EXPLORE
Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

May 3rd, 2015

Case Study: Sliding Geniopasty with Indwelling Chin Implant

 

Background: Horizontal chin augmentation can be done using either a synthetic chin implant or a sliding genioplasty. There are advantages and disadvantages with either approach and they must be considered in an individual patient basis. The decision in any patient ultimately depends on their perception of an alloplastic vs. an autogenous approach, the risks of the procedure and its recovery and what other dimensional changes of the chin that are needed beyond just that of the horizontal change.

But the use of a chin implant does not always produce the desired amount of chin augmentation change that every patient desires. This may be due to inadequate implant selection, the chin implant settling into the bone thus losing some horizontal projection, chin implant malposition or an accommodation to the initial chin augmentation result.

When further improvement is desired after an initial chin implant augmentation, the options are either a larger implant or to convert it to a sliding genioplasty method. A larger implant is usually done as this is the simplest revisional approach provided that a new implant can create the desired horizontal change. When a larger chin implant offers but a modest additional augmentation (e.g., 5mms or less) the the sliding genioplasty option becomes a consideration. It would be either that or have a custom chin/jaw implant made.

Chin Implant Settling (Erosion) Dr Barry Eppley IndianapolisCase Study: This 26 year-old male wanted additional chin augmentation after having a prior chin implant placed several years previously. He always felt that is lower jaw was smaller. His original chin implant provided 7mms of horizontal projection but it could be seen that it had settled into the bone a few millimeters. He opted for a sliding genioplasty as he felt that would more reliably give him long-term augmentation.

Sliding Genioplasty with Chin Implant intraop Dr Barry Eppley IndianapolisUnder general anesthesia, an intraoral approach was used to access the chin. The chin implant was easily identified and it was nestled nicely into the bone. A horizontal osteotomy cut was made above it from side to side and the bone downfractured. The chin segment was then advanced 12mms and stabilized with a step plate and screws. The chin implant was never moved from its original position during the procedure.

Sliding Genioplasty with Chin Implant result Dr Barry Eppley IndianapolisSliding Genioplasty with Chin Implant 3D CT scan Dr Barry Eppley IndianapolisA sliding genioplasty can be successfully done with an indwelling chin implant. It can be argued that this is a good technique to take advantage of some of the prior procedure (and investment) and gain additional horizontal augmentation. Whatever implant settling has occurred into the bone has already reached its peak and no further inward change would be anticipated.

Case Highlights:

1) An unsuccessful chin implant result can be improved by a sliding genioplasty.

2) It is not always necessary to remove an existing chin implant when doing a sliding genioplasty.

3) A sliding genioplasty can be performed by making the osteotomy cut above the chin implant and moving both forward simultaneously.

Dr. Barry Eppley

Indianapolis, Indiana

April 30th, 2015

Need Plastic Surgery Help For A Physical Deformity?

 

Are you, a loved one or a family member suffering from a physical deformity that is seriously affecting the quality of your life? Such physical deformities can occur from birth defects, traumatic injuries (e.g., burns, motor vehicle accidents, domestic violence, work-related injuries) or surgery for different types of tumor removals. These events can have severe and devastating effects on one’s appearance and certain body functions.

Plastic surgery at reduced cost may be available for select patients to treat such physical deformities. Please e-mail your summarized story in 3 to 5 sentences with pictures of your physical deformities to see if you qualify for plastic surgery help. Such submissions will be reviewed and determined if you qualify for this special program. We are looking for patients with physical deformities where their improvement/correction through reconstructive plastic surgery could literally change their lives.

Dr. Barry Eppley

Indianapolis, Indiana

April 30th, 2015

Kybella Injections for the Treatment of Double Chins

 

atx101 or Kybella Injections for Double Chins Dr Barry Eppley IndianapolisIn clinical trials for years as an injectable fat reduction treatment, ATX101 has finally received formal FDA approval. Now known as Kybella from Kythera Biopharmaceuticals, medical grade deoxycholic acid has been approved to treat double chins. Specifically it is intended to create an improvement in the appearance of moderate to severe submental fullness in adults.

