw empty cartridge cases out of the way of
the cannoneers.
—Forget the tow and waste.
—Talk.
Dont’s for Number 3:
—Run between the carriages.
—Throw the muzzle cover on the ground.
—Throw the front sight cover on the ground.
—Slam the apron.
—Fail to see that fuze is set at safety at “March Order.”
—Fail to look directly down at the fuze setter while
adjusting scales.
—Take right hand from the corrector worm knob and left
from the range worm crank, during drill.
—Forget to set range zero in “Fire at Will.”
—Cross your legs.
 —Forget to set each announced range regardless of the
kind of fire being used.
—Talk.
Dont’s for Number 4:
—Throw the fuze setter cover on the ground.
—Slam the apron.
—Forget to set the fuze at “Safety” in “March Order.”
—Fail to glance into the bore to get the alignment.
—Touch a round after inserting it in the breech.
—Fail to completely set each fuze.
—Forget to take the round from No. 5 from beneath in
percussion fire and from the top when the hand
fuze setter is used.
—Forget to say, “3200, 2, last round,” only loud enough
to reach the chief of section.
—Forget to secure the cover on the fuze setter.
—Attempt to move the caisson with the door open.
—Forget to set and release the caisson brake (Model
1902).
—Turn the round to the left after setting.
—Talk.
Dont’s for Number 5:
—Slam the apron.
—Attempt to move the caisson with the door open.
—Forget to put your left elbow on the outside of your left
knee in using the hand fuze setter.
—Forget to set the brake on the 1916 caisson.
—Throw the waterproof caps under your feet.
 —Talk.

TRAINING GUN CREWS.

