Tag Archives: Physician Assistant Cullinane

Body Contouring Using CoolSculpting

Did you know that body contouring is among the most common cosmetic surgical procedures performed in the United States? The American Society for Aesthetic Plastic Surgery reports that it is more popular than breast augmentation.

CoolSculpting® (technically known as cryolipolysis) involves placement of a CoolSculpting device that combines vacuum suction with regulated cooling to impede blood flow in just the area being treated. This results in crystallization and removal of the targeted fat tissue. Importantly, at the temperatures used, cryolipolysis is limited to fat cells and has have no permanent effect on overlying dermis and epidermis tissues.

Not for Weight Loss

Cryolipolysis is not used to help people lose weight; and it is not an alternative to diet and exercise. Rather, Coolsculpting is replacing liposuction as the go-to procedure for body contouring. Our office has been doing this procedure for over 4 years.

CoolSculpting achieves body contouring by targeting stubborn localized areas of fat. Areas of treatment include “love handles,” the upper and lower abdomen, upper arm, and inner and outer thigh. Men also find CoolSculpting useful to sculpt the chest.

Response to CoolSculpting

While some patients may see results as early as 3 weeks after initial treatment, the most dramatic results are usually seen between 1 and 3 months following treatment.

Among 19 studies of cryolipolysis, each reported a significant reduction in fat volume in treated areas. The average 2- to 6-month reduction in fat volume ranged from 15% to 29%. The researchers concluded, “Cryolipolysis is a promising procedure for nonsurgical fat reduction and body contouring and presents a compelling alternative to liposuction and other, more invasive methods.”

Following two treatments in the hip and thigh area, the average fat layer reduction was 29% compared with 20% for patients receiving only one treatment.

Most, importantly, it was possible for people not involved in the treatment to see improvement in 79% to 89% of patients. And, most people can return to their normal activities immediately after CoolSculpting.

Importance of a Qualified Professional When CoolSculpting

When performed by a qualified and experienced aesthetic dermatologist, CoolSculpting has a low risk of side effects. During the 2 weeks following cryolipolysis there is minimal discomfort, with less than 1% of patients experiencing pain, which goes away without treatment. Other side effects are temporary redness, bruising, and short-lived numbness.

But like any medical procedure, inexperience can lead to unwanted results.  For example, earlier this year a patient experienced frostbite following CoolSculpting treatment for love handles performed in a beauty salon. It appears that the person performing cryolysis didn’t recognize the early signs. In fact, medical attention was not sought until one week later.

In California, the applicator may only be placed on the patient, by a Physician, Physician Assistant, Registered Nurse, NOT by a Medical Assistant, Licensed Vocational Nurse, nor an Esthetician.

The authors rightly concluded, “Emphasis must be placed on increasing patient awareness of the potential hazards of seeking cosmetic treatment from unregulated providers.”

CoolSculpting at Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D. follows a strict procedure that ensures you will enjoy the best results. For consultation and more information about our approach to CoolSculpting to achieve the best look for you, call our San Francisco office at (415) 956-8686, or in Mill Valley call (415) 383-5475.

Two New Treatments for Laugh Lines

Two new facial fillers—Restylane® Refyne and Restylane® Defyne—are now approved by the U.S. Food and Drug Administration and are offered as treatment options by Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D.

Photo. The nasolabial folds commonly known as "smile lines" or "laugh lines", are the two skin folds that run from each side of the nose to the corners of the mouth.

Photo. The nasolabial folds commonly known as “smile lines” or “laugh lines”, are the two skin folds that run from each side of the nose to the corners of the mouth.

Both fillers target moderate-to-severe “laugh lines” in adults. This is the area known as nasolabial folds (NLF), which extend from the nose to corners of the mouth, as shown in the photo. Restylane Refyne is designed to treat moderate wrinkles and folds, while Restylane Defyne is meant to plump and fill deep-set lines.

Refyne is the softer of the two, better for thinner skin, Defyne is the thicker product with more  up lift and better for thicker skin. Both products can be used off label in other facial areas such as the oral commissures, marionette lines, cheeks etc.

