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Monday
Mar062017

Pricing Dermal Fillers: Radiesse, Sculptra, Belotero, Juvederm, Kybella... 

filler injection pricing MD

Should I switch to a new filler? Can I increase my profits or decrease my cost? Fillers are a must-have in any cosmetic practice, so how do you make sense of the options?

You've got to have them since they're one of the primary reasons you're generating new patients AND they keep those patients coming back every month or two. Many generalized (includes surgical treatments) generate 40% of their income from injectables and others (nonsurgical) can turn these needles into wildly profitable practices. But you can also spin your wheels just bumping along the barely-breaking-even line by either under-pricing or over-paying. So what's the current state of cost/price in the market?

In a market report released in 2015, according to Research and Markets, dermal fillers average price (in the US at least) are estimated around $400-$1500 per treatment (patient cost). That's quite a range. So what's going on here? It's a busy and (increasingly) confusing market but here are some stats/thoughts on some of the market leaders.

RADIESSE

Radiesse is primarily around the patient's mouth (specifically correcting nasolabial folds but also lips) