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Archive for the ‘plastic surgery case study’ Category

Case Study – Custom Skull Implant in Sagittal Ridge Skull Reshaping

Sunday, December 18th, 2016


Background: The shape of one’s skull is determined by numerous factors. But the most important two are the cranial sutures and the underlying expanding brain. The sutures permit the growing brain to increase in size without constriction by a tight overlying ‘bone box’. These sutures are strategically placed to allow a circumferential expansion of the skull while keeping the different pieces of the skull together.

One of the key and most evident cranial sutures is the one that runs down the midline of the skull and initially connects the front and back soft spots. This long suture allows the skull to grow in width. When the sagittal suture fuses together too soon a well known abnormal skull shape ensues marked by a lack of skull width and a very long skull length. (sagittal craniosynostosis)

There are different degrees or expressions of sagittal craniosynostosis, some of which may escape early surgical intervention or felt not severe enough to justify infantile cranial vault surgery. They present in adulthood with prominent sagittal ridges, narrow bitemporal widths and a triangular shape to the top of their head when viewed from the front. Skull reshaping of these deformities in adults requires a completely different surgical approach than what is used in infants.

Case Study: This 42 year-old male desired to change his skull shape. It had bothered him since his hair had thinned when he was younger and he had managed his head shape concerns by constantly kept his head covered by hats and caps. He had been through several unsuccessful hair restoration treatments including scalp reduction and scalp micropigmentation.

sagittal-ridge-reduction-3d-ct-planning-dr-barry-eppley-indianapoliscustom-skull-implant-design-for-sagittal-ridge-deformity-dr-barry-eppley-indianapolisHis skull reshaping surgery was planned using a 3D CT scan. Some reduction of the most prominent height of the sagittal ridge was imaged and around it a custom skull implant designed to build up the deficient parasagittal and upper occipital skull areas.

skull-reduction-and-implant-surgical-plan-and-incision-dr-barry-eppley-indianapolisskull-implant-and-sagittal-reduction-intraop-dr-barry-eppley-indianapoliosUnder general anesthesia his old midline scalp reduction scar was used for surgical access. The posterior sagittal ridge was burred down and the custom skull implant placed.  Despite the amount of scalp expansion caused by the implant, the incisional closure was not excessively tight.

custom-skull-implant-results-front-view-dr-barry-eppley-indianapolisHis several month postoperative result showed a life changing improvement in the shape of his head. It had a more round shape and the elimination of any sagittal ridging.

Adult skull reshaping of the sagittal ridge deformity always involves some reduction of the height of the ridge. But in more severe cases this alone is inadequate. Building up the skull around it essential and this is most effectively using a 3D design approach to the custom skull implant.


1) The prominent sagittal ridge skull deformity seen in an adult is caused by an untreated infantile sagittal craniosynostosis of varying expressions.

2) Reshaping the adult high sagittal ridge requires a combination of some sagittal ridge reduction and major parasagittal augmentation.

3) A custom skull implant is the most effective method for a major skull reshaping change.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Rib Removal for Maximal Waistline Reduction

Monday, December 12th, 2016


Background: Rib removal is a body contouring procedure for which there is much misinformation. It is a real surgical procedure that is done for numerous aesthetic reasons, one of which is reduction of the waistline. This is reduction of the anatomic waistline which is located at the level of the belly button and not that of the hips.

ribs-11-and-12A review of the anatomy of the lower ribs reveals why their removal might be effective. Unlike the ribs that lie above, the true free floating ribs of #11 and #12 have a very downward angle to them. This downward angle combined with their long length can serve as an ‘obstruction’ if one wants to go beyond the natural waistline shape. In some people these ribs can be very long and there is little space between their ends and the iliac crest.

While the term rib removal is used, it is important to understand that it is subtotal rib removal. There is no aesthetic benefit to taking the whole rib as only the outer portion has an impact on the anatomic waistline. The ribs are only removed back to the lateral border of the erector spinae muscle. This makes the length removed of 6cm to 8cm of rib #12 and 12cm to 15cms of rib #11. These are still substantial lengths but just not the whole rib length.