Deoxycholic Acid Kybella Injections for Double Chins Dr Barry Eppley IndianapolisKybella is a proprietary formulation of a synthetic version of deoxycholic acid. Deoxycholic acid, also known as deoxycholate (and technically as  3?,12?-dihydroxy-5?-cholan-24-oic acid) is a bile acid that in the human body in naturally produced by the liver and stored in the gall bladder. It is secreted into the small intestine to help break down dietary fat. Sodium deoxycholate, the sodium salt of deoxycholic acid, is often used as a biological detergent to breakdown cells and cell membranes and has served as one of the agents that has been used in mesotherapy for years.

As a liquid formulation of deoxycholic acid, Kybella is an injection that causes the destruction of fat cells through cell membrane breakdown. Once broken down the fatty acids in the fat cells are released and subsequently absorbed, creating the external appearance of reduced fullness. Kybella is an injection series that requires multiple treatments for maximum submental fat reduction. The submental area is injected in a grid pattern with a small 30 gauge needle spaced about 1 cm apart. The injection sessions are spaced four to six weeks apart and can take up to  four to six treatment sessions to see the full effect.

How safe and effective is Kybella for reducing double chins? In two clinical trials of over 1,000 patients (Kybella vs. a placebo), a significant percent of patients (up to 20%) who received Kybella had at least a two-grade improvement on a physician Submental Fat Rating Scale and a Patient-Reported Submental Fat Rating Scale. This compares to just 3% of the placebo patients. Nearly three-quarters of Kybella patients had at least a one-grade improvement. Additional testing showed that Kybella also had significant improvement as demonstrated by MRI scans of fat reduction and patient-rated appearance assessments.

While Kybella can help dissolve submental fat and is a non-surgical  treatment, there are some short-term after effects. The most common and are expected is swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. These occur because it works by creating an inflammatory reaction which is how it breaks down the fat cells. Most of these reactions resolve in about one week after the injection treatment.

Kybella Double Chin Injections Indianapolis Dr Barry EppleyCurrently, Kybella is only FDA-approved for the treatment of double chins. (submental fat fullness) But it is only a question of time and further study that it will be applied to other small fat problems. (e.g., small abdominal fat collections, lipomas)

Dr. Barry Eppley

Indianapolis, Indiana

April 28th, 2015

Revisional Nasal Implant Surgery

 

Certain types of rhinoplasty surgery requires considerable augmentation to achieve its aesthetic effects. This is most commonly seen in the need for bridge or dorsal line augmentation but can extend to include the tip as well. This is most frequent in ethnic Asian or African-American rhinoplasties but can be needed in other nasal shape conditions as well. (e.g., saddle nose deformity)

Nasal Implants Dr Barry Eppley IndianapolisTo achieve considerable nasal augmentation the choices often come down to using either a synthetic implant or natural rib cartilage. These are incredibly diverse augmentation options that are at opposite ends of the material choice spectrum. Because of the simplicity of a synthetic implant and avoidance of a donor site harvest (and lower cost) an implant rhinoplasty is far more commonly done around the world than rib grafting.

But as would be surmised, the use of synthetic implants in the nose is not without potential complications and the need for revision rhinoplasty with them is not rare. Nasal implant complications can include infection, displacement, malposition and skin thinning/exposure. Should any of these occur the intraoperative question is whether the implant should be ‘recycled’ and reimplanted or even a new one put in.

In the May issue of the Annals of Plastic Surgery journal, an article entitled ‘Immediate Re-Insertion of Non-Autologous Materials in Revision Augmentation Rhinoplasty’ was published. In this paper the aim was to determine whether immediate re-insertion of an implant in revision augmentation rhinoplasty produces an uncomplicated and favorable aesthetic outcome. Eleven patients who had immediate re-insertion of their implants were analyzed. Nine of the eleven patients (81%) had favorable aesthetic outcomes. One patient had a recurrent infection and another patient had implant displacement. These two unsuccessful patients shared the similarities of a silicone implant and using an endonasal approach for their surgeries.

