Nano Fat Transfer San Jose
Art of Face Sculpting with Your Own Fat.
Jenesis is specializing in Laser Liposculpting , Face Recontouring with your own fat or fillers
What are Nanofat Transfer and Facial Injection?
Ever heard of the Vampire Facial or the Vampire Facelift? If you are reading this then you probably have. The trend of drawing blood and injecting blood products back into the face or applying topically is the concept of both “Vampire” procedures. These two procedures are some of the latest in the trend of harnessing the body’s own healing powers in areas that need rejuvenation. I perform nanofat injections in my Southlake and Fort Worth clinics and the demand has increased. Therefore I wanted to touch on a few of those procedures here.
What is Nanofat?
Nanofat is a procedure that is different than traditional fat transfer to the face for a number of reasons. To briefly summarize, nanofat isn’t really injecting fat cells, it is injecting everything around the fat cells that help stimulate growth of collagen and elastin. By removing the large fat cells but preserving the surrounding growth factors an environment is developed that helps restore the skin.
How is the facial Nanofat procedure performed?
The procedure can be done under local with any other procedures. This begins with harvesting of fat, usually from the outer thigh or abdomen. The fat in the syringes is then broken up and separated so that the large fat cells are not preserved but only the growth factors.
Nanofat can then be injected either into or under the skin in order to improve skin texture and volume (if desired). Oftentimes nanofat is combined with traditional fat transfer in order to add additional volume.
Dr. Jane performs fat transfer and nanofat injections in her San Jose office.
Many people seeking a perkier, firmer backside use fat transfer to add volume and improve the texture of the faces, breasts, or buttocks. Other areas that can be treated with fat grafting include the hands, sternum, hips, biceps, triceps, and calves. Fat transfer can effectively diminish superficial scars by filling in the area surrounding the scar tissue and creating a smooth, firm surface.
Fat Transfer can be used to create a nicely rejuvenated face, in someone with loss of fat over the years from his/her face, or someone who has had a facelift and wants more plumpness in their face.
Recently, fat grafting has been shown to have added benefits found in the injected fat, which not only provide volume, but also create skin improvement, wrinkle improvement, and other positive changes that are not explainable by volume alone.
A highly specialized procedure that takes years to perfect and master, Dr. Jane has been using Nano Micro-Fat Grafting technique to rejuvenate and contour his patients since she learned the original technique from many doctors from Europe, South Korea, and US as well. Dr. Jane modified and created her own technique to provide long lasting, pleasing aesthetic results, and adapted the technique to contour the face, hands, breasts, and buttocks.
- To restore volume lost with aging
- To enhance the cheek bones or augment the cheeks
- To enhance the chin
- To add shape and frame the bone around the eyes which softens their appearance
- To raise the eyebrow
- To straighten the jaw line or hide the Jowl
- To shape the nose
- To add volume to the earlobes
- To fill the Naso-labial fold
- To augment the lips
- To repair scars
- To rejuvenate the skin
- Breast Augmentation
- Buttock Augmentation
- Defects after adipoaspiration
- Post traumatic defects
- To improve contour in breast augmentation or in other areas (buttocks, calves, lips)
Candidates for Facial Nano Fat Grafting
To be a good candidate for facial fat grafting, you have to be in good health, not have any active diseases or pre-existing medical conditions, and must have realistic expectations of the outcome of this procedure. Fat grafting can make you look more youthful, but it will not change anything else about your life. If you think anything else will change, you don’t have realistic expectations.
You may not be a good candidate for fat grafting if you have a history of poor wound healing or if your overall health is poor.
Facial Fat Reshaping: Most Popular Treated Areas
Fat grafting can be done on almost all areas of the face and body. However, the most common treatment sites are the areas under the eyes, the tear troughs under the eyes, the temples, the cheeks, the chin, the lips, the jaw line, the forehead, and the glabella (the area just above your nose in between the brows). Fat grafting can also be used to help fill in scars on the face and has been used on the buttocks and hips and the sternum.
The site being treated must have good blood circulation and enough capillaries and larger blood vessels so that the injected fat cells are nourished and can form their own blood supply. This is a key factor in getting the best and longest lasting results.
Preparing for Your Procedure
You will probably be given an information packet that explains everything you should do and know before your procedure date. The packet should include a list of any medications you should not take before your procedure. These will include any products containing aspirin or ibuprofen. Make sure your doctor has a complete list of all medications that you take, including dietary supplements and herbal products.
You may be asked to have blood tests done in advance of your procedure to check on your health. This is usually an out-of-pocket expense.
How Fat Grafting Is Performed
This procedure involves both a donor site (where the fat is taken from) and the treatment site (where it is being put). You may be given an oral sedative and receive injections of sterile saline, lidocaine, and possibly epinephrine. If you are having liposuction for body contouring and will be having some of that suctioned fat injected, you will probably be under intravenous sedation. (You can read more about liposuction at our sister site, Liposuction4you.com).
If all you are getting is fat injections, the fat will probably be removed from a site treated with a local anesthetic. Usually, the donor site will be the buttocks or abdomen.
Although you would think they could just use a syringe to suck out the fat from one spot and use the same syringe to inject it where you want it, this is not done. The fat must be treated to remove blood and other fluid and any damaged fat cells. Whole healthy fat cells are best for reimplantation. So the surgeon suctions out a little fat and this fat is then spun in a centrifuge or treated in some other way to remove excess fluids and the damaged fat cells are separated out. The fat (which looks like a yellowish liquid in the syringe) is then injected using a separate smaller hypodermic needle.
Rather than inject fat cells, some surgeons implant individual strands of fat cells one by one. This procedure takes time, but is said to last the longest. The down side is that there may be extremely small incisions.
After the procedure, you will be brought to the recovery room where you will be monitored until you are ready to be released. Most people are released about 2 hours after the procedure is finished. Your face may feel tight and quite tender as the anesthesia wears off and your donor site may be sore as well.
You will need to be driven home by a responsible adult because you will not be able to drive yourself home. Most patients do not have too much pain or discomfort. However, if you believe your pain to be out of the ordinary once you get home, call your surgeon or the on-call staff immediately.
The Road to Recovery
You shouldn’t wear cosmetics until at least the day after. You will be told to try not to move the treated area or massage it for a few days after a fat grafting procedure. I know it is impossible to keep it totally immobilized, but try. The reimplanted fat cells can be given a better ‘chance at life’, if you are careful not to move the area around.
Some surgeons recommend that you do not use ice packs or cold packs on the treated area. However, conversely, other surgeons recommend using cold packs for the first 24 to 48 hours. Do what your surgeon recommends.
Some patients report mild or moderate bruising, although swelling can be pretty moderate to severe. Most of the swelling will last anywhere from 24 to 72 hours; although it should be gone completely in 2 to 4 weeks. If you have excessive pain, redness, pus or other symptoms that do not appear normal, contact your surgeon immediately! Take your temperature regularly. An elevated temperature could mean an infection.
With fat grafting, anywhere from 10% to 90% of the fat may be absorbed by the body. Most surgeons who offer fat grafting offer repeat treatments to their patients at a discount. May patients may need more than one treatment. The benefits of fat grafting can last anywhere from 3 months to 3 years, and probably more.
You will probably be asked to see the surgeon about 6 to 8 weeks after your treatment. This is when most swelling has subsided and early results can be evaluated. If you need more treatment, you will probably to asked to wait about 3 months after your first treatment to allow all swelling to resolve and blood vessels to grow and support the fat grafts.
The Risks and Complications of Fat Grafting
The most common problems with fat grafting are aesthetic ones. You may have too little fat tissue reimplanted or too much. You may also be happy with the results for several weeks or months, but then have most of the transferred fat be absorbed.
However, the answer to fat absorption is not simply injecting large amounts of fat the first time, assuming some of it won’t last. Placing too much fat in a particular area can overwhelm the growth of new blood vessels and the fat cells can all die at once, leading to irregularities or migration of fat out of the area where you want it.
Other risks include an allergic reaction to the anesthesia or local anesthetic. There is a risk of infection, bad bruising, and asymmetry. Occasionally, bruising caused by a ruptured superficial blood vessel at the treatment site may be permanent. Fat embolism, where some of the injected fat enters the bloodstream, is a rare and serious complication, and can result in stroke or heart attack.