Here’s What We Know about Refyne and Defyne

Both injectable products are based on hyaluronic acid—the most commonly used injectable for facial rejuvenation. They differ from other products in the class because of a unique manufacturing process called XpresHAn Technology, which gives a more natural-looking appearance due to “cohesiveness”—the ability of a filler to “stick to itself” and blend with the surrounding tissues.

Although new to patients in the U.S., both fillers were approved for use in Europe back in 2010. So, there’s lots of experience with them; and this positive experience has been confirmed in two studies in the U.S. These studies are referred to as “Natural Expression” and “Dynamic Strain.”

Natural Expression Study

In this study, the product selected (Restylane Refyne or Restylane Defyne) and the amount injected in each of 63 women was based on the assessment by an expert in facial aesthetic procedures. Following correction of wrinkles and folds along the NLF in the lower face, each woman rated the naturalness of their appearance of facial contractions during movement and at rest (natural expression).

There was broad agreement among 95% (60/63) of the women treated that attractiveness was enhanced. In addition, 89% (56/63) of women reported that attractiveness was enhanced, while 79% (50/63) agreed they looked younger.

Dynamic Strain Study

As in the Natural Expression Study, this study evaluated the naturalness of facial expressions following correction of wrinkles and folds along the NLF. It differs in that facial expressions were measured three dimensionally to objectively (and dynamically) record surface strain on the skin.

The results from 30 women (40 to 65 years old) showed a statistically significant reduction in the average peak dynamic strain for various standardized expressions one-month after treatment compared to before treatment.

Importantly, the women agreed. More than 8 out of 10 reported enhanced attractiveness. They thought they looked younger, with a naturalness of their expressions.

Both Restylane Refyne and Restylane Defyne were well-tolerated by the women taking part in the studies. Initial treatment injection site responses (redness, swelling, bruising, lump/bump formation, pain/tenderness) were predominantly mild-to-moderate in intensity and resolved in one to two weeks.

Which Treatment Is Right for You?

These products offer the latest advances in the ongoing effort to provide improved treatment for aging skin. But which treatment is right for you?

As treatments improve and become specialized, the role of an expert board-certified aesthetic dermatologist to recognize the best option and then to achieve the best results becomes ever more important.

For consultation and more information about our approach to using facial fillers to achieve the best look for you, contact Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D. Drs. Binstock, Layton, and Physician Assistant Cullinane will answer your questions. Call our San Francisco office at (415) 956-8686, or in Mill Valley call (415) 383-5475.

 

 

A Woman’s Lips and the Importance of First Impressions

A woman’s lips are the most attractive part of her body. During the first ten seconds after meeting a lady for the first time, the average man spends more than half his time gazing at her mouth.

Sue Leeson, who is marketing director of QVC, tell us, “It seems that no matter what your lips are like naturally, there is a solution for everybody.” So, it’s not surprising to learn that lip enhancement is one of the most frequently requested cosmetic procedures. It’s also technically demanding. To achieve the most aesthetically pleasing lips, the aesthetic dermatologist must weave art with science.

Getting Started

The goal for lip augmentation with dermal fillers like Restylane® Silk and Boletro® is to harmonize the appearance of the lips with other facial features. The process begins by applying the basic artistic principle known as DaVinci’s classic proportions—defined as PHI or the golden ratio.

Treatment targets as many as six anatomic areas: the philtrum columns, Cupid’s Bow, the vermilion-cutaneous junction, lower lip “pillows”, oral commissures, and the nasolabial creases. Each is shown in the photo.

Philtrum Columns 

Sculpted philtrum columns are in style. Yet, with age, these well-defined vertical columns are lost, leading to a flattened, unattractive upper lip. In such patients, it’s important to re-create them.

Cupid’s Bow

The pouty, Cupid’s Bow appearance of the central portion of the upper lip is considered sexy, desirable, and very much in fashion. Skilled placement of filler supports the projection of this area.

Vermillion Border

Precise injection technique is critical if this area is to be treated properly. Careful! A common error that results from a poor understanding of the delicate features of the lip occurs when filler is placed too far along the border, leading to a “sausage” or “duck” lip.

Lower Lip “Pillows”

Adding volume to the areas has a sexy effect.

