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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘facial aging’

Smoking Accelerates Facial Aging

Sunday, November 10th, 2013


Smoking is known to have many adverse health effects. The negative effects of the smoke and the many toxins that it contains seem to exert their greatest effect on the lungs due to direct contact. But that does not mean many other parts of the body may not be affected as well.

It is often stated that smoking can make you look old. This is assumed to be true since smoking has so many negative effects. This is usually associated with the development of lip lines from puffing on a cigarette. And it is thought (although never yet proven) that it also ages the skin presumably from the effects of the encircling smoke.

A recently published study in the October 2013 issue of Plastic and Reconstructive Surgery entitled ‘Facial Changes Caused by Smoking: A Comparison between Smoking and Nonsmoking Identical Twins’ has confirmed that smoking makes you look old. Using photos of 79 pairs of identical twins at the annual Twins Day Festival in Ohio. Forty-five (45) sets of twins had one smoker and one non-smoker. The smokers had more wrinkles and other signs of aging but the differences were often small. Of the remaining 34 twin pairs, one twin had smoked for an average of 13 years longer than the other. The twin who smoked for more years had more noticeable lower eyelid bags and more lip wrinkles. Judges who didn’t know which twin smoked said the smoker looked older almost 60 percent of the time. That pattern held when both twins were smokers but one had smoked for many years longer than the other.

This study adds good evidence that smoking does impact how the face ages. It likely does it by the toxins in smoke that accelerate the breakdown of collagen, elastin and glycosaminoglycines that help make up the skin. Also by decreasing the amount of oxygen that gets to the skin, there is less nutrients for collagen regeneration.

There are many other factors that affect how one’s facial skin ages including sun exposure, alcohol use, and stress. Smoking adds to that list and helps accelerate facial aging when combined with excesses of any of the others. Besides lung cancer, heart attacks and strokes, worsening of one’s facial appearance adds to the list of reasons to never start.

Dr. Barry Eppley

Indianapolis, Indiana

The Relationship between Dental Health and Facial Aging

Thursday, September 19th, 2013


There are many factors that contribute to how one’s face ages and they are well known. But one cause of facial aging is not so apparent…your dental health. At least according to a newsletter that I recently received from a local dentist.

According to the newsletter…’untreated dental problems can have dire consequences on oral and overall health and can also contribute to rapid facial aging. Together we can do something about it!!’

While this was obviously a promotional piece from a local dental practice, there is more than just a smidgeon of truth to it. Having had formal dental education and a degree as part of my long plastic surgery education, I can speak for the relationship between the state of your teeth and gums and how your face looks and ages.

A more youthful and defined jawline is part of an attractive face and is the result of the underlying shape and density of the jawbone. (mandible) Loosing teeth, regardless of the cause, results in loss of its supporting bone known as the alveolus. (top part of the jawline.) The body simply recognizes that it doesn’t need as much bone when there are less teeth transmitting forces to it. (it’s a lot like losing bone mass in the leg bones from being immobilized or bedridden for awhile) Thus as the teeth go so goes the mass of the mandible and some shape of the jawline.

As the most common cause of tooth loss with aging is gum or periodontal disease, advanced gum disease can contribute to gradually reshaping your jawbone. As the jawbone loses structure it provides less support to the overlying soft tissues. With loss of soft tissue support, skin sagging over the jawline (jowls) and into the neck becomes more apparent.

Therefore, there is a correlation between dental health and facial aging. In time, the loss of jawbone support results in collapse of the supporting muscle and tissues between the cheeks and the jawline as well. This creates that caved in look which is magnified in the face of natural fat atrophy which is not a well recognized phenomenon of facial aging.

Gum disease, in addition to causing alveolar jawbone loss, is well known to cause the gum levels to recede. (the height of the gums simply follows the underlying level of the bone) As the gums recede it make your teeth look longer, hence the well known phrase getting ‘longer in the tooth’. Between longer looking teeth and sagging face with a weakened jawline, the appearance of facial aging becomes very apparent.

While plastic surgery provides many excellent facial procedures to reverse some of the very visible problems caused by facial aging, good dental health focuses on providing sustained support to slow the process down.