Nasal Implants Indianapolis Dr Barry EppleyThis study shows that re-implanting a synthetic implant can be done successfully in revision rhinoplasty. Removing a nasal implant augmentation material, unless in the presence of overt infection, is usually not appealing given the effect that it has created. The desire to retain its augmentation benefits is understandably high. The key question and a more practical one is why the same implant? The cost of nasal implants is relatively inexpensive in the overall costs of a surgery. A new unused and sterile implant, even in a clean nasal implant pocket, should be an option to consider also if there are any doubts about potential material inoculation.

Nasal implants are also uniquely hard to reposition if displaced.  The implant capsule has a smooth surface as does a silicone implant. Adjusting an implant’s pocket, unless some method of form fixation is used for the implant, is fraught with the potential of sliding back into its original displaced location.

Dr. Barry Eppley

Indianapolis, Indiana

April 27th, 2015

Case Study – Secondary Brow Bone Reconstruction with Cranial Bone Grafts

 

Background: Most frontal sinus problems can be successfully managed with an endoscopic approach. But if frontal sinus drainage can not be successfully established, an open approach for its treatment may be needed to eliminate the entire frontal sinus.. The osteplastic bone flap approach for frontal sinus obliteration has been around for a long time  to treat such problems as chronic frontal sinusitis, mucopyoceles frontal sinus tumors and frontal sinus fractures that involve the posterior table.

In frontal sinus obliteration there are three key manuevers, complete removal of all sinus lining, sealing of the frontonasal duct and filling in of the entire frontal sinus. The only variable historically has been what material to opacify the frontal sinus. Historically it has been the use of autologous fat. But hydroxyapatite cement was introduced in the 1990s and offered an off the shelf material that did not require a fat graft harvest. Hydroxyapatite cement has the potential to osteointegrate into the surrounding bone and provides a stable contour to the frontal forehead area.

Regardless of the material used, the key to success in frontal sinus obliteration is the complete removal of mucosa and obliteration of the frontonasal duct. No implanted material will be successfully of residual mucosa remains which can ultimately become a source of chronic pain and/or a mucoceole.

Case Study: This 35 year-old female had a history of frontal sinus obliteration which was needed because of infection that developed after an open brow bone reduction procedure. She had chronic pain over the central sinus area that persisted for several years. A CT scan showed a radiolucent cystic area under the brow bone area where her pain was. She requested that the hydroxyapatite cement be removed and replaced with cranial bone grafts.

Frontal Sinus HA Removal with Central Nasal Communication Dr Barry Eppley IndianapolisUnder general anesthesia, her original hairline incision was used for access to the brow bone area where the hydroxyapatite cement was immediately obvious. Using a handpiece and burr the cement was drilled out of all four frontal sinus sections. On its removal a large central cavity was encountered in the midline. It communicated directly into the nose. The mucosal lining was removed and a temporalis fascia was initially packed into it and covered with fibrin glue. Multiple split thickness cranial bone grafts were harvested from the posterior frontal bone area on both sides. Multiple layers of bone grafts were layered into the defect.

Nasofrontal Communication Obliteration Ddr Barry Eppley IndianapolisFrontal Sinus Reconstruction with Cranial Bone Grafts Dr Barry Eppley IndianapolisThe remaining frontal sinus areas were filled with demineralized bone and the outer brow bone area reconstructed with cranial bone grafts stabilized with small plates and screws. The cranial bone graft harvest sites were contoured to the surrounding bone level with hydroxyapatite cement.

Secondary frontal sinus obliteration can be done using cranial bone grafts after removal of hydroxyapatite cement. A smooth outer brow bone contour can be obtained with careful shaping and adaptation of monocortical cranial bone grafts. Any small defects in the gaps can be filled with demineralized bone paste.

Case Highlights:

1) Obliteration of the frontal sinus with hydroxyapatite cement is an alloplastic method that is historically very successful.

