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Archive for the ‘browlift’ Category

Techniques in Endoscopic Brow Lift Surgery

Monday, January 22nd, 2018


The endoscopic brow lift has been the most popular forehead rejuvenation technique for some time now. Its appeal is that it eliminates most of the scalp or hairline scarring that occurs from either the traditional coronal or pretrichial incisional approaches. While this is certainly true it is also important to remember that it is not effective or indicated for all types of brow ptosis or sagging. Patients with very deep forehead and glabellar rhytids or a long skin distance between the eyebrows and the frontal hairline may be better served by these more long incision brow lift approaches.

The endoscopic brow lift is predicated on three basic principles, limited small separate scalp incisions for endoscopic access and instrument dissection, a deep subperiosteal brow bone tissue release and bone fixation of the elevated forehead/brow tissues. Such scalp incisions are usually four with the more central paramedic ones centered over the vertical direction of the desired inner brow pull.

The endoscope allows the periorbital tissues to elevated off of the forehead and down to the brow bones. At this point the periosteum is opened and the supraorbital nerves dissected out with glabellar muscle release around them. The periosteal release must be carried out along the entire brow bone edges from one lateral orbit to the other.

One of the key elements of the success of the endoscopic brow lift is the fixation of the elevated brow tissues. Many techniques have been described for it but my favorite continues to be suture anchorage to the bone using a screw. The screw I prefer is the Lactosorb endobrow screw. It has a hole in the top of the screw through which a suture can be passed, making it in effect an intraoperatively fashioned suture anchor. A hole is made in the bone by a handpieee and burr into the resorbable screw is pushed and locked into place. The needle of the suture is then used to to grasp the galea of the elevated forehead flap and tied down.

While the head of the polymer endoscrew may be felt for several months after surgery, it will disappear through a natural hydrolytic resorption process. This is long after the forehead flap has healed back down to the skull bone in its elevated position.

Dr. Barry Eppley

Indianapolis, Indiana

The Direct Browlift

Sunday, April 23rd, 2017


Browlift surgery is done by a variety of techniques. Most commonly it is performed from above lifting the brows using either an endoscopic, pretrichial, coronal or mid-forehead incisional approaches. Less commonly it is done from below with a transpalpebral technique pushing up the brows from below and securing with a reorbable Endotine device.

The remaining browlift technique is a direct one with the brow lifted through skin excision right above the brow at the superior hairline. Undoubtably it is the most effective because it attacks the brow position and shape directly, giving maximum control over brow shape and the amount it is lifted. While effective the direct browlift is the least commonly used technique due to visible scar line concerns.

In the March 2017 issue of the Aesthetic Surgery Journal, an article was published entitled ‘Transcutaneous Brow Shaping: A Straightforward and Precise Method to Lift and Shape the Eyebrows’. In this paper, the authors described their experiences with a direct brow reshaping technique either done alone or in conjunction with blepharoplasty and facelift surgery. A total of 212 patients underwent a direct brow lift procedure. All patients were evaluated clinically and by means of pre- and postoperative photographs. Patients completed questionnaires indicating scar quality and satisfaction with the results.

There were no major complications. Scar visibility was low, and patients expressed a high level of satisfaction with the aesthetic results of TBS.

The authors state that a misconception of the direct browlift procedure is that they create visible scars. With good incision placement, limited undermining, and presurgical use of Botox application, they have found that the direct browlift does not create visible scarring and is the easiest, most precise, and most reliable procedure for brow shaping. It is also the only technique that enables precise correction of minor brow asymmetries.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – The Pretrichial Temporal Browlift

Thursday, June 23rd, 2016


The position of the eyebrows on the brow bones over the eyes plays a major role in facial expression. Low eyebrows can convey an impression of anger or tiredness. Conversely, high eyebrows can make one look surprised  or very wide-eyed/alert.

But beyond facial expression there are some basic gender differences in their shape as well. It is commonly believed that a woman’s eyebrows are significantly higher than that of men. While this is a commonly held belief, it is not really true as the top edge of the eyebrows (middle of the eyebrow arch) is actually fairly similar. A woman’s eyebrow’s may appear higher because they are usually thinner and do come as close together in the middle. (all due to plucking)

Details of beauty. French manicured nails and eye with ceremonial makeup

Details of beauty. French manicured nails and eye with ceremonial makeup

But the shape of the eyebrow arch is also more exaggerated in women with an often higher arch position at the tail of the brow. Conversely, a male eyebrow besides being thicker is more flat. This change in the eyebrow shape and that of a thinner female eyebrow is probably why a browlift has a feminizing effect.

The temporal browlift is largely a female procedure because it provides a tail of the eyebrow upward tilt. It lifts the tail of the eyebrow up and off the lateral brow bone. The traditional temporal browlift places the incision behind the temporal hairline. It achieves its lifting effect by excising temporal scalp tissue. While effective this pulls back the edge of the temporal hairline and leaves a scar back in the hairline which has the potential to become wide.

Right Pretrichial Browlift intraop result Dr Barry Eppley IndianapolisLeft Pretrichial Temporal Browlift result intraop Dr Barry Eppley IndianapolisAn alternative incision location for the temporal browlift is right at the hairline. This is a more direct approach that is usually more effective as the location of the pull of the lift is closer to the eyebrow. It also allows the direction of the lift to be well controlled by where along the temporal hairline the incision is placed.

Bilateral Pretrichial Temporal Browllift result intraop Dr Barry Eppley IndianapolisWhile the pretrichial temporal browlift has the potential to create a noticeable scar as it is not back in the hairline, its effectiveness outweighs these risks in some patients. This is particularly useful in the women who desires a strong an exaggerated temporal browlift effect.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Male Transpalpebral Browlift

Wednesday, June 15th, 2016


Background: Aging effects the periorbital region through changes in the eyelids as well as the brows. Descent of the brows is a common feature of it but has aesthetic gender differences. Because men have a naturally lower and non-arched brow, some degree of brow sagging is much better tolerated in men than women. Unlike women, a low brow in men is not as often interpreted as being a negative facial feature.

But as some men age the combination of excessive upper eyelid skin and a dropping brow create both aesthetic and functional issues. The upper eyelid develops pseudoptosis due to the weight of the skin and overhanging brows. This causes a partial or complete loss of the upper visual field. This also creates a very tired and often unhappy appearance.  Combining browlift and upper blepharoplasty surgery is a great combination for the older male who suffers this type of periorbital aging effect.

While a blepharoplasty in a male is no different than in females, the browlift technique often is. The lack of an existing or sufficient frontal hairline and scalp hair makes the choice of many standard browlift methods unusable due to visible scar concerns. (e.g., coronal, endoscopic or pretrichial browlifts) Incisions in the mid-forehead through a horizontal wrinkle line can be used but the scars take a long time to mature in a highly visible area.

Case Study: This 58 year-old male wanted to improve his tired eye appearance. He also did not like the heavy look of his eyes and how he also looked like he was squinting. He was a good candidate for a combined eyelid and browlift periorbital rejuvenation surgery.

Male Transpalpebral Brow Lift technique 1 Dr Barry Eppley IndianapolisUnder general anesthesia, the skin removal for upper blepharoplasties was initially performed. Dissection was then done through the orbicularis muscle to approach the tail of the brow bone. Sunperiosteal undermining exposed the entire outside half of the brow bones.

Male Transpalpebral Browlift technique 2 Dr Barry Eppley IndianapolisA drill placed a hole in the bone 15mm above the lower end of the brow bone.

Male Transpalpebral Browlift Technique 3 Dr Barry Eppley IndianapolisAn endotine brow lift device was inserted with the prongs of it oriented in an upward direction. This device permitted the soft tissue of the brow to be lifted up and engaged into the device on its underside. The upper blepharoplasty incisions were then closed. He also had lower blepharoplasties performed as well.