Dr. Barry Eppley

Indianapolis, Indiana

The Biology of Facial Aging on Facial Rejuvenation Approaches

Monday, March 21st, 2011

We all are aging even as you read this. It is inevitable, it exists all around us, and it is part of everyday life. You might say it is an integral and, maybe even an essential, component of the human condition. As a plastic surgeon, trying to improve or reverse the symptoms of aging is part of our everyday work. This makes us a student of aging and hopefully an astute one.

Recent studies into facial aging has brought new insights into how it happens for many people. Historically, it was believed that faces aged by falling or the descent of facial tissues. Thus the emergence of facelifting operations. Facial and neck skin was moved in an opposite direction to that which the tissues fell, forward and downward. For some patients, there is no doubt this descent is the primary reason that their faces look older as some faces do look better when the skin is lifted and pulled tight. But this is not completely true for everyone.

It is now been shown that volume loss or fat atrophy plays a significant part of what ages many faces. Today’s widespread use of injectable fillers, including fat, is the offspring of this new facial aging understanding. Interestingly, this may have been recognized over a hundred years ago when the first injectable facial fillers were used. Injecting paraffin into facial hollows was done before the turn of the century but was abandoned due to predictably high complications and infections. Synthetic fillers and fat have now emerged as the modern-day version of this old facial aging treatment concept…with more predictable results and much more limited side effects.

As part of this volume loss aging concept is the influence of one’s facial weight. Some faces are fat even when they are older and others are more thin. Usually this facial weight does correlate with one’s body weight and habitus but not always. Heavier faces have thicker skin and they wrinkle less but their heaviness leads to deeper nasolabial folds and marionette lines and ‘meatier’ sagging jowls and necks. Less heavy faces have thinner skin and develop a much larger number of wrinkles particularly around the eyes, forehead and mouth. But they do not develop large amounts of sagging neck and jowl skin until they are quite advanced in years. In essence, fat faces fall while thin faces deflate. For most people, however, their aging is a mixture of varying ratios of falling and thinning.

This new paradigm shift in facial aging understanding allows for dual and often intertwining roles for tissue lifting and volume addition. This is most relevant for those patients in their 40s and 50s where the aging process is not severely advanced and may be visually slowed to a greater degree. More limited facelifting procedures combined with volume enhancement with fat injections can be very effective and not associated with long recovery times.

Dr. Barry Eppley

Indianapolis, Indiana

The Temporal Tuck-up for Cheek Sagging

Saturday, June 12th, 2010

Lifting of aging and sagging facial tissues is often perceived as a facelift. In reality, a traditional facelift only affects the lower third of the face…the neck and jowls. That leaves out the two other major facial areas which can be lifted, the forehead (brows) and cheeks. Browlifts are well known and very effective facial rejuvenation procedures whose numerous techniques and methods are well established. Browlifts are often done in combination with a facelift. The cheek area, while aging as much as the brows and the neck, does not have a simple  and consistently effective  surgical lifting procedure.

Cheek lifts, also known as midface lifts, are intended to lift sagging tissues that were once on top of the cheeks. When the soft tissue falls off of the bony cheek due to loosening of its ligamentous attachments to the skin, it creates what are known as malar festoons. These are bags or bunching of tissue that often creates a ‘double bubble’ look to the midface. Or the midface can look like wax melting off of candle. Most people think that a facelift or a browlift will somehow correct this cheek sagging but it will not.

Midface lifts are relatively new compared to facelifts and numerous techniques have been used. The fundamental midface lift approach can be ascertained based on the vector of pull and incisional access. The traditional midface lifts is done through a lower eyelid incision and pull the cheek tissues directly upward. When using this technique, I will fix the cheek tissues to a cranial fixation point directly above a vertical line up from the cheek. This is a very powerful method for lifting sagging cheek tissues but involves manipulation around and through the eyelid. The eyelid is very unforgiving and numerous complications can result. Eyelid deformities, particularly ectropion, is not rare with this type of midface lift. This cheek lift requires absolute precision and is very unforgiving of any slight technical deviation.