2) Hydroxyapatite cement can be removed from the frontal sinus and replaced with autogenous bone grafts

3) Reconstruction of split thickness cranial bone graft sites can be done with hydroxyapatite cement.

Dr. Barry Eppley

Indianapolis, Indiana

April 26th, 2015

Techniques in Endoscopic Browlift Forehead Rejuvenation

 

The upper third of the face, which is composed of the skin bearing forehead and the hair bearing brows, is major aesthetic unit of the face. Like the rest of the face below it, it is equally exposed to changes caused by aging such as the development of horizontal wrinkles and a lowering of the brows. While the number one aesthetic treatment of the forehead are Botox injections, some patients will need actual forehead rejuvenative surgery for substantial improvement.

The main surgery for forehead rejuvenation is that of the browlift. While once a wide open procedure done using a long scalp scar, the trend over the past two decades has been  to use a less invasive approach through endoscopic techniques. This fundamentally results in much less scalp scarring but what is done under the forehead flap is somewhat the same as in more open browlift procedures.

In the December 2014 issue of the journal Plastic and Reconstructive Surgery, an article on this topic appeared entitled ‘Finesse in Forehead and Brow Rejuvenation: Modern Concepts, Including Endoscopic Methods’. In this paper the author review their experience in 546 endoscopic browlift operations s a tailored approach to the endoscopic browlift using four small scalp incisions in normal length foreheads and permanent suture fixation through outer cortical bone tunnels. The endoscopic dissection is done in a more limited fashion at the medial brow level but mire extensive laterally to release the lateral brow retaining ligaments. In high or long foreheads a hairline incision is used and the frontal hairline is advanced and forehead skin removed to create a vertical forehead reduction at the same time as the browlift. No infections occurred in their series. They experienced no cases of permanent nerve injury of either the sensory or motor nerves. Only 2% of patients experienced any temporary hair loss issues. No case experienced any loss of brow fixation using suture fixation to cortical bone tunnels.

The endoscopic browlift is now the workhorse of surgical forehead rejuvenation. As this paper illustrates it can be used for a wide variety of brow sagging problems. Its limitation is that it will cause some increase in vertical forehead lengthening since it works through a generalized epicranial shift of tissues from the brows backward. In this cases a frontal hairline incision is needed to either keep the hairline at its existing location or to allow a simultaneous frontal hairline advancement with the browlift. The endoscope serves little use once a more open forehead technique is used.

Cortical bone tunnels for fixation offer a very effective method of forehead fixation. It does make the scalp incisions longer to get the proper angles for drilling. There remains a role for more direct fixation devices such as Lactosorb screws and even larger Endotine devices. They make the fixation process easier although probably sightly less secure. Th weak link in browlift fixation, however, is in the attachment of the suture to the forehead tissues and to do so without causing persistent skin dimpling.

Men remains a challenge for any type of browlifting due to the location and quality of their frontal hairline. (or often complete lack of it) This is why the transpalpebral browpexy technique, marginally effective as it is, is the browlift procedure of choice for many men. In men with reasonable fronta hairlines, however, I have been impressed with how well their scars can do as also evidenced in male frontal hairline advancements.

Dr. Barry Eppley

Indianapolis, Indiana

April 26th, 2015

Case Study – Breast Augmentation Rejuvenation in Older Women

 

Background: The demand for breast implants has not waned in women over the past several decades. This is a testament to the success of the procedure in accomplishing its single goal…effective breast enlargement. The devices used to accomplish this body contouring goal have been modified and improved over the years, and are not without their own non-lifetime issues, but the demand for their use had remained unwavered.

Older Women for Breast Augmentation Dr Barry Eppley IndianapolisThe placement of breast implants is not age dependent. While the demand for breast implants has been historically lower in ‘older’ women that is a trend that is changing. More women over the age of 55 are seeking breast enhancement than ever before. While over 55 age women will never rival in numbers those woman under age 30 for the procedure, it is now being seen publicly as just as safe and equally effective.