Case Study: This 26 year-old female desired maximal waistline reduction. She was at a low body fat level, exercised regularly, and had a prior procedure of liposuction of her waistline and back. She also waist trained using a corset. Her current circumferential waistline measurement was 26 inches.

rib-removal-for-waistline-narrowijng-intraop-left-siderib-removal-for-waistlione-narrowing-incision-dr-barry-eppley-indianapolisUnder general anesthesia and in the prone position, bilateral 5 cm skin incisions were made on her low back. These incisions were marked in an oblique orientation based on a skin crease line that was created by her twisting around her waistline to the sides. Rib #11 and 12 were identified, detached from their musculature and taken back to the lateral border of the erector spinae muscle. What was impressive about these ribs was how angled downward and long they were. At the midportion of rib #11 the pleura of the lung was visualized in one area. Rib #10 was treated by removing a several cm portion of the lateral aspect of the rib to allow it to collapse inward.

rib-removal-for-wasitline-narrowing-specimens-dr-barry-eppley-indianapolisrib-removal-intraop-back-view-resultseffects-of-rib-removal-for-waistline-narrowing-intraop-dr-barry-eppley-indianapolisWhen finished with one side of rib removal/modification it could be seen how much the waistline on that side collapsed inward.

Rib removal for waistline reduction is usually done on very motivated women that seek maximal waistline narrowing. They have done numerous maneuvers to reduce their waistline and are seeking rib removal as the last stop on this body contouring journey.  They often have previously pursued fat reduction efforts through liposuction and have done or are currently doing corset waistline training.


1) Maximal waistline reduction can be achieved by removal of the outer portions of the true free floating ribs

2) A subtotal ostectomy of rib #10 (arc reduction) can also be helpful for reducing its circumference around the waistline.

3) Rib removal for anatomic waistline reduction is a safe and effective procedure.

Dr. Barry Eppley

Indianapolis, Indiana



Case Study – Shaping Custom Skull Implant

Sunday, December 11th, 2016


Background: The top of the head usually has a slightly convex shape between the temporal lines that border its sides. This normal superior skull shape can be altered during development and often occurs by how the midline sagittal suture develops and grows. In many cases of undesired superior skull shapes, the sagittal suture line becomes a raised ridge creating a peaked shape to the top of the head.

Rather than a raised ridge the top of the head can also develop without much convexity. It can be relatively flat between the temporal lines creating a more square head shape. While this flatness can be camouflaged by various hairstyles, it can still be very bothersome to some who are so affected.

The best way to create increased convexity to the top of the head and a little bit more height is with the use of a custom skull implant. It does not have to be particularly thick or big to have a noticeable effect. Designed to add skull height between the temporal lines, it extends from behind the frontal hairline back past the crown area down slightly into the occiput.

heightening-skull-implant-design-dr-barry-eppley-indianapolisCase Study: This 44 year-old male disliked the very top of his head, feeling that it was too flat and did not have a nicer more rounded shape. Drawings of his desired head shape change showed that a cap on the top of the head gave the desired effect. Using a 3D CT skull scan, a custom skull implant was designed that added convexity to the top of the head without adding much vertical height.

heightening-skull-implant-placement-dr-barry-eppley-indianapolisUnder general anesthesia, a small 7 cm long scalp incision was made closer to the back of the head. The custom skull implant had numerous perfusion holes placed throughout it. After the development of the subperiosteal pocket, the implant was inserted in a folded fashion. Once inside the implant was unrolled, positioned as designed and secured with two small titanium microscrews.

small-skull-augmentation-results-front-view-dr-barry-eppley-indianapolissmall-skull-implant-augmentation-results-side-view-ddr-barry-eppley-indianapolisA custom skull implant can be designed to create a cap for the top of the head to increase its convexity. This provides a more rounded head shape, a small amount of vertical height and a small amount of additional front to back length.


1) The shape of the top of the skull can be flat, have an irregular shape or be asymmetric.

2) The top of the head can be augmented with a custom skull implant to increase his height or make it have a more convex shape.