An alternative and less problematic approach is that of the temporal cheek lift. The incision is right at the junction of the  preauricular and temporal hairline. By placing it here, the hairline will not be shifted upward and the delicate lateral eyelid area is completely avoided. Skin flaps elevated for about an inch or inch and a half downward so that its pull lifts the cheek tissues. This is then combined with the use of barbed sutures or threads which are inserted underneath the skin flaps. They are directly toward the sagging cheeks and then tied together to further lift the cheeks. The combination of the skin pull and the barbed sutures creates a very nice cheek tuck-up. The excess raised skin, now lying over the incision is trimmed and closed.

This temporal cheek tuck-up has numerous advantages including ease of execution, lack of any problems in the eye area, and very minimal recovery. It can be performed in the office under local anesthesia. Its disadvantage is that it is not as powerful as the cranially-directed midface lift so patient selection and expectations are critical. I have found it useful for those patients with more mild forms of cheek sagging, after a facelift procedure, and when a conventional midface lift needs further improvement.      

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Augmentation as a Complementary Strategy in Facial Aging

Wednesday, March 31st, 2010

The  most recognized signs of facial aging is sagging and loose skin.  Therefore, the use of facelifting techniques and other soft tissue suspension procedures have been the foundation of any facial rejuvenation treatment program.  But recent published and presented research in plastic surgery in the past few years has shown that the underlying bone structures over which the soft tissue sags is a contributing cause as well. Bone resorption along facial bony prominences occurs  as well and this contributes to the falling tissue process. As the soft tissues slide off of the face with aging, that process is accentuated by loss of bone structure.

Bone loss with aging has been shown to occur amongst most facial bones. Many studies support these facial findings including changes along the jaw line. Jaw resorption is well known to occur with tooth loss (edentulism) and this is the result of loss of alveolus or the top part of the jaw bones. Recent work has shown, however, that the basal part of the lower jaw changes as well. This area of the jawbone was previously thought to be unaffected with aging.

From a recently presented study from the University of Rochester, new insights have been provided by studying facial CT scans. Researchers used a computer program to measure the length, width, and angle of the lower jaw bone and compared the results for different age groups. CT scans allow for more accurate tmeasurements than traditional jaw x-rays.  Their study shows that he angle of the jaw increases markedly with age, which results in a loss of definition of the lower border of the face. Jaw length and a decline in jaw height also decreases significantly in older age groups.

Since the jaw is the principal support for the lower face, its shape and size affects the overlying soft tissues. As the size of the jaw decreases with age, the soft tissues of the lower face and neck also loses support. This loss of bony volume may contribute to sagging facial skin, decreased chin projection, and loss of jawline definition. As jaw volume decreases, soft tissue of the lower face has less support, resulting in a softer, oval appearance to the lower face and sagging skin, which also affects the aging appearance of the neck.

This raises the question of the role of facial augmentation as part of the rejuvenation strategy to the aging face. Augmenting or increasing the size of facial bones can only be done with implants. The influence of a chin implant with a facelift is a well recognized combination that produces a very noticeable improvement. Is its effect a function of improved chin projection or the appearance of a large jaw bone overall? Would other enhancements of the jaw be equally beneficial? Is jaw angle augmentation (the back end of the jaw) as beneficial as that of the front?

One bone change that I have seen that is particularly advantageous is inferior border augmentation. This can be particularly useful in men. Vertical lengthening of the chin and back along the edge of the jawline adds vertical facial height. This expansion  of jaw volume speaks to exactly what this recent study has shown. No current off-the-shelf implants exist for this application but it would be a useful addition to the current array of available facial implant styles.   

Dr. Barry Eppley

Indianapolis, Indiana

Injectable Eyebrow/Brow Bone Enhancement

Monday, March 29th, 2010

One of the most prominent facial area that changes as we age is that of the eyes. Known collectively as the periorbital region, it includes the eyelids, brows and all of the attached soft tissues. Periorbital  age changes include brows that fall, eyelid skin that becomes excessive, and fat atrophy around the bone of the eye that can make it appear more prominent.