FREQUENTLY ASKED QUESTIONS
A. Microfat grafting or microfat tranfer injection relies on the premise that by adding more volume to certain areas of the face with micro injection technique for longer lasting result, Dr. Jane can improve signs of aging. It is a well-known fact that as we age, the face loses volume of muscle, fat, and bone. For many decades, we thought of aging as an excess of skin. It is now recognized that the apparent excess of skin is at least in part due to the loss of soft tissue bulk, or fat from the face. Fat may be transferred from other parts of the body (usually from the abdomen, flanks, or thighs) to areas of the face in need of volume enhancement
A. Microfat grafting can smooth certain deep wrinkles, enhance the volume of thinning lips or soft tissue of the cheek and chin, and can help the appearance of sunken eyelids. The main advantage of fat injection is that it is a 100% natural filler. The other advantage of fat is that there is usually an adequate supply of fat for areas requiring a large volume of augmentation.
A. The procedure is relatively simple and straightforward. A patient, who is deemed a good candidate for this procedure, is given antibiotics, and anesthetized in the operating room. The body is injected with tumescent solution to the donor area such as abdomen or thighs, where the fat is usually removed via a special technique and specially designed syringe and annular to increase the survival rate of the fat cells and to keep as much of the fat cells alive as possible. Afterwards the fat is harvested using a small syringe, then prepared and placed in other small syringes for the injection. The fat is placed in very tiny amounts, mostly on the deep layer, next to the bone and inside of muscle layers. Special placement of micro sized-fat droplets at various layers also improves the percentage of fat survival. A small cannula is used so that small packets of fat are placed and they easily take on a new blood supply and survive. The popular treatment areas are the cheeks, smile lines, lips and the pre-jowl area.
A. Microfat grafting to small areas may be performed in the office under local anesthesia. For larger volumes of fat injection, we use mild sedation which involves giving sedating medication that will make you very relaxed and sleepy during the procedure but does not require putting a breathing tube in the throat.
A. You are encouraged to resume normal activities as this decreases the amount of pain and increases the speed of your recovery. The areas of the face where fat was placed should be left alone unless you are instructed by Dr. Jane to massage the area. Massaging of the areas where the fat was harvested, particularly over the flanks, will speed the healing process. A Compression Garment may be needed for one to two weeks after surgery, depending on the degree of swelling.
A. Fat grafting is longer lasting than most other injectable fillers (such as Collagen, Restylane, Hylaform, and even Radiance). Because fat is a natural substance, there is typically less reaction to the injected fat by the body. The fat does however absorb over time and repeated injections may be necessary to maintain the desired fullness of the treated areas.
Micro Fat Grafting generally requires two to three treatments to achieve lasting results. Approximately 65 percent of the injected fat is absorbed back into your system during the first few months following the procedure. About 25-35 percent of the injected fat will remain in place. When patients notice the results fading, they can receive another fat transfer. After a few treatments, skin can maintain its firmer, smoother appearance for years.
A. Fat transfer procedure typically involves little or no downtime, though patients receiving sedation should not drive themselves home after the procedure. If you don’t need sedation medication, you can drive yourself.
A. Patients can typically return to work and other normal activities shortly within 2–7 days after the procedure depending on the areas treated.
A. No two individuals are the same, and results may vary. Some conditions can improve dramatically in some patients and not respond in others. Overall, patients with severely volume loss can have satisfactory improvement with 1-3 times of fat grafting 1-3 months apart.
A. Microfat grafting procedure may be used to enhance the results of another procedure, such as Active FX Laser Resurfacing, Exoderm nonsurgical facelift, chemical peels, eyelid surgeries, brow lifting, or smartlipo liposculpting for double chin and thick neck.
A. Fat is harvested from areas with excess fat – typically the tummy, flanks, lateral or medial thigh – depending on the area the patient prefers, the volume of fat required, and the quality of the fat. The key is to avoid creating a defect in the donor area. A compression garment may be worn after harvesting but this is not always necessary.
A. For the right patient, fat grafting can be an extremely gratifying operation. The advantages are natural looking results, long-term enhancement, quick recovery period, and no scarring. This procedure takes about 1-3 hours, depending on where and how much fat grafting is going to occur.