Oral Commissures

Proper injection technique here creates a natural looking pout.

Nasolabial Creases

Filling the nasolabial creases makes the upper lip turn outward for a natural looking pout.

The Bottom Line

Lips are one of the most sensual part of a woman’s body and play a critical role in human sexual attraction, according to researcher, Dr. Geoff Beattie. Yet, each person has special needs and expectations—Caucasian women differ from African-American women and from men, for that matter. There is no single prescription for a “perfect” lip, nor a “one size fits all” approach for lip augmentation.

In addition to a lip assessment, expect that your consultation with the aesthetic dermatologist will include a discussion of treatment options, downtime after treatment, and medications and other conditions you may have. Photographs will aid before and after treatment assessments.

For a satisfactory aesthetic outcome, seek a board-certified aesthetic dermatologist who is experienced in evaluating and treating this complex soft tissue area. For consultation and more information about our approach to lip augmentation, contact Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D. Drs. Binstock, Layton, and Physician Assistant Cullinane will answer your questions. Call our San Francisco office at (415) 956-8686, or in Mill Valley call (415) 383-5475.

 

Benefits of a Long-term Strategy for Facial Rejuvenation

Today we know that repeated treatments with Botox® lead to improved results long-term, while the response to fillers appears to continue beyond the initial treatment period. Both have implications for achieving the best response possible when applied as part of a strategy for facial rejuvenation.

“The greatest benefits,” according to international experts, “are obtained if patients return for treatment when the previous results start to diminish rather than after they disappear completely.”

Support for follow-up Botox injections comes from a review of 194 patients who received Botox treatments over an average of 9 years for the vertical wrinkles that developed between their eyebrows—commonly known as frown lines. Ongoing evaluation and treatments as needed lead to sustained improvement and, most importantly, “very high patient satisfaction!” Those treated for longer periods reported greater perceived benefits in terms of increased pliability and elastic recoil.

The long-term restorative potential of hyaluronic acid filler (Juvéderm® Ultra) was shown among more than 350 patients. Improvement persisted beyond the time that could be accounted for by space-filling effects alone! It is suggested that in these patients there was an up-regulation in collagen and elastin formation after injection of the filler—a response not seen when saline is injected.

The bottom line.

We keep learning more about facial fillers and Botox. Now more than ever, consultation with an expert aesthetic dermatologist is essential for anyone seeking to restore a youthful facial appearance. For a consultation and more information about the benefits of fillers and Botox for you, contact Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D. Drs. BinstockLayton, and Physician Assistant Cullinane will answer your questions. Call our San Francisco office at (415) 956-8686, or in Mill Valley call (415) 383-5475.

Treating Rosacea with IPL

Intense pulsed light (IPL), or photofacial therapy, uses high intensity pulses of visible light to improve the appearance of people with rosacea.

Figure. Illustration of the skin showing the upper epidermis and lower dermis layers.

Figure. Illustration of the skin showing the upper epidermis and lower dermis layers.

IPL systems work on the lower layers of skin (dermis) without affecting the top layers (epidermis) as identified in the illustration. During treatment, light energy is absorbed into colored target cells and converted to heat energy. This heat energy is what treats the targeted area, leaving surrounding areas damage free.

IPL systems differ from lasers in that they deliver 500 wavelengths of light in each pulse of light instead of just one wavelength as a laser does. Filters refine the energy output and enhance penetration. A qualified aesthetic dermatologist will know the correct energy and filters for the patient.

An advantage of IPL therapy is its minimal downtime. Patients can often have the procedure done during their lunch break and then return to work.

As an example of the benefits of IPL in selected patients with rosacea, here is a summary of a study where IPL significantly reduced erythema (facial redness) and telangiectasia (threadlike red lines or patterns on the skin caused by tiny blood vessels).

Here’s what was done.

Changes in erythema of cheeks and chin were measured before and at the end of 4 treatments given at 3-week intervals.

Using a 10-point scale, a consultant dermatologists evaluated the response based on digital photographs. Patients also recorded their own assessments. Outcomes measures were repeated 6 months after treatment.

Here’s what they found.