The role of injectable treatments for the aging periorbital region has largely been that of weakening the muscles to decrease frown lines and crow’s feet wrinkling. The use of the other form of injectable treatments, fillers, has heretofore been of minimal value for improving the appearance of aging eyes. It has traditionally been the role of surgery to provide real improvement in this facial area.

One new use of injectable fillers around the eye is to add volume to the sagging brow by injecting along the brow line. Filling in the brow helps lift it which can make the eye more open, longer and fuller, all characteristic features of a more youthful eye. The injections can be threaded into the brow, usually placing more to the outside of the brow. Injecting to the inside must be done with care as the feeling nerves to the forehead, with blood vessels, come out of the brow bone in this area.    

While the standard method for adding volume to the brow has been with injectable fat, its retention is highly variable and does require a harvest site and a method of fat preparation. Off-the-shelf injectable fillers avoid these steps and provides an immediate effect that will last as long as the filler’s composition allows. Hyaluronic acid-based fillers, such as Juvaderm, provide an injectable gel that is soft, easy to inject, moldable, and has a numbing agent in it. While it is not permanent, it appears to last longer in the brow that other facial areas. It will usually last at least one year and often longer. That may be because it is not exposed to a lot of facial movement, unlike the lips or nasolabial folds.  

Injection into the brow does not require a lot of volume, often as little as 0.2 to 0.4ccs is all that is needed per brow. It is best to begin with small volumes, more can always be added later. Combining brow volume enhancement with Botox or Dysport in the glabellar and lateral canthal areas can provide a nice rejuvenative effect that looks natural and non-surgical.

Dr. Barry Eppley

Indianapolis Indiana  

Fat Injection Facial Volume Restoration – Does It Improve The Skin As Well?

Wednesday, September 9th, 2009

Loss of facial volume is now a well recognized phenomenon of aging as well as part of certain disease processes. As subcutaneous fat volume is lost in the cheek, side of the face, and the temporal areas, one can acquire a more gaunt facial appearance. While this may be somewhat desirous when one is young as it highlights the cheekbones and other facial skeletal structures, it has the opposite effect as one gets older, creating a more aged and unhealthy appearance.

Fat has turned out to be a good, although often only, option for facial volume restoration. Although its survival after injection is variable, many parts of the face have at least a 50% or more long-term volume retention.

One of the consistent comments that I hear from my plastic surgery colleagues who perform the procedure is that it has a beneficial or rejuvenative effect on the skin. Anectodal reports abound that the skin looks better after fat transplants have been under it.

In the September 2009 issue of Plastic and Reconstructive Surgery, the concept of improvement in facial skin quality after fat grafting was experimentally evaluated. Using a mouse model, a study looked at skin histology after fat grafting to their backs. After eight weeks they were histologically able to show that the skin was thicker and with better texture. There results suggest that besides adding volume underneath the skin, fat grafts have the potential to have a regenerative effect as well on the skin itself.

The  motivation for performing this study was undoubtably the consistent observation of how much better facial skin looks after fat graft volume has been added underneath it. And like many experiments, you can find exactly what you are looking for. Having performed many animal implantation experiments in the past, I can testify how you can design and conduct experiments that will ultimately support the premise (motivation) for the study. You often find what you hope you would.

Does fat grafting really change the quality of the skin overlying it? It may well do so but the biologic evidence remains absent despite this recent experimental report. It is hard to imagine how the subcutaneous biologic mileau, regardless of how it has been supplemented, would change the epidermis-dermis structure of the skin. More likely, this is the effect of ballooning the skin back out which reduces wrinkles and makes it look better. In my Indianapolis plastic surgery practice, I have observed this many times with injectable fillers which creates very much the same effect. Despite the injectable manufacturers claims no one has yet been able to show maintained long-term skin thickness in a convincing fashion. The effect lasts as long as the injectable filler and is mainly mechanical.

From a patient’s perspective, however, they really don’t care about the science. All they want to know is will it make me look better and how long will it last…and how much does it cost? As such, fat injection facial volume restoration in the properly selected patient does work and the skin will look improved with less wrinkling. But we should hesitate to promote fat injections as a primary skin rejuvenation method. Skin improvement, for now, is a secondary benefit that is caused by the volume restoration and not necessarily by fat graft-induced stimulation on the skin directly.