The one challenge that older women present with for breast augmentation is that they often have increased degrees of breast sagging and may have poorer tissue quality. The thickness of any residual breast tissue is often less and the skin may be thinner. But as long as the amount of breast sagging is not severe, breast implants may actually have a mild lifting effect if the implant volume is large enough.

Case Study: This 57 year-old female wanted breast implants to enlarge her small and shrunken breast mounds. She had just gotten a divorce and was actively dating and felt this would have a positive effect on her self-esteem. She had been a smoker all of her life at one pack per day and had no intention or desire to quit.

Older Breast Augmentation result front view Dr Barry Eppley IndianapolisOlder Breast Augmentation result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, she had silicone gel breast implants placed in a dual plane position through an inframammary approach. She wanted large implants and opted for 550ccs based on using preoperative volumetric sizers. Her inframammary fold levels were dropped down to accomodate the implant volume and avoid too high of an implant positioning. This also helped overcome the small amount of breast sagging that she had.

Older Breast Augmentation result side view Dr Barry Eppley IndianapolisHer result demonstrates that breast augmentation has a rejuvenative effect on an older women’s chest and more than effectively corrects age-related tissue deflation. While smoking is not ideal or preferred for optimal healing of any elective surgery, an implant that is placed under well-vascularized tissue, such as muscle, can heal well in spite of a decrease in tissue perfusion levels.

Case Highlights:

1) Breast augmentation is done commonly done in older women today with just as much success as in younger women.

2) Breast augmentation in older women has a rejuvenating effect on the chest making one’s body look younger.

3) While smoking is not ideal for any surgery, it does not impede healing in submuscular placement of breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

April 26th, 2015

Small Sagittal Skull Implants

 

While the skull is often envisioned as a perfectly smooth oval shape, it often isn’t. Due to how the cranial sutures fuse and intervening bones form, the surface of the skull is often irregular. Such irregularities often occur along the suture lines due to their early activity during development and closure right after birth. They are frequent sites of  high spots, bumps and dips and indentations.

The sagittal suture is the longest of the cranial sutures due to its midline longitudinal course from the upper forehead to the top of the back of the head. Its midline position gives it a visible form in both the front and profile views. Any abnormalities along the fused suture line is most easily seen in the short haired or shaved headed male. One such sagittal deformity is a dip that appears between the front and back portions of the sagittal suture line. This is usually due to higher bone formation that occurs around the areas of the former front and back soft spots (fontanelles) as they initially fused together.

Sagittal Skull Implant Dr Barry Eppley IndianapolisCorrection of this sagittal skull dip can be done by filling in between the raised front and back skull areas. This can be done by using a linear shaped skull implant that sits in the dip. Such a small and unusually shaped skull implant can be made from various materials including silicone elastomer. They can be designed from measurements, an elastomer moulage or even from a 3D CT scan of the patient.

sagittal skull implant indianapolis indianaThis small linear implant can be placed under local or IV sedation through a small 2.5 cm scalp incision. It is inserted after making a very precise midline pocket that does not extend beyond the length of the implant. Small perfusion holes are placed in the implant to allow for tissue ingrowth and long-term stabilization.

Skull augmentation can be done for a diverse group of skull defects even those as small as the sagittal dip.

Dr. Barry Eppley

Indianapolis, Indiana

April 20th, 2015

Plastic Surgery’s Did You Know? The Golden Ratio

 

The search for what makes a face beautiful or attractive goes back hundreds if not thousands of years. Long before the possibilities of plastic surgery were even remotely envisioned, painters and sculptors used mathematical numbers and rations to create their works. Numerous contemporary studies have both qualified and quantified ‘beauty’ and have been able to apply some basic principles to it. (e.g., symmetry)

Golden Ratio in Plastic Surgery Dr Barry Eppley IndianapolisBut the most appealing numerical approach to beauty in the face and body as well as nature is that of the Golden Ratio. Much has been written to seemingly verify its use to show that its ration (1.618) represents the perfect shape from just about anything from natural to man made objects including the human body.