Male Transpalpebfal Browlift result front view Dr Barry Eppley IndianapolisMale Transpalpebral Browlift results oblique view Dr Barry Eppley IndianapolisHis results at three months after surgery showed good improvement of is eyelid appearance. The heavy look to his eyes was gone and he expressed that he could see better because there was more light. His field of vision opened up.
endotine browlift devices dr barry eppley indianapolisThe resorbable endotine browlift device offers a transpalpebral approach to performing a browlift. Unlike every other browlift achieves its effect by llifting the brows up. Coming from below the transplpebrak approach creates its effect by a ‘push’ effect rather than a pull. This makes its effects limited to the tail of the eyebrow and of a modest nature. There is no risk of creating a browlift result that is too elevated or overdone. These characteristics makes its use mainly for the male browlift candidate. Fortunately men prefer a very subtle browlift effect anyway. They are at much greater danger of looking surprised or unnatural from a browlift procedure.


1) The male browlift is challenging because most superior approaches rely on adequate scalp hair coverage.

2) The transpalpebral browlift offers a scarless technique that relies on the placement of a resorbable brow bone device placed through an upper blepharoplasty incision.

3) The transpalpebral browlift provides some modest lifting of the tail of the brow which is most appropriate for men.

Dr. Barry Eppley

Indianapolis, Indiana

The Transpalpebral Browlift Explained

Sunday, April 17th, 2016


Correction/repositioning of sagging brows is done by well known browlift procedures. The vast majority of browlift surgeries are done in women with access to do the procedure coming from above in and behind the frontal hairline. The three different female browlift techniques (coronal, pretrichial and endoscopic) are chosen based on forehead skin length and the position of the frontal hairline.

Browlifts in men, however, are more challenging because of the typical lack of a stable hairline, poor hair density or no hairline at all. Thus, most men can not have a superior scalp approach due to concerns of visible scarring or disturbed hairline concerns. Browlifts in many men have more limited options and include either a mid-forehead, direct (superior eyebrow hairline) or a transpalpebral incisional approaches.

endotine browlift devices dr barry eppley indianapolisThe transpalpebral browlift technique is used almost exclusively in men and relies upon a device (Endotine) to achieve the browlifting effect. In addition it has a browlifting effect that is largely limited to the outer half of the brow (temporal brow) and creates a more modest lifting effect. This location of the browlift is what makes it most useful in men as inner browlifting creates an unnatural appearance for most men.

Transpalpebral Browlift brow bone exposure Dr Barry Eppley IndianapolisThe transpalpebral browlift is done from an upper blepharoplasty incision and is often done in conjunction with removal of upper eyelid skin. After the upper eyelid skin is removed, the outer brow bone is accessed in a subperiosteal fashion. Dissection is carried above the lower edge of the outer brow bone in excess of 15mms to allow the Endotine device to fit.

Transpalpebral Browlift drill hole and endotine device Dr Barry Eppley IndianapolisAt 15mms above the lower edge of the brow bone an outer cortical bone is drilled. This allows the Endotine device to be inserted into the hole and oriented in an upright triangular position. This allows the prongs on the device to be angled upward.

Transpalpebral Browlift endotine device [placement Dr Barry Eppley IndianapolisOnce the Endotine device is inserted, the outer brow tissues are lifted and suspended on the device’s prongs. The soft tissue are then closed over the device and the upper blepharoplasty incision closed.

The transpalpebral browlift is essentially a ‘push’ browlift from below. This is stark contrast to the more traditional browlift methods which are ‘pull’ procedures from above.  The Endotine device makes this possible. It is composed of a resorbable polymer material which breaks down and is absorbed completely within 6 to 9 months after it is inserted. This should be enough time to allows the brow lift tissues to scar down and heal to the bone in a slightly more elevated position.

Patients will feel the device under the skin for a few months after the procedure although it is not visible on the outside. For men the transpalpebral approach, while having a modest result, avoids scar concerns at the eyebrow or on the forehead which can take a long time to mature and their imperceptibility is not always assured.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Endoscopic Browlift Fixation with LactoSorb Screws

Friday, January 1st, 2016


Endoscopic Browlift Supraorbital Nerve Dissection Dr Barry Eppley IndianapolisThe most common surgical treatment today for sagging brows is the endoscopic browlift. As opposed to browlifts that involve long incisions and remove forehead or scalp tissue to create the lifting effect, the endoscopic technique uses minimal incisions and removes no tissue. It achieves a browlifting effect through a deep subperiosteal brow tissue release and a superior forehead and scalp backward tissue shift.