3) A custom skull implant to smooth out the top of the head can be inserted through a small scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Buffalo Hump Reduction with Power-Assisted Liposuction

Saturday, December 10th, 2016


Background: The accumulation of fatty tissue at the back of the neck is a well known side effect from certain HIV medications. One of these lipodystrophic sites is the cervicodorsal region where abnormal fat distributions can occur. Because of its raised area below the back of the head it has been given the moniker of a ‘buffalo hump’. Such disfigurements can be very distressing to those patients so affected.

The mainstay of treatment for such buffalo humps has been surgery. No non-surgical therapies have been shown to be effective. Excision lipectomy has been most commonly used and has good success rates in small clinical series. The most common complications have been a high rate of seromas and wound dehiscences. Such complications are usually self-resolving and have not required reoperations. Recurrent fat accumulations have also not been reported to occur.

Liposuction offers a treatment approach to the buffalo hump that does not involve an open excisional approach. This avoids the risk of wound dehiscence, significant visible scars and a very low rate of seroma formation. With the many different types of liposuction devices available today, improved reductions are possible compared to traditional suction-assisted lipectomy using standard cannulas.

Case Study: This 47 year-old male presented with a large and painful buffalo hump that had been growing for years. It had gotten big enough that it caused pain on neck extension and was also a source of embarrassment.

buffalo-hump-reduction-result-back-view-dr-barry-eppley-indianapolisUnder general anesthesia and in the prone position, the buffalo hump was infiltrated with a tumescent solution. Using a power-assisted liposuction device (PAL) and a 4mm basket cannula, a total of 700cc of aspirate was obtained from a two point access approach.

buffalo-hump-reduction-result-side-view-dr-barry-eppley-indianapolisAt his two week follow-up he had a complete flattening of the cervicodorsal area and no signs of fluid accumulation. The treated area was still sore and that would take up a month or more to be completely pain free. The skin over the treated area was numb and would be expected to be so for several months after the procedure.

Cervicodorsal lipodystrophy, aka buffalo hump, is a well known complication of the extended use of HIV protease inhibitor drugs. Because of the fibrofatty composition of the buffalo hump tissue, it has been suggested that only excision can prevent its recurrence or be effective in removing it. This clinical directive is based on the use of traditional liposuction techniques and not on more contemporary liposuction technologies. Today’s energy or power-driven liposuction devices are far more effective at treating denser or scarred fat accumulation sites.


1) A buffalo hump deformity at the back of the neck is a well known sequelae of HIV protease inhibitor therapies.

2) While excision of buffalo hump deformities is effective it is associated with scars and seroma formation.

3) Liposuction of buffalo hump deformities is equally effective as open excision with a lower risk of complications.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Breast Implant Replacements

Thursday, December 8th, 2016


Background: Breast implants are often perceived as one-time lifelong devices. But this is the exception and not the rule. Depending upon the age at which they were placed, breast implants are often replaced at some point in a woman’s life. (and in more rare cases even removed) They are numerous reasons for why breast implants would be replaced including device failure as well as an aesthetic desires for a change in breast size.

The desire to change breast implant size, while often believed to occur early after their initial placement, is usually much later. It often is a decade or more particularly if one has had them placed before children. The breasts will undergo changes from pregnancy and weight loss and this often leads to loss of breast tissue and a real negative change in breast size and shape.

When replacing breast implants for a size increase, it is important to remember the volumetric rule that it takes at least 25% to 33% more volume to see an external change. For example, existing 300cc implants would need to be replaced with 400cc implants to see a visible change. This is usually a 1/2 cup or so. Large increases in breast size will require a 50% or greater volumetric increase. Thus 300cc implants need to be replaced with 450cc implants for a full cup size increase.