This article is not intended to cover all of the work of the gun crew,
it is intended merely to cover certain points sometimes lost sight of.
References are to the 3” gun, but any crew efficient in serving that
excellent weapon will have little trouble in mastering any other.
All refinements taught have but one prime object, that is accuracy
of fire. It is of no value to make atmospheric and velocity corrections
if still greater variations are constantly introduced by poor service of
the piece. The foundation of battery efficiency is well-trained gun
crews. Officers may be able to lay out orienting lines with the
greatest facility, may know the range tables in the dark, but it will
avail little if they cannot train men to apply properly and accurately
the data determined.
The safety of our own infantry and the effectiveness of our fire are
absolutely dependent on the continuous training of gun crews, and
the resultant precision and sureness with which they perform their
work. This can only be obtained by constant drill from the day the
recruit joins until the day of his discharge; not by long drills in which
he grows tired and loses interest, but by short periods broken by
instruction in other subjects; not by many hours one week and none
the next, but by a short period every day of the week. The best
gunners grow rusty in a very few days; constant short drills will give
results and are the secret of success. Every man must get
instructions every day, be he raw recruit or expert gunner.
Cannoneers should be taught that the greatest crime that can be
committed in laying the piece is to make an error—the only crime for
which there is no punishment. An error or mistake in the correct
service of the piece should not be punished, but it should be
carefully explained how the efficiency of the battery depends on
each member, and to insure that crime is not committed again,
additional hours of instruction beyond that required for the rest of the
crew will be necessary.
Every man must be on his toes from the time he comes in sight of
his gun, every movement at the piece must be at a run. Slow and
sleepy motions of one man will kill all the snap and energy of every
other member of the crew. Do not, however, confuse speed of
performing any given motion with hurry in execution of detail. For
example, the gunner must move with snap and energy in getting his
eye back to the sight and his hand on the traversing handwheel after
the piece is fired, but he must never be hurried in getting the vertical
wire exactly on the aiming point, or in making the ordered changes in
the deflection setting. Stop watches should not be used. They are a
fruitful cause of errors. Speed comes from continual practice and it
cannot be artificially attained by stop-watch timing. Do not
understand that speed is not desirable, it is highly desirable, but
practice alone will give it and it will nearly always be found that the
best-trained crew is the fastest crew. Competitions between crews
must be for accuracy, not speed. If every motion is made with a snap
and at a run the results as regards speed will be satisfactory.
The accuracy of fire is affected by brakes not being adjusted for
equal tension, by direction of recoil not being in line with the trail, by
No. 2 sitting on the handspike and shifting his weight after the
gunner has called “Ready;” by No. 1 jerking the firing handle; by the
gunner not keeping his shoulder against the guard; by elevating
cranks not being properly assembled; by sights and quadrants not
being properly adjusted or locked with means provided (this subject
deserves several pages); by variations in the amount of oil in the
cylinder; by improper adjustment of the gland; by the gunner coming
on to the aiming point sometimes from the right, sometimes from the
left; by the No. 1 centering the bubble sometimes from front to rear,
sometimes from rear to front.
You may have stood behind a battery firing and noticed how one
or two guns jump violently in recoil, while others would hardly disturb
the proverbial glass of water on top of the wheel, although all guns of
equal service. This was due almost entirely to the lack of proper
adjustment of some of the parts mentioned above.
 Every member of the crew must know his duties so well as to
make his motion automatic; the direction to turn the various
handwheels, milled heads, and gears to obtain the desired result,
and he must always do these things in the same way. The effect of
small differences in laying may be graphically shown the gun crew
by firing sub-caliber ammunition at a small arms steel target which
rings a bell when a bull’s-eye is made. Erratic shots means poor
adjustments of equipment or poor training of the gun crew. Pleas that
worn material or lost motion, or defective ammunition are the causes
of erratic shooting are largely excuses for ignorance, laziness, and
lack of proper instruction. Worn materiel requires more makeshifts,
takes longer to lay and more careful watching, so that fire cannot be
so rapid, but except for wear in the bore of the gun it is possible to
do almost as accurate shooting with worn materiel, especially if the
new materiel has not been thoroughly worked in.
Among the more important duties of the men may be mentioned in
the following:
Chief of Section.—Must teach his men to have pride in the gun
they serve, and the reputation of the section. He shows each
member how the accuracy of firing is dependent on him, and that
one man may ruin the best efforts of all the others. He must keep his
materiel as clean as when it left the makers hand, every part
functioning properly, every screw and nut tightened, no burred nuts
or bolts, or missing split pins. He helps each member to take a pride
in keeping the part for which he is responsible as clean as a new pin
and in perfect condition. He sees that the various canvas covers and
sponge and rammer never touch the ground where they will gather
dirt. He knows the proper use of his tools, and the correct adjustment
of the firing mechanism. He must be able to assemble and
disassemble blindfolded the firing lock and breech mechanism. In
firing he knows the settings of all scales without reference to a data
book.
The Gunner.—Knows that turning the levelling screw clockwise
moves cross bubble to the right; that turning scroll gear clockwise
increases the range; that turning the peep sight screw clockwise
increases deflection, and so on with all handwheels, etc., that he
operates and must know these things so well that he operates them
in the proper direction automatically. Must always bring vertical wire
on aiming point from the left to take up any play in traversing
mechanism. He verifies that he is on the aiming point after the
breech is closed and if there is any delay, again immediately before
firing. He gets his eye back to the sight and relays immediately the
gun returns to battery. He knows his scale readings at all times. He
keeps his sight scrupulously clean, never permits his finger to touch
the objective prism when turning the rotating head, nor wipes off eye
piece with hand. He keeps his shoulder against the guard at all
times.
The Number 1.—He knows his site and range scale readings
without having to look at them. In centering the bubble he brings it
always from front to rear to take up play in the elevating mechanism.
He centers the bubble so accurately that it is not the thickness of a
sheet of tissue paper nearer one graduation than the other, and what
is most important he sees that it stays there until he fires the pieces,
when he promptly recentres it. (The latitude allowed in centring the
bubble by our gunners’ examination is responsible for 20 per cent. of
our field probable error.) He must not fire the piece with a jerk but
with a constant even pressure, else he may destroy all his accuracy
of levelling. The same principle applies if he uses the lanyard. He
keeps his quadrant free from any sign of dirt and assures himself
that it is in perfect condition. If the gunner fails to keep his shoulder
against the guard when the piece is fired he reminds him of it. In
centring the bubble or setting the scales he gets his eye squarely
opposite the scale or bubble.
The Number 2.—He knows the width of the spade, float, etc., in
mils, and is able to make any shift under two hundred mils, within 5
mils. He shifts the trail so as to bring the direction of recoil in line with
it (except for moving targets). In receiving empty cases he should not
permit them to strike the trail or throw them against each other, as
they must then be resized before they can be again used. If he sits
on the handspike he must not shift his weight after the piece is laid.
The Number 3.—He knows that turning the corrector worm knob
clockwise decreases the setting; turning the range worm crank
clockwise increases the range. In making these settings he keeps
his eye squarely over the scales. He knows his scale settings at all
times. He is taught to keep his fuze setter and its cover clean, and is
shown how a small pile of dirt or wax behind the stop pin or in the
rotating pin notch can throw out his settings and ruin the reputation
of his section. Gum from the fuze often collects in these places. The
surest way is to keep a match stick handy and clean out these
places whenever there is a lull in the firing.
The Number 4.—If necessary to reset the fuze he must turn the
projectile until it brings up against the stop pin, then cease all turning
movement and draw the projectile straight out of the fuze setter. If he
continues the turning motion unconsciously he can easily alter the
setting by a fifth of a second. In loading he is careful not to strike the
fuze against the breech and so alter the fuze setting.
The Number 5.—He knows where the rotating pin notch is in the
fuze setter, and where the corresponding pin is on the fuze. He
places the fuze so that the pin is seated in the notch with little or no
turning movement and turns rapidly but with no more force than
required. He is careful to set all fuzes with the same force, that is,
not turn one with a violent twist and the next barely up to the stop.
APPENDIX “B”—Comparative table of
guns used in World’s War.
Gt. U. U.
Austria, France, Germany, Italy, Russia,
Britain, States, States,
1905 1897 1906 1912 1903
1917 1902 1916
Caliber, inches 3.01 2.95 3.03 3.3 2.95 3. 3. 2.95
Weight of
14.72 16.00 15.00 18.00 14.3 14.41 15.00 16.00
shrapnel, lbs.
Muzzle velocity, f.
1640 1750 1760 1680 1510 1930 1700 1600
s.
Muzzle energy, ft.
275 335 242 340 224 273 300 311
tons
Weight of gun 700 1000 766 880 690 785 710 765
Weight of gun and
2000 2650 1860 2600 2260 2075 2230 3000
carriage
Weight of g., c.
3750 4150 4200 4100 3350 3850 3730 4400
and limber
Maximum
18 18 16 33 65 16$ 16 53
elevation
Total traverse,
8 6 8 8 52 5½ 8 45
degrees
Length of recoil, 18-
51.5 47 44 28-48 42.5 50 18-46
inches 53
Height of wheels 4’3” 4’ 4’5½” 4’3” 4’3½” 4’4” 4’8” 4’8”
Independent line
No. Yes. No. Yes. Yes. No. No. Yes.
of sight
Sights,
goniometric,
telescopic, P. G. T. G. O. P. T. P. O. P. O. P. O. P.
panoramic,
ordinary
Breech block, W. E. S. W. S. W. S. B. S. B. W.
wedge
swinging,
 eccentric
screw.
Traverse, axle or
P. A. P. A. P. A. A. P.
pintle
Recuperation,
spring or
S. H. S. H. H. S. S. S.
hydro-
pneumatic
Length of gun,
30 36 27.3 28.0 30 30 29.2 30.8
calibers
Width of track,
60 60 60 66 58 60 60 60
inches
Range, maximum 6400 7550 7600 9000 8850 7800 6500 9650
 APPENDIX “C”