This relocation of the entire soft tissue of the forehead up and back, known as an epicranial shift, must be initially held in place to create the brow lift. A wide variety of endoscopic browlift fixation methods have been described since this browlifting technique was introduced about twenty years ago. Fixations methods including metal pins, metal screws, transosseous bone tunnels and resorbable grids or platforms. Each of these devices and methods have their advantages and disadvantages and the fact that so many endobrow fixation methods exist indicates that there is no perfect way to do it.

LactoSorb Endoscopic Browlift Screw Dr Barry Eppley IndianapolisHaving used all of these endobrow fixation methods, there is one that I found to be my favorite over the twenty years of performing the procedure. The use of LactoSorb resorbable screws offers a simple and very reliable soft tissue fixation method. This is a low profile 2.0mm screw made out of PLLA-PGA material which is naturally resorbed after 6 months of placement. It is a special resorbable screw that has a hole placed though its head and a pushpin design rather than that of a threaded shaft.

LactoSorb Endoscopic Browlift Drilled Screwhole Dr Barry Eppley IndianapolisLactoSorb Endoscopic Browlift Screw Suture and Lift Dr Barry Eppley IndianapolisThis fixation method issued by initially placing an outer cortical bone hole at the back end of the endo scalp incision. A suture is initially passed through the screwhead and then the screw is pushed into the bone hole. A snug fit allows the introducer for the screw to be removed. With the screw in place holding the suture, the uplifted scalp and forehead tissues are grasped with a bite of the suture and tied down. The overlying scalp incision is then closed.

Between the temporal lines of the skull, LactoSorb Endobrow resorbable screws can be used for central brow fixation. They are slightly palpable for a few months but their profile eventually flattens as they resorb over time. The time needed for natural fixation by healing of the elevated periosteum back down to the bone is reported to be a but a few weeks. So the months of fixation provided by the resorbable screw is more than adequate.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Pretrichial Browlift

Sunday, December 27th, 2015


Background: Aging around the eyes is the earliest and most visible signs of facial aging. Periorbital aging affects both the upper and lower eyelids as well as the brows that sit above them. Unless the eyelids which develop excessive skin, the eyebrows age by ‘falling down’, changing their position on the brow bone and losing their arch shape. As the brows descend they close down the eye space making the eyes look smaller and more tired.

The most common form of periorbital rejuvenation is blepharoplasty surgery. Since every person has four eyelids, cleaning up loose eyelid skin and fat can make a dramatic difference in the appearance of the eyes. Provided blepharoplasties are not overdone, blepharoplasty creates a refreshened or rejuvenated look to the eyes. Lifting the brows above the eyelids may or may not be also beneficial at the time of blepharoplasties and requires a presurgical lift test to determine.

Browlift surgery can be done by a variety of superiorly based methods. One of these browlift methods is the pretrichial technique. Through an incision along the frontal hairline the brows can be directly lifted without increasing vertical forehead length. (and can be used to actually lower it if desired) Its disadvantage is the concern about visible scarring along the hairline.

Case Study: This 50 year-old female was undergoing a variety of facial rejuvenation procedures. While she had blepharoplasties done in the past, her periorbital aging issue could be discerned to be more in her brow position than that of her eyelids. Here brows were low on the brow bones with a flat arch shape. This contributed to an almost angry facial appearance.

Female Pretrichial Browlift result front view Dr Barry Eppley IndianapolisFemale Pretrichial Browlift result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, he had a pretrichial browlift done using an irregular zigzag hairline incision. After undermining down to the brow ridge and releasing the periosteal attachments, a 7mm strip of upper forehead tissue was removed centrally and 9mms out laterally. The upper edge of the forehead tissues were secured in an elevated position by suturing it to the bone through outer cortical interosseous holes.