Dr. Barry Eppley

Indianapolis, Indiana 

The Effect of Facial Exercises on Facial Aging

Wednesday, June 17th, 2009

As I was returning on a flight from NewYork after a plastic surgery meeting, scanning the SkyMall magazine is almost a ritual. While I never buy anything from it, the seemingly endless array of gadgets and devices that are contained within its pages are always entertaining. As part of their health offerings, devices for facial toning and wrinkle reduction are almost always seen. I have seen devices that look like dental appliances that we used to use for stretching lip and mouth scars to those that exercise the jaw. There are also numerous books available in book stores, including all old one from the 1950s that I keep in my personal library, that teach facial exercises.

Does the principle of facial exercise, no matter what method is used, really work? Claims are made that the face and neck muscles need a workout to stay fit and healthy. It is promised that sagging brows, cheeks, lips, jowls, and necks can be lifted. A more youthful appearing face can be achieved by these daily programs. The premise, of course, is an extension of well-known exercise physiology of the body that muscles can be toned and enlarged by increasing and repetitive workloads.  

While this sounds like an intuitive assumption, it largely represents flawed thinking…what I like to call a ‘truism’, something which sounds like it should be true but fails to be so on closer inspection and more in-depth analysis. The world in general, and medicine in particular, is filled with them. The flaw in thinking is two-fold: that facial muscles can actually be tightened and that the facial muscles play a significant role with the signs of facial aging that we see.

Facial aging is a multi-factorial process that largely deals with the loss of volume of different tissues. From the collagen in the skin to fat compartments in the face to even the underlying bones, tissues shrink, wither, and atrophy with time. Some people do it faster than others, but the tissue loss eventually exceeds the rate of any tissue regeneration. So droopy  brows, cheeks, jowls and necks are primarily the result of skin, fat, and fibrous layers loosening and sagging but not muscle tissue atrophy. While no definitive facial muscle studies have ever been done on how the facial muscles change with age (and I suspect they do have some atrophy in very advanced aging states),  facial muscles don’t weaken very much nor do they become loose or stretched. Your jowls don’t develop because your jaw (masticatory) muscle droop nor does your brow, cheeks or lips go south because your muscles of facial expression sag. The one exception is that of the neck where the platysma muscle does separate in the middle and sag and has formed the basis of successful facelift manipulation  for many decades.

There may be something to some neck exercises given the size and surface area of the platysma muscle, but any changes that it can make (besides never have been objectively proven) is likely to be too small to make much of a visible difference. Such evidence for improvement is completely testimonial and all before and after photographs that I have seen are glaringly inconsistent and of poor photographic quality.

Muscles of facial expression, like the muscles that move your eyes, are unique. They are quite small, work quickly due to spontaneous expression, and are of a high twitch quality. Meaning they must work fast and are already at a highly toned state given their constant repetitive movement. Like the difficulty one has with enlarging the calf muscle, toning a facial muscle is quite difficult…enlarging it is darn near impossible. The workload to do so would be more than a full-time job. Given that these muscles are ‘quite fit’ to begin with, trying to tighten or tone them for a facial rejuvenation benefit seems illogical. And trying to do so will have the opposite effect…the creation of more and deeper wrinkles from trying to work these muscles.

Facial exercising is not like that of the body. It has not aerobic benefit and cannot lift sagging facial tissues. Just like all the sit-ups in the world will not get rid of that overhanging belly and loose thighs, exercising facial muscles can not be expected to avoid the effects of time and gravity….and it certainly can’t achieve what any plastic surgery procedure can do. 

Dr. Barry Eppley

Indianapolis, Indiana

The Anatomy of the Aging Neck

Tuesday, April 14th, 2009

When seeing someone considering having a facelift (necklift), I frequently get asked in my Indianapolis plastic surgery practice,  ‘How did my neck get like this?’ They often say it looked just fine until a few years ago and then suddenly it looks like it does now. That question is a good one and understanding why and how a loose and low hanging neck developed helps one appreciate what plastic surgery approaches may or may not work for its improvement.