Case Study: This 47 year-old female originally had saline breast implants placed fourteen (14) years previously. They were 300cc implants filled to 350ccs. Between her age and loss of some weight she now desired a significant size increase with the desire for a two cup size increase.

large-breast-implants-replacements-front-view-dr-barry-eppley-indianapolisUnder general anesthesia her existing areolar incisions were used to remove her saline implants. The upper and inner capsule was released to accommodate the larger implants. Ultra high profile silicone implants of 700cc size were placed.

large-breast-implants-replacement-results-oblique-view-dr-barry-eppley-indianapolislarge-breast-implants-replacement-results-side-view-dr-barry-eppley-indianapolisThe reason it takes much more implant volume than one would think is due to multiple factors. The stretch of the breast tissue and skin that now exists that was not present initially during the initial procedure is a major reason. There is also the long-standing perception of breast size which initially seemed like a dramatic change but is now well visually accomodated.

As a general rule a moderate breast size increase requires 25% to 33% more volume, a moderate increase requires 50% more volume and a dramatic change requires 100% more volume.


1) Some women over their lifetime may desire to replace their breast implants to a larger size.

2) Secondary breast implant replacements surgery has a much more rapid recovery than their initial placement.

3) To make a visible difference in breast size with implant replacement the volumetric increase is usually greater than one would think.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Transgender Breast Augmentation

Monday, December 5th, 2016


Background: Transgender plastic surgery is a large compilation of feminizing face and body procedures. Of all of these procedures breast augmentation has the greatest impact on making a feminization change. It also do so in a rapid and assured manner, creating an instantaneous body shape change as all breast augmentation surgeries do.

On average transgender breast augmentation consistently creates good breast mound shapes. This has to do with the genetic male chest which is not exposed to the tissue stresses of pregnancy and weight gain/loss. Even in the male chest that may have some slight sagging the volume expansion effects of a breast implant quickly overcome any loose tissue.

To avoid scarring many transgender breast augmentation are done through an axillary incision. But with larger breast implants or when the use of a textured anatomic shaped implant style is desired, the axillary incision is more problematic. It is far better to switch to an inframammary incision to successully get these types of breast implants into good partial submuscular position.

Case Study: This 21 year-old transgender female desired breast implants. She had been on hormone therapy for several years but had developed little breast tissue or enlargement. She wanted a fairly large breast increase but also wanted a more natural shape and opted for anatomic silicone breast implants.

transgender-breast-augmentation-intraop-result-right-side-dr-barry-eppley-indianapolisUnder general anesthesia and through 4cm long inframammary incisions, 600cc shaped anatomic silicone breast implants were placed in a partial submuscular position.

ar-bam-results-front-viewar-bam-result-oblique-viewWith good overlying breast skin and nipple position, the results of her breast augmentation were satisfying. The tautness of the breast skin and the size of the implants made for rounder breasts than what one would think from using anatomic shaped implants.


1) Breast augmentation is one of the most important of all body contouring procedures for male to female transgender patients.

2) There is nothing unique about the genetic male chest that would not make it amenable to successful breast implant placement.

3) Because of the good quality of the genetic male chest skin, transgender breast augmentation is highly successful with the creation of good breast mound shape.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Cheek and Jaw Angle Implant Replacements