Female Pretrichial Broiwlift results side view Dr Barry Eppley IndianapolisThe pretrichial browlift is an almost exclusively female periorbital rejuvenation procedure. The usually stable and more dense female hairline allows for good hairline scar results. The opening of the eyes from the browlift as this point in your age is far more important than what a blepharoplasty could create.


  1. Sagging of the brows is defined by the position of the eyebrows on the brow bones.
  2. In women brow ptosis is defined as eyebrows that have a flat arch shape and are positioned at or below the brow bones.

3) The pretrichial browlift is the most direct approach to elevating sagging brows.

Dr. Barry Eppley

Indianapolis, Indiana

Multi Point Fixation Temporal Browlift

Sunday, October 11th, 2015


One of the signs of periorbital aging, amongst many, is the descent of the outer aspect or tail of the eyebrow. This is almost always more of an aesthetic issue in women than it is in men. For some women this may be the only aspect of brow descent that is troubling.  Botox injections are a good treatment for it but that is not a long-term strategy. Browlift surgery produces a more definitive result with longer lasting effects.

Different types of browlifts can be done from endoscopic to full coronal variations. The endoscopic technique is the most commonly performed browlift today. But as a trade-off for its limited use of incisions, it is prone to result in undercorrection. Specific temporal browlifts exist which involve different planes of dissection and methods of tissue fixation.

In the September 2015 issue of the Archives of Plastic Surgery, a paper on browlifts appeared entitled ‘Lateral Brow Lift: A Multi-Point Suture Fixation Technique’. In this clinical study a total of 519 patients were treated with a lateral brow surgery that essentially was a ‘dual plane’ technique. A temporal hairline incision was made with dissection along the deep temporal fascia to the superolateral bony orbital rim. Elevation of fixation of the lateral brow/orbital muscle tissues done up to the lateral edge of teh incision. Additional suture fixation was also done between the intermediate and superficial temporoparietal fascia and the deep temporal fascia. The excess temporal hair-bearing skin created by this elevation was then excised. Good ateral brow elevation was obtained in most patients (94%) with a relatively small number of complications. Total brow relapse (1.5%), partial relapse (4%), weakness of the frontal branch of the facial nerve (1%), and temporal scar widening/alopecia. (2%)

Temporal Bowlift results front view Dr Barry EppleyTemporal Browllift results oblique view Dr Barry Eppley IndianapolisSagging of the lateral brow usually occurs much earlier than that of the inner half of the eyebrow. The merging of the frontalis and orbicularis muscle out laterally can create a droop which pulls the skin below it downward as well. Isolated temporal browlifts attack this area directly. The most common temporal browlift is a skin only method that lacks any deeper tissue support. Multilayer or composite temporal browlifts have been described with dissection on top of the deep temporalis fascia to the orbital rim.

The temporal browlift technique described by this paper also involves a deep temporal plane of dissection but incorporates a periosteal release along the orbital rim. This creates greater tissue mobilization. Such tissue mobility allows for a greater elevation and expansion in the lateral canthal area. The different points of fixation of the different temporalis fascial layers to each other as well as the galea is major advantage of this technique and creates longer-lasting results.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Pretrichial Browlift Long-Term Results

Sunday, September 20th, 2015


Background: Like the rest of the face the brows and forehead tissues do fall or go south with age. Besides the horizontal forehead lines and vertical glabellar wrinkles, the lowering of the brows is the most noticeable feature of aging of the upper third of the face. Sagging of the brows, as defined by where they are compared to the underlying brow bones, becomes relevant when the brows hang over the brow bones. This causes a frowning or scowling appearance and pushes upper eyelid skin downward.

Browlift surgery is a well known cosmetic procedure to lift sagging brows and partially deanimate some of the hyperactive forehead muscles. There are several types of browlift techniques which fundamentally differ by incision location and size and whether forehead/scalp tissues are removed or repositioned. The corona browlift is the historic procedure and the endoscopic technique is the more modern technique.

An intermediary browlift technique between the coronal and the endoscopic methods is that of the pretrichial approach. This browlift techniquesdoes use a scalp incision but it is located right at the hairline. This allows excess forehead skin to be removed to do an excisional browlift but does increase the vertical length of the forehead or create a scar back in the hairline that may cause some hair loss. It also allows a shorter open access to modification of the frontalis and glabellar muscles.