After four treatments, the consultant dermatologist determined that changes in the photographs revealed that erythema improved 46%, while telangiectasia improved 55%. The severity of rosacea was reduced on average 3.5 points on the 10-point scale.

Patients and physicians agreed there was overall improvement of rosacea. More than 50% improvement was reported by 73% of patients and 83% of physicians. Importantly, the results were sustained at 6 months after the last treatment; and side-effects were minimal and self-limiting.

The bottom line.

The benefits experienced by these patients was due to the ability of an experienced aesthetic dermatologist who could identify the best treatment administered at the most effective dose to meet each patient’s special needs. Remember, there are many treatments for rosacea. However, success with IPL (or any treatment) is maximized when patients consult a experienced board-certified aesthetic dermatologist.

For a consultation and more information about treating rosacea, contact Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D. Drs. BinstockLayton, and Physician Assistant Cullinane will answer your questions. Call our San Francisco office at (415) 956-8686, or in Mill Valley call (415) 383-5475.

Using the Excel V Laser in People with Rosacea

Once a debilitating disorder, rosacea has become a manageable condition with many treatment options. The key to success starts with identifying an experienced board-certified aesthetic dermatologist who is skilled in identifying the specific subtype and severity of the condition. The next step is tailoring treatment to best suit your expectations.

Today, dermatologists recognize that certain types of lasers offer important options for managing more difficult-to-treat rosacea. In fact, according to the textbook, Update on the Management of Rosacea, “Lasers have created a paradigm shift in the treatment of the redness and telangiectasia [threadlike red lines or patterns on the skin] associated with rosacea.”

Excel V Laser

One option is the Excel V laser, which emits two wavelengths: KTP (potassium titanyl phosphate at 532 nm and Nd:YAG (neodymium-doped yttrium aluminium garnet at 1064 nm). KTP targets redness, hyperpigmentation, and damaged capillaries at the surface of the skin. Nd:YAG is designed to treat deeper, larger purple blood vessels. Following absorption of energy, abnormal blood vessels are sealed off, while hyperpigmented lesions are fragmented, resulting in an overall improved appearance. The results from two studies show how each wavelength contributes to a better outcome in selected patients with rosacea.

KTP

KTP targets melanin and oxyhemoglobin, which is present in oxygenated blood. Based on its short wavelength, the KTP laser treats superficial telangiectasia and redness. In one study, there was 62% clearance after the first treatment and 85% clearance three weeks after the third treatment. Patients experienced some swelling and redness following treatment. Because KTP targets melanin, it is reserved for people with lighter skin.

Nd:YAG

The Nd:YAG laser reaches deeper layers of skin tissue, targeting the lower absorption peak of oxyhemoglobin. In patients with purple facial telangiectasia treated twice, 30 days apart, 73% (11/15) showed moderate-to-significant improvement after the first treatment and at Day 30. At the 3-month follow up evaluation, 80% continued to show improved appearance.

The bottom line.

To achieve the best results, studies are always designed to ensure that patients are best matched to the treatment received. The same is true in a dermatology practice—recommendations are matched to your condition and your desired response. For a consultation and more information about treating rosacea, contact Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D. Drs. BinstockLayton, and Physician Assistant Cullinane will answer your questions. Call our San Francisco office at (415) 956-8686, or in Mill Valley call (415) 383-5475.

 

 

 

Fraxel: An Option to Treat Acne Scars

Not only are acne scars physically unappealing, evidence indicates that adults with acne scarring encounter prejudice at both work and play. So, it’s understandable that many people wish to minimize (if not eliminate) them.

Treatment of acne scars varies depending on the type of scar (often referred to as icepick, boxcar, or rolling). Therefore, advice from a qualified dermatologist is essential as you consider the effectiveness and tolerability of treatment, as well as downtime following therapy.

Today, there are two types of fractional lasers. The focus of this post is the gentler non ablative, erbium-type fractional lasers, like the Fraxel® Restore. The results of the study summarized here relate to important concerns among people with acne scars: effectiveness, tolerability, and overall satisfaction with treatment.

Here’s what they did.