The Golden Ratio, represented by the Greek letter phi (?), is the relationship between two sides of a rectangle (1.61803) where the ratio of the larger side to the smaller side is equal to the ratio of both sides to the larger side. In mathematics, the Golden Ration occurs in the well known Fibonacci sequence where each subsequent number is the sum of the two previous ones. (:1, 1, 2, 3, 5, 8, 13, 21, 34, 55, 89 etc) If you divide each number besides the first one) by the previous number it is surprisingly close to 1.618 or the Golden Ratio.

Golden Ratio in Facial Plastic Surgery Dr Barry Eppley IndianapolisBut is the Golden Ratio useful in helping the plastic surgeon create a more beautiful face? Studies have shown that there are aesthetic correlations with many facial features relating to each other through this relationship. (e.g., the ratio of the length of a person’s face to its width is 1.6) It does seem to be a number that when assessing faces defies historical, racial and cultural differences.

However, a plastic surgeon’s ability to change one’s facial features is based on a knowledge of anatomy, surgical techniques and the desired end goal. While being an artist does not make one a good plastic surgeon (contrary to popular perception), there is a role for understanding aesthetic proportions and relationships.The Golden Ratio is as good a guideline as any other one might use.

Dr. Barry Eppley

Indianapolis, Indiana

April 20th, 2015

Subfascial vs. Intramuscular Buttock Implants

 

Buttock Enlargement Dr Barry Eppley IndianapolisButtock augmentation has gained tremendous popularity as a surgical procedure in just the past decade. This has largely been due to the use of fat injections for buttock augmentation, an approach that offers a diametric effect with enlargement of one body area (injection site) and reduction of many other body areas (liposuction harvest) during the same procedure. While buttock implants have been around much longer, their use is a fraction of that of fat injections due to a more invasive procedure with greater risks and a longer recovery.

But despite the popularity and success of buttock fat injections (aka the Brazilian Butt Lift or BBL), it is not for everyone that desires buttock enlargement. The biggest reason is lack of adequate fat to harvest. Thin or even medium build patients may not have enough to harvest by liposuction to make an immediate or sustained buttock enlargement result. Gaining weight for a BBL can be a flawed approach since such fat volumes can be lost after surgery with dieting an exercise.

Buttock implants will continue to play a small but important role in buttock augmentation. And more buttock implants are done today than ever before because of the overall societal desire for larger and more shapely buttocks. But the rise in buttock implant procedures has given risen to some misunderstandings with their use. The main issue to consider is the pocket into which they are placed. Understanding the implications  between subfascial and intramuscular location is the most important buttock implant decision.

Subfascial Buttock Implants result back viewSubfascial Buttock Implants result right oblique viewThe subfascial buttock implant location has several advantages. It is technically easier for the surgeon to perform, has somewhat shorter and less uncomfortable recovery and permits the placement of much larger buttock implant sizes. Its disadvantages are that the development of seroma and the risks of infection are higher. The use of postoperative drains are critical to educe these risks. In addition, the occurrence of capsular contracture  and implant ‘show‘ is also higher as well as that of chronic discomfort. An important anatomic key is that one should have good soft thickness between the skin and the deeper fascia for this buttock implant location.

Intramuscular Buttock Implants back view Dr Barry Eppley IndianapolisIntramuscular  Buttock Implants right side view Dr Barry Eppley IndianapolisThe intramuscular buttock implant has several advantages. It has a lower risk of seroma and infection due to a partial muscular cover. It also has no risk of implant show and probably has the best long-term retention due to its thicker soft tissue cover. Its disadvantages are that it is technically harder for the surgeon to master, limits the size of implant that can be placed (rarely bigger than 350ccs) and has a longer and more uncomfortable recovery. Patients that have thin tissues over the buttock with a scant subcutaneous fat layer or only want a more modest buttock augmentation result are the best candidates for the intramuscular implant position.

As can be seen by their various advantages and disadvantages, buttock implant augmentation results are highly influenced by the pocket location. Besides the recovery, the biggest difference is the size of the implant that can be placed.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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