Sunday, December 4th, 2016


Background: Facial reshaping surgery is a broad collection of bone augmentation and reduction procedures. Almost all of the facial bone augmentation procedures are done by some form of onlay augmentation, most commonly preformed by preformed implant styles. Of all available facial implants the four most common areas augmented are the chin, nose, cheek and jaw angles. All of these represent facial projection points where augmentation can make a big difference on the perception of the face.
Of all available facial implants the hardest ones to choose a proper style and then surgical place are the cheeks and jaw angle locations. Cheek implants are technically easier to place but getting the right style of implant can be difficult as they are major gender aesthetic differences in this part of the midface. Jaw angle implants have less style choices but is very hard to place and position on the bone properly and are highly prone to malposition.
The success of facial implants is most fundamentally controlled by the style and size of the implant chosen. A perfectly performed facial implant placement that heals without complications may be viewed as a surgical success. But if it fails to meet the patient’s facial change goals it is still an aesthetic failure.
wrong-cheek-and-jaw-angle-implants-dr-barry-eppley-indianapoliswrong-cheek-and-jaw-angle-implants-2-dr-barry-eppley-indianapolisCase Study: This 36 year-old male had a prior history of standard cheek and jaw angle implants placed one year previously. The implant creased undesired facial shape changes. The submalar cheek implants created a more feminine ‘apple cheek’ look rather than the high cheekbone look he desired. He had high jaw angles but widening jaw angle implants were used. This made his face look look wide and fat. A 3D CT scan showed that the implants were well placed but they simply were the wrong style and size.
cheek-and-jaw-angle-implant-exchange-dr-barry-eppley-indianapolischeek-and-jaw-angle-implant-exchange-2-dr-barry-eppley-indianapolisNew custom cheek and jaw angle implants were made that were designed to create a high cheekbone look and vertical lengthening of the jaw angles. The differences between the old and the new custom implants can be seen in the 3D overlay.
custom-cheek-and-jaw-angle-implant-designs-dr-barry-eppley-indianapoliscustom-cheek-and-jaw-angle-implant-designs-2-dr-barry-eppley-indianapolisUnder general anesthesia a complete intraoral approach was used to remove the old implants, perform capsulectomies, extend the pockets and place the new implants. The horizontal portion of the chin part of the jawline was removed as that the chin ended up more square but did not additional horizontal projection.
How to choose proper facial implant style and size is not only not an exact science, it is really not something that any plastic surgeon learns to do in their training. It is still a judgment by the surgeon who tries to understand the patient’s facial goals and then makes an aesthetic judgment about implant selection.
1) Facial reshaping surgery often includes cheek and jaw implants.
2) Incorrect styles of cheek and jaw angle implants can lead to undesired facial shape changes.
3) Certain types of facial reshaping changes requires custom cheek and jaw implants to achieve the patient’s desired aesthetic result.
Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Forehead Osteoma Removal

Saturday, December 3rd, 2016


Background: Osteomas are the most common bony tumor of the craniofacial skeleton. They are benign bone growth that is typically seen growing on another piece of bone. They appear as an outcropping or ‘mushroom’ of slowly growing bone and are easily disinguishable by appearing as a hard bump on an otherwise smooth bone surface. This makes them very identifiable on the skull where such bumps appear evident even when they are small.

Their are various causes of osteomas but the most common one is a history of prior trauma. Low impact blunt trauma to the skull is common since the head is a large object that frequently is inadvertently hit. If the head is struck in just the right location with enough force a perforating blood vessel may bleed and create an external bruise.When blood gets under the periosteum it can serve as a trigger for bone growth.

large-forehead-osteomaCase Study: This 56 year-old female had a large bump of the left brow bone that began over 17 years when she was accidentally struck by an attic door on her forehead. She developed a large bruise from which a small bump eventually grow to the big bump now seen. It has finally gotten big enough that she could no longer hide it. A CT scan showed that it was an outcropping of bone emanating from the outer cortex of the brow bone.

dl-forehead-osteoma-removal-specimen-dr-barry-eppley-indianapolisdl-forehead-osteoma-removal-intraop-top-vew-dr-barry-eppley-indianapolisUnder general anesthesia the brow bone osteoma was approach through a hairline (pretrichial) incision directly above it. Through a subperiosteal tunnel of the forehead skin the osteoma was exposed and dissected off of the overlying scalp tissues and the supraorbital nerve. An osteotome was used to separate it from the normal surrounding bone. The osteoma was composed of poorly calcified bone that was softer than normal skull bone.

dl-forehead-osteoma-removal-intraop-side-view-dr-barry-eppley-indianapolisThe removal of forehead osteomas are often dramatic as the removal of a large bump on the upper face resumes a normal appearance. The removal of a benign bony tumor should be done, if possible, through a discrete incision to avoid creating any adverse aesthetic trade-offs. Incisional approaches include a direct incision (right over it) and the remote approaches of a pretrichial or scalp incision.


1) Osteomas are benign bony tumors that are common in the craniofacial region.

2) Forehead osteomas are often the result of prior trauma and are slow growing over many years.