Fifty-three patients with skin phototypes ranging from pale white skin to brown skin (Fitzpatrick I-V) were studied. Each had mild-to-moderate atrophic [depressed] facial acne scars. Treatment was given monthly with the gentler laser described above. Two assessors who were not involved with treatment rated the response at each treatment visit and 6 months after the final treatment session, while the patients assessed their side effects and satisfaction with treatment.

Here’s what they found.

After three-monthly treatments, nearly 90% of patents had an average improvement of 51% to 75%. And, improvement increased proportionately with each successive laser session. Age, gender, or skin color did not influence the response in this study.

Side effects included short-lived superficial reddening of the skin and swelling. There was no change in skin color; and nobody reported ulceration or scarring.

The bottom line.

It’s important to consider that the results reported in this study were dependent on the experience and the expertise of the aesthetic dermatology professional. Also, each participating patient was screened to ensure they were candidates for this treatment.

There many options for treating facial acne scars. Each has its own relative strength and weakness. Start your treatment search by seeking the advice of a board-certified aesthetic dermatologist who has experience using the treatment options that best meet your needs.

For a consultation and more information, contact Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D. Drs. BinstockLayton, and Physician Assistant Cullinane will answer your questions. Call our San Francisco office at (415) 956-8686, or in Mill Valley call (415) 383-5475.

 

 

Successful Treatment of Acne Scars in People of Asian Descent

When it comes to treating acne scars, the scaring and pigmentation issues faced by Asian Americans can be as troublesome as the original condition. This is because darkly pigmented skin is more vulnerable to dyspigmentation—an abnormality in the formation or distribution of pigment in the skin.

Non-ablative fractional resurfacing is one of several treatment options for acne scars in people of Asian descent (or anyone, for that matter). During this treatment, a laser delivers heat to targeted areas, while areas of healthy skin are left untreated. The fractional approach allows more rapid healing than if the entire area was treated.

Success following non-ablative fractional resurfacing

The results of two studies in people of Asian descent show that the number of treatments, the time between treatments, and use of the laser must be skillfully combined to get the best results.

For example, in a study of 27 Korean patients, with moderate-to-severe facial acne scars, the doctors assigned them to received 3 to 5 sessions of treatment, each spaced 3 to 4 weeks apart. The patients compared their results 3 months after the final treatment to photographs taken before treatment. Eight patients (30%) said the results were excellent, 16 patients (59%) described the improvement as significant, while 3 patients (11%) concluded they had moderate improvement. Side effects were limited to short-lived pain, redness, and swelling.

In another study of 47 Asians with facial scaring, where the dose and the number of treatments (8 passes or 4 passes) were assigned based on each patient’s needs, both treatments resulted in significantly improved skin texture and acne scarring. There was also improvement in enlarged pores and overall pigmentation irregularity compared to their initial photos. In this study, the risk of post-inflammatory hyperpigmentation was less among those who received 4 treatments.

The bottom line.

Treatments used in both studies were successful and support the role of non-ablative fractional resurfacing as part of a comprehensive treatment of acne scars among people of Asian descent.

Smooth skin and a flawless complexion are highly desired. And the most successful outcomes result from treating the initial concern (facial acne scaring), as well as minimizing changes in pigmentation as shown in the photos. Achieving this balance is where consultation with an aesthetic professional is indispensable. This is because many treatment options, including non-ablative fractional resurfacing, are available.

Photos are courtesy of Solta—pretreatment (left) and post-treatment (right).

Learn more about treating acne and other scars. For a consultation and more information about our approach to correcting acne scars with Fraxel Restore, our non-ablative fractional laser system, contact Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D. Drs. Binstock, Layton, and Physician Assistant Cullinane will answer your questions. Call our San Francisco office at (415) 956-8686, or in Mill Valley call (415) 383-5475.

Platelet Rich Plasma: The Body’s Own Healing Factors

Platelets are probably the best-known part of the blood clotting system. When we are injured and bleed, platelets are activated to help form the clot that stops the flow of blood. But there’s more to platelets than clotting. Every platelet is a biochemical storehouse of molecules that contribute to tissue healing.

Importantly, platelet-rich plasma (PRP) used in aesthetic dermatology procedures is a natural, safe product. Preparation requires taking a small amount of a patient’s own blood, which is spun in a centrifuge. A small amount of fluid containing concentrated platelets and growth factors is removed. Nothing else is added, so there’s no risk of allergy, reaction, or rejection. Therapy with PRP is a natural process that uses the body’s own healing factors.