TABLE OF EQUIVALENTS.
1 mil. 3.37 minutes.
1 meter (m) 39.37 inches.
1 centimeter (cm) .3937 inch.
1 millimeter (mm) .03937 inch.
1 kilogram (kg) 2.2046 pounds.
1 dekagram (dkg) .3527 ounce.
1 gram 15.432 grains.
1 liter 1.05671 quarts (U.S.).
1 inch 2.54 centimeters.
1 foot .3048 meter.
1 yard .9144 meter.
1 square inch 6.452 square centimeters.
1 cubic inch 16.39 cubic centimeters.
1 cubic foot .02832 cubic meter.
1 cubic yard .7645 cubic meter.
1 ounce 28.35 grams.
1 pound .4536 kilogram.
1 quart (U. S.) .9463 liter.
1 degree 17.777 mils.
1 kilogram (kg) per square 14.223 pounds per square
centimeter inch.
 INDEX
Abatage, French 75-mm, 95
Action of Recoil Mechanism, 3-inch Gun, 70
Aiming Circle, 274
Air and Liquid Pumps, 155-mm Howitzer, 189
American 75, 105
Ammunition, 199
Ammunition 3-inch Gun, 214
Ammunition, Definition of, 11
Ammunition Marking, 233
Ammunition Truck, 334
Angle of Site Mechanism, American 75, 127
Anti-Aircraft Guns, 60
Armament, Modern, 46
Army Artillery, 57
Artillery, Definition of, 11
Artillery Tractor, 330
Assembling 3-inch Gun, 76, 242
Assembling American 75, 133
Automatic Pistol, 315
Automatic Rifle, 322, 325
Axles, Discussion, 44