A. At the Jenesis Lipoplasty Surgery Center, we take pride in making sure we provide for our patients the best cosmetic surgical experience possible , anticipating problems or set-backs, and addressing them before they happen. This is a process that includes the pre-operative preparation, the actual surgery, and the after care.
to as autologous fat transplantation or micro-lipoinjection. This procedure is used to plump up facial features and also other parts of the body such as the breast and buttocks with a patient’s own fat. Face Fat Transfer with Face Liposculpting is also considered as Jenesis Non-surgical Facelift on the selected patients. Fat transfer breast augmentation is also referred to as Natural Breast Augmentation and a fat transfer buttock augmentation is often known as a Brazilian Butt Lift . All of these procedures are growing in popularity as alternatives to fillers and implants.
Pre Fat Transfer Instructions
We would like to provide you with the very best surgical care. You can help to minimize the risk of complications by carefully reading and following your preoperative and postoperative instructions. Please ask us to clarify anything you don’t understand.
ONE – TWO WEEKS PRIOR TO SURGERY
- DO NOT take ASPIRIN (Anacin, Bufferin, or Baby Aspirin) IBUPROFEN (Advil, Motrin, or Nuprin), NAPROXEN (Aleve) or any other non-steroidal anti-Inflammatory drugs (NSAIDS) similar to these medications for 10 days before surgery; these will promote bleeding and bruising. It is permissible to take acetaminophen (Tylenol or Anacin-3). Check the labels of all your medications, even those which you purchase without a doctor’s prescription, to be sure you are not taking any aspirin or aspirin-like substances. Remove any products containing aspirin from your medicine chest so that you do not inadvertently take it during the week before your surgery. Consult your physician before you stop taking any prescribed medicines. Please inform us if you are taking any medications to treat arthritis, or any blood-thinning (anti-coagulant) medications.
- DO NOT drink alcohol for one week prior to surgery. This might cause excessive bleeding.
- DO NOT fast or undergo dramatic weight loss just prior to surgery. You should be on a stable, healthy, well-balanced diet for at least 2 weeks before surgery. Liquid diets, extreme low calorie diets, and rapid weight loss diets may predispose you to cardiac irregularities, surgical complications, or poor wound healing.
- DO NOT take decongestants such as Sudafed or Actifed for 5 days before surgery.
- DO NOT take appetite suppressants such as phentermine (Fastin) for at least 2 weeks before surgery.
- DO NOT take Zoloft or other antidepressants and all herbal remedies, unless specifically approved by your surgeon, for two (2) weeks before surgery.
- DO NOT use moisturizers or soap that contains moisturizers for one week before surgery. The ink markers used to outline the areas on your body to be treated by liposuction will rub-off too easily if you have recently used a moisturizer.
- Antibiotics, such as cefadroxil (Duricef), cephalexin (Keftab) relatives of penicillin, doxycycline (Monodox), or ciprofloxacin (Cipro) are to be taken twice daily in order to minimize the risk of a surgical infection. Antibiotics should be taken with food to reduce the risk of gastric upset. Start taking your antibiotic the day before surgery, and continue until the entire supply is completed. If your surgery is scheduled to begin in the early morning (before 9:00 a.m.), taking your antibiotic and eating should be postponed until after surgery.
- Lorazepam (Ativan) is a mild sedative and sleeping pill that does not make one feel “drugged.” Surgery is more easily tolerated if you are well rested and relaxed. We suggest that you take one lorazepam the night before surgery.
DAY OF SURGERY
- DO NOT wear unnecessary jewelry, perfume, and minimize use of cosmetics. You may use deodorant.
- DO NOT drive home. Arrange to have someone drive you home from the Pelosi Medical Center after the surgery.
- Diet: You should eat a light, low fat meal, such as toast and juice, fruit, dry cereal and/or non-fat milk no less than two hours prior to surgery. Avoid whole milk, cream, butter, cheese and other foods that are high in fat content as dietary fat slows digestion and delays stomach emptying. Minimize caffeine intake the day of surgery. You will be given a snack as soon as surgery is completed.
- Wear loose clothing. There is usually quite a lot of drainage of slightly blood-tinged anesthetic solution after surgery. Since this drainage might stain clothing, choose your clothing with this in mind. Because we will apply elastic support garments on top of some bulky absorbent gauze padding, your clothing should be very loose and comfortable.
- Women: Wear a comfortable bra that you would not mind getting stained from the blue ink that is used to mark the surgical areas. Do not wear an exercise sports bra if you are having liposuction on your abdomen or torso.