Using PRP

The goal of PRP in skin rejuvenation is to improve skin tone and texture, tighten skin, and softening lines and pores. Following topical application or injection into specific areas of the skin, PRP acts as a matrix or a scaffold that promotes your own collagen to grow, regenerating naturally smooth skin.

When treating wrinkles, skin tone, and acne scars, there is minimal downtime.

Combining treatments

Platelet-rich plasma can be combined with neuromodulators such as Botox® and with hyaluronic acid fillers such as Juvéderm® and Restylane® to produce the best outcomes in aesthetic rejuvenation. It’s also used with laser treatments and microneedling, You can read more about using PRP layered on top of skin that has been treated microneedling to reduce wrinkles.

Even though it is safe and produces positive aesthetic results, many aesthetic medicine practitioners do not offer PRP as a treatment option. At Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D., we are experienced in using PRP alone or with other procedures to achieve the best results for our patients.

For a consultation and more information, contact Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D. Drs. Binstock and Layton will answer your questions. Call our San Francisco office at (415) 956-8686, or in Mill Valley call (415) 383-5475.

 

Microneedling and PRP Treats Wrinkles Seen in Aging Skin

Microneedling is a proven treatment for reducing the appearance of wrinkles and lines in aging skin.

As you might expect, microneedling refers to the use of needles or ‘microneedles’ to achieve a therapeutic effect. During the procedure, thousands of microchannels are believed to start a cascade of naturally occurring factors that stimulate the normal process of wound healing.

Here’s a summary of a study in patients treated with microneedling. The results will help you decide if microneedling is right for you.

Here’s what they did.

Microneedling treatments to the mid and lower face were given to 49 people each month for 3 months. Then, they were followed for another 3 months after their last treatment. Changes in wrinkles were evaluated using the Fitzpatrick’s Classification (Table 1). Pain and any side effects were also recorded.

Table 1. Fitzpatrick Classification of Facial Wrinkling

Here’s what they found.

The average Fitzpatrick score before microneedling was 5.0—fine-to-moderate depth wrinkles with a moderate number of lines.

By 1 month after 3 treatments were completed, the Fitzpatrick score declined significantly by one Class, from II to I, with an average score of 3.8—fine wrinkles.

When the patients were re-evaluated 3 months after the final treatment, their average score was 3.5. This confirmed that improvement was maintained.

Mild-to-moderate reddening of the skin was reported immediately after treatment and lasted up to 12 hours. On a scale ranging from 1 (no pain) to 10 (worst imaginable pain), the average level of pain reported by the patients was 4 (mild pain).

The researchers concluded that this treatment achieved significant wrinkle reduction, skin tightening, and lifting of the treated mid and lower face.

Here’s what you need to know.

Microneedling is performed after applying a topical anesthetic cream. Once the cream takes effect, the area is cleaned. Then, the microneedling device with a needle length based on your specific need is selected. The instrument is held like a pencil and rolled in three different directions over the area being treated. Platelet-rich plasma (PRP) is then rubbed into the skin.

Platelet-rich plasma is made by taking a small amount of a patient’s own blood, which is then spun in a centrifuge. This fluid containing concentrated platelets and growth factors is then removed. Nothing else is added, so there’s no risk of allergy, reaction, or rejection. Platelet rich plasma therapy is a purely natural process using the body’s own healing factors.

Any small amounts of blood are washed away, a final coating of PRP is then applied, and you will be given a post-treatment skin care program. Sun avoidance and regular sunscreen application are recommended during the post-treatment period. The small pinpoint injuries on the treated skin heal in 2 to 3 days.

Skillful use of microneedling and PRP by an experienced aesthetic dermatologist offers an opportunity to minimize facial wrinkles and lines, and restore your youthful appearance. For a consultation and more information, contact Aesthetic Dermatology and Skin Cancer: Jeffrey H. Binstock, M.D. Drs. Binstock and Layton will answer your questions. Call our San Francisco office at (415) 956-8686, or in Mill Valley call (415) 383-5475.