3) Forehead osteomas can be removed through either a hairline incision or an endoscopic approach further back in the scalp.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Breast Implant Replacements

Thursday, December 1st, 2016


Background: Breast implants are known to have a limited lifespan due to potential disruption of the implant shell. But as long as the implant shell remains intact the volumetric effect of the implants persist. Yet while breast implants remain stable the long-term effect of the appearance of the breast changes many years or decades later.

Whether a woman has an implant in or not, the breast tissue and skin envelope changes. Breast tissue may be lost and the skin will develop some sag. This effect is accentuated with pregnancies and weight gain/loss. The presence of implants may delay or blunt these body-related changes but they almost always occur. Over time the natural breast tissue may slide off of the implant as the tissues weaken and the breasts will look much less perky.

With these breast changes women may seek to exchange their breast implants for larger ones to get a breast rejuvenation effect. The question is what size increase is needed to see a visible change.

Case Study: This 44 year-old female had 350cc saline breast implants placed twelve years ago. She had two subsequent children and then lost some weight as she became much more of a fitness enthusiast. While her saline implants remained intact her breasts had developed some sag and she felt they had lost overall size. She wanted new breast implants that produced a dramatic change in implant size and upper pole fullness.

large-breast-implants-replacements-front-view-dr-barry-eppley-indianapolisUnder general anesthesia through her existing areolar incisions, her saline implants were removed and replaced with 700cc ultra high silicone implants into her existing submuscular pockets.

large-breast-implants-replacement-results-oblique-view-dr-barry-eppley-indianapolislarge-breast-implants-replacement-results-side-view-dr-barry-eppley-indianapolisWhen replacing breast implants for a larger and fuller look, it takes more increased volume than one would think. Of course it depends on what final breast size one wants but anywhere from a 50% to 100% volume increase is needed. That could be anywhere from 150 to 300ccs for most women.


1) As long as breast implants remain intact, they maintain a persistent volume.

2) The tissue around breast implants does change over time through some loss of volume and tissue sag off of the implants.

3) To re-expand saggy breasts with new implants a much larger breast implant size must be chosen than one may think.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Head Width Reduction by Muscle Removal

Tuesday, November 29th, 2016


Background: An aesthetically displeasing size of the head can occur at various skull areas. One such area is at the side of the head most commonly located above the ears. When it is too wide there is a noticeable convexity or bowing out of the temporal region above the ears. A more aesthetically pleasing shape at the side of the head is more of a straight line or one with a minimal convex shape to it.

Because the temporal region is located on the side of the skull it is logical to assume that it is bone and can only narrowed by bone reduction. But careful analysis of many CT scans reveals the thickness of the posterior temporal region above the ears is about 50:50 bone and muscle. The thickness of the posterior temporal muscle is a lot thicker than most would think. In men it is 7 to 9mm thick while in women it can be 5mm to 7mms thick.

Thus removal of the posterior temporalis muscle offers an effective treatment strategy for narrowing the side of the head. It can also be done with less scar that would be required for temporal bone reduction.

posterior-temporla-muscle-thicknessCase Study: This 36 year-old male wanted to reduce the fullness on the sides of his head. A CT scan revealed that the side of the head above the ears had a sufficiently thick muscle layer that could allow for a significant reduction.

posterior-temporal-reduction-by-muscle-removal-dr-barry-eppley-indianapolisposterior-temporal-reduction-incision-dr-barry-eppley-indianapolisUnder general anesthesia a straight 5 cm long scalp incision was made just above the ears. The temporalis fascia was split through which the entire posterior temporalis muscle was removed. Closure of the incision made for an inconspicuous scar line.

posterior-temporal-reduction-result-front-view-dr-barry-eppley-indianapolisBilateral removal of the posterior temporalis muscle bellies changed the shape of the sides of his head from convex to straight. With muscle thicknesses that average 7mms, bilateral removal can result in a transverse head width reduction of up to 1.5 cms. This demonstrates that temporal bone removal may not be necessary to achieve a visible head width shape change.


1) The wide side of the head is aesthetically determined by an increased convexity above the ears.

2) An increased head width above the ears is caused by both increased bone thickness  and muscle thickness.

3) Head width or temporal reduction is best done by removal of the entire belly of the posterior temporal muscle.

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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