- Men: Speedo-type swim trunks are the easiest type of garment to wear into the operating room for surgery. Jockey-type underpants are acceptable. Boxer-type underpants are less convenient, and may prevent optimal results. Bring extra underpants to wear after surgery.
- Bring warm socks to help keep your feet warm during surgery. If you tend to get cold hands, you are welcome to bring clean mittens (no leather gloves) to wear during the surgery. The operating room is kept relatively warm at 71 – 74 degrees F.
- Bring some snacks
- Towels & Plastic Sheets. Plan ahead to avoid staining the car seat with blood-tinged anesthetic solution: Bring a towel and a plastic sheet (such as a trash can liner) to cover the car seat during your ride home. Prior to surgery pad your bed at home and your living room chair with towels and plastic. Be careful to avoid allowing drainage to stain carpets.
- Music to relax by: Patients usually enjoy listening to soothing quiet music during surgery. If you have any favorite CDs which you would like to share with us on the day of surgery, you are welcome to bring them with you. Please label the plastic case that holds your CD so that we will know to whom it belongs.
Post Fat Transfer Instructions
1. You may have bruising, swelling, and mild discomfort in both the face and the part of the body from where the fat was harvested. This is normal and will gradually resolve over a period of a few days to weeks. You may also notice some pressure and tightness in your face after surgery, and this is normal and should resolve over a period of the first 1 to 2 weeks.
2. You should use ice packs liberally in the areas of the face where fat was transplanted for the first two days after surgery in order to minimize swelling and to speed up the resolution of swelling. The body area where fat was harvested experiences any discomfort, some icing over the harvested area can also be undertaken for the first couple of days. If you wake up with a lot of facial swelling during the first week, you can continue to use ice over the swollen areas for the entire first week after surgery as needed.
3.Tylenol Extra Strength (Acetaminophen) 500 mg capsule or tablet does not require a prescription. You may take two tablets, three to four times daily as needed beginning after surgery, to help minimize postoperative swelling and treat any minor post surgery discomfort. If for some reason Tylenol is not acceptable, then notify us at 408-737-9100 so that we can arrange for a suitable substitute.
4. For the first two nights, it is preferred that you sleep in a semi-upright recliner, like a La-Z-Boy, if you have one. If not, sleeping with an additional pillow under your head will help reduce the swelling more quickly. It is preferable if you continue to sleep with your head elevated in this fashion for the entire first week after surgery if it does not interfere with the restfulness of your sleep.
5. You will notice that you will look more swollen either 2 or 3 days after surgery, and this appearance should be expected and should not raise any alarm or concern. The swelling should continue to decrease after the first several days.
6. You may notice that one side of the face is more swollen or lumpy than the other side. This again is normal. Swelling resolves unevenly and you may notice these imperfections even for several weeks after surgery.
7. Dietary salt should be limited if possible in order to reduce the swelling of the area where you have the fat transferred.
8. During your rest and recovery at home, you should avoid the temptation to do a lot of household busywork like cleaning and gardening that involve bending over and straining, which in turn can lead to pronounced and prolonged swelling.
9. Vigorous exercise should be avoided for two weeks to lessen swelling. If you are accustomed to routine and frequent workouts and would like to resume your fitness regimen early, then you may start lighter exercise after the first few days of rest. If you notice significant facial swelling after your workout, you should reduce the amount of exercise you are engaged in. Light exercise with half to one third of your normal weight and with only slow muscle contractions is allowed.
10. There are no restrictions in activity for the body part from where the fat was harvested. However, care should be taken to avoid straining and raising stomach pressure that can lead to increase facial swelling.
11. As the “incisions” Dr. Jane Chung uses are only the width of a needle, you do not need to clean or take care of these areas. There are also no sutures that need to be removed if all you had was a fat transfer.
12. You can apply makeup to the face the day after surgery if needed.
13. You may notice ongoing changes for up to a year after surgery. This does not mean that your fat is going away, but typically a little swelling can persist even up to 6 months after surgery. Follow-up and discussion with Dr. Jane Chung will help guide you as to the changes that you are observing.
14. You should avoid any significant weight gain after surgery, e.g., 20 or more lbs., as the fat that was transferred to your face can also similarly enlarge and make your face appear fatter than you would desire.