Ballistics, Definition of, 11

Battery Commander’s Telescope Model 1915, 270
Biblical References to Artillery, 16
Bicarbonate of Soda, 239
Bore, Definition of, 11
Borax, 238
Bracket, Fuze Setter, 283
Breechblock, 4.7-inch Gun, 156
Breechblock, British 75, 150
Breechblock, French 75, 87
Breechblocks, Discussion of, 31
Breech, Definition of, 12
Breech Mechanism 3-inch Gun, 63
Breech Mechanism, American 75, 106
Breech Mechanism, G. P. F., 162
Breech Mechanism, 155-mm Howitzer, 173
British 75, 147
Browning Automatic Rifle, 325
Browning Machine Gun, 323
Built-up Guns, Discussion of, 29

Caisson 3-inch Gun, 74

Caisson, Definition of, 12
Caliber, Definition of, 12
Camp Telephone, 286
Canvas Buckets, 241
Care of 3-inch Gun, 242
Care and Cleaning of Cloth, 252
Care and Cleaning of Leather, 249
Care and Cleaning of Metal, 252
Care and Inspection of Sights, 267
Care and Preservation, French 75, 101
Care of Guns During Firing, 253
Care of 155-mm Howitzer, Notes on, 194
Care and Preservation of Materiel, 236
Carriages, Gun, 3-inch, 65
Carriage, Gun, Definition of, 12
Carriage, American 75, Description, 111
Carriage 4.7-inch Gun, Description, 154
Carriage 155-mm Howitzer, Description, 179
Cartridge Case, Care of, 219
Cartridge, Case, Definition, 12
Charge, Definition, 12
Classification of fuzes, 224
Cleaning Material, 236
Cleaning Schedule, 254
Clock Oil, Use of, 237
Cloth Equipment, Care of, 252
Coal Oil, Use of, 237
Combination Fuzes, Tables of, 232
Cannoneers’ “Don’ts”, 360
Conventional Signals, 301
Corps Artillery, Discussion, 55
Cradle, Definition of, 12