Three specific anatomic factors contribute to a change in one’s neck profile or angle, skin, fat, and muscle. The skin of our face and neck is held up into place through ligaments that run from the underside of the skin down to the bone. (osteocutaneous ligaments) With aging and gravity, these ligaments loosen and the skin and fat from the side of the face and neck begins to fall. This process is accentuated by a loss of elasticity of the skin due to chronic moisture loss and UV irradiation. Together, loose skin develops in the neck and one begins to see the appearance of jowling.

The muscle component of the problem comes from the midline separation of the platysmal muscle. Running from the collarbones up to the lower edge of the jaw, this large sheet of fairly superficial neck muscle keeps fat and other structures tucked up underneath or close to the jaw. As one ages, this thin muscle separates in the midline from the chin down past the adam’s apple in an inverted V fashion. As the muscle splits, the fat in the center of the neck falls furthering contributing to a lowering of the neck angle. In thick-skinned neck with more fat, the neck angle simply becomes more obtuse. In thin-skinned necks, the edges of the muscle can be seen as commonly observed neck bands.

Understanding how the neck ages helps one understand what to do about it.  The most successful neck treatment strategies (e.g., facelift) deal with all three anatomic problems, removing fat, tightening skin, and putting the muscle back together. This is why more simple, less invasive procedures such as liposuction alone, skin tightening devices, or small tuck-up operations are not very successful at major neck aging issues. Although they can be useful if they are done when the signs of neck aging are just beginning.

Dr. Barry Eppley

Indianapolis, Indiana

The Role of Midface Lifts in Facial Rejuvenation

Monday, April 13th, 2009

The earliest signs of facial aging often appear in the midface area, a triangle defined by the inner and outer corners of the eye and the corner of the mouth. There may be loose lower eyelid skin and bulging fat bags. The line of demarcation between the lower eyelid and the cheek (lid/cheek junction) begins to drift lower. In addition, the cheek tissues slowly fall downward, making the nasolabial fold more prominent. The aging midface area can look a little like wax melting off a candle.

Traditional plastic surgical procedures are ineffective in correcting these midface problems, even when a lower blepharoplasty and facelift are done at the same time.. The classic lower eyelid tuck could remove excess skin and fat bags, but could do nothing with the fallen cheek tissues. The traditional facelift, or neck-jowl lift, offers virtually no changes in the cheek, nose, and upper lip area despite that many patients believe that it will.

As a result, the midface lift (not a facelift) procedure has emerged to correct this historically unreacheable aging area. The midface lift is done through an incision immediately below the lashes of the lower eyelid and extends slightly out from the outer corner of the eye in a crease line. By dissecting down to the cheek bone, the fallen cheek tissues are separated from the bone, lifted vertically, and put back up in a higher position on the cheek bone. Excess lower eyelid skin and fat can also be removed if necessary after the cheek tissue is repositioned. (which is almost always needed) The eyelid incisions are closed with dissolving sutures under the lashline and very small sutures out into the crease skin.

One of the keys to a good and stable midface lift is where to secure the cheek tissues which are lifted up by sutures. Here is a point of plastic surgery debate and different surgeons have their own methods. In my Indianapolis plastic surgery practice, I prefer to use a high cranial suspension point which is immediately vertical to the direction of upward pull. This requires a small incision in the scalp above the temporal area.

Midface lifts result in a smoother lower eyelid, a fuller cheek bone prominence, and a less deep nasolabial fold. Many patients will look like they have had a small cheek implant placed. Such changes created a less tired look and a face that has a more youthful and full appearance. Remember that this operation is not a facelift, it will not improve the neck or jowl area. It may frequently be done at the same time as a facelift to create a more complete facial rejuvenation.

A midface lift is often done with upper and lower eyelid tucks (blepharoplasty) at the same time, or even a facelift. As a result, the eye and cheek area will get fairly swollen and bruised after and the corners of the eye will feel tight. One will not look fairly reasonable in most cases until about 7 to 10 days after surgery. (non-operated look) One should be capable of returning to sedentary-type work – perhaps with some camouflage makeup – within a week after surgery. More vigorous activites must usually await three to four weeks until one is ready.

 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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