15. Do not hesitate to contact Dr. Chung should you have any questions regarding your care or your concern.
Post Fat Transfer Instructions for Donor Area
- Post-Op Garment: If Liposuction on donor area is done, a post-op garment is worn in order to hold the absorbent pads in place and to provide mild compression that encourages the drainage of the blood-tinged anesthetic solution. The morning after surgery, when you remove the garment to take a shower, you may experience a brief sensation of dizziness. Feeling lightheaded is similar to what you might experience when standing up too quickly. It is the result of rapid decompression of the legs as the post-op garment is initially removed. Should you feel dizzy, simply sit or lie down until it passes.
- Beginning the day after surgery, remove the post-op garment daily prior to showering and to wash the garment. The first morning after surgery it is easier if you have someone to help you. The post-op garment and binder (if applicable) should be worn day and night until all the drainage has completely stopped plus an additional 24 hours. Do not be concerned if you drain for several days. Discontinuing the use of the garment and binder early may result in more prolonged drainage. Typically, patients need to wear the garment for 3 to 6 days, although many choose to wear the garment longer because of the comfort it provides. Wearing the post-op garment for more than the minimal number of days provides no significant advantage in terms of the ultimate cosmetic results.
- Managing Post-Op Drainage: You should expect a large volume of blood-tinged anesthetic solution to drain from the small incisions during the first 24 to 48 hours following liposuction. In general, the more drainage there is, the less bruising and swelling there will be. During the first 36 hours, you should sit, or lie, on towels. When there is a large amount of drainage, you may want to place a plastic sheet beneath the towel. For the first 24 to 36 hours, bulky super-absorbent pads are worn under the garment. After most of the drainage has stopped, you need only place thin absorbent gauze dressings over the incision sites that continue to drain.
- Wound Care & Bathing: Keep the incisions clean. Do not allow scabs to form in the first 72 hours. Shower once or twice daily. Avoid very hot water during the first 48 hours following surgery. First wash your hands, then wash incisions gently with soap and water; afterwards gently pat incisions dry with a clean towel. Apply new absorbent dressings. Incisions that have stopped draining no longer need padding but should be covered with Neomycin or Bacitracin ointment for the first six weeks. Apply sunblock (day) and/or Triluma (night) on any exposed incisions in the first twelve (12) months after surgery to prevent hyperpigmentation. Take antibiotics as directed until the prescription is finished.
- Take antibiotics with food. Call our office if you notice signs of infection such as fever, foul smelling drainage, or local redness, swelling, and pain in a treated area.
- DO NOT apply ice-packs or a heating pad to skin overlying the areas treated by liposuction.
- DO NOT apply hydrogen peroxide or plastic Band-Aids to incision sites.
- DO NOT soak in a bath, Jacuzzi, swimming pool, or the ocean for 7 days after surgery.
- Common side-effects of laser liposuction: Menstrual irregularities with premature or delayed onset of monthly menstruation is a common side effect of any significant surgery. Flushing of the face, neck and upper chest may occur after liposuction and usually lasts for a day or two. Slight temperature elevation during the first 48 hours after surgery is a natural consequence of the body’s reaction to surgical trauma. Discomfort and soreness is worse the second day after surgery, then improves daily.
- Two extra-strength Tylenol every 4 hours, while awake, for the first 48 hours will reduce the inflammation, swelling, and soreness associated with surgery. Do not take aspirin, ibuprofen or medications that contain these drugs, such as Bufferin, Anacin, Advil or Nuprin for 3 days after surgery; these can promote bleeding.
- Bruising is minimal with tumescent liposuction. Nevertheless, the more extensive the liposuction surgery, the more bruising you can expect.
- Pain and swelling due to an inflammatory reaction to surgical trauma may occur and increase 5 to 10 days after surgery; this is treated with antibiotics and anti-inflammatory drugs. Itching of the treated areas several days after surgery may occur as part of the normal healing process. To help relieve the itching, you may try taking Benadryl 25mg
capsules/tablets as directed on the packaging. Be aware that Benadryl causes drowsiness. You may also try using oatmeal soap. After 7 days (as long as the incisions are closed), you may soak in a bath with an Oatmeal bath preparation. Benadryl and Oatmeal products may be purchased at most drugstores.
- Schedule a follow-up appointment at our office at 6 weeks after surgery. You are welcome to return to our office for follow-up visits at no charge as often as you like. Please contact Jane Chung, MD by telephone (24 hrs/day) at 510-468-0311if you have any urgent questions