Case Study: This 56 year old female wanted a forehead rejuvenation to lift her sagging brows and open up her upper eyelids. She wanted her brows back up over the brow bones and to reduce some of her forehead wrinkle lines.

Under general anesthesia, she has a pretrichial browlift using an irregular hairline incision. Some of the glabellar muscles were excised and strips of frontalis muscle were removed. A total vertical length of 12 mms of upper forehead skin was removed along the hairline tapering it into the temporal area.

Ten Year Pretriochial Browlift result front view Dr Barry Eppley IndianapolisTen Year Pretrichial Browlift result oblique view Dr Barry Eppley IndianapolisPretrichial Browlift Scar result long-term Dr Barry Eppley IndianapolisWhen seen at ten years after the original procedure it could be appreciated that her brows were still up higher than they were just before the original browlift surgery. Her forehead wrinkles were not much worse and her hairline scar was nearly imperceptible.

No anti-aging facial surgery is a permanent procedure. Aging of the face continues unabated and it is just a question of time until the results of the surgery is overcome. While each patient is different, it is a general statement that many facelifting procedures will last about ten years. This patient’s browlift shows that she is just about back to where she started a decade ago.


1) Browlift surgery is not meant to have a permanent result and does degrade over time.

2) An excisonal technique, like a pretrichial browlift, should have fairly long-term results over other non-excisional techniques.

3) This is an example of a ten year pretrichial browlift result which still shows some persistence of improvement over her initial preoperative result.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Skull Implant Browlifting Effect

Monday, July 6th, 2015


Background: Skull implants are used today to treat a variety of aesthetic head shape concerns and deformities. While many think of skull implants of filling in craniotomy or other traumatic skull defects, aesthetic skull implants are placed in a subperiosteal onlay fashion to build out usually normal thickness skull bone areas. Skull implants placed in this manner are used for correcting skull asymmetries, flat spots, irregularities or just to create an overall larger circumference to the head.

Skull Cap Imnplant Design Dr Barry Eppley IndianapolisThe success of skull implants is partially dependent on the overlying scalp. The scalp has to stretch to accommodate what is placed beneath it. The skull implant can not be too large or too thick or the scalp will be too tight and the incision to place it will not be able to be closed. The bigger the skull implant or the larger the skull surface area that it covers the more that the scalp tissue is ‘recruited’ from elsewhere as the overall scalp stretches to accommodate the implant pressure underneath it.

Interestingly, some patients think that a skull implant will naturally have a bit of a facelifting effect. They envision that the upper pull of the scalp will translate into a distant effect low on the face. This is not what occurs, even in the largest of skull implants that I have placed. But there are certain circumstances with skull implants where a browlifting effect can be created.

Case Study: This 42 year-old female presented for a combination of forehead contouring and a near circumferential skull implant to build up the sides and the back of the head. A custom skull implant was designed with maximal thickness of 8mms in the back.

Skull Implant Browlift result front viewSkull Implant Browlift result oblique viewUnder general anesthesia, a pretrichial incision was made. Going anteriorly the slope of the forehead was reduced by bone burring. Going posteriorly the scalp was elevated over the temporal and occipital regions of the scalp. The custom made implant was inserted, trimmed where needed and secured with small titanium screws. Prior to placement multiple perfusion holes were placed through the implant.

Skull Implant Browlift result side viewHer postoperative results showed a larger circumference to the head but also that she had developed a significant browlifting effect. This was a desireable aesthetic side effect of the skull implant. It occurred most likely because the access point for the implant’s insertion was at the frontal hairline. (pretrichial incision) As the scalp behind the incision became elevated, closing the pretrichial incision (after elevation of the forehead flap and contouring) resulted in the brows moving upward.


1) Skull implants of substantial size can elevate the scalp through underlying volume addition.

2) If a skull implant is placed close enough to the frontal hairline and of sufficient size it can have a browlifting effect.

3) The pretrichial approach to skull implant placement can both contribute to a browlifting effect from skull implants or can be used to create a browlift if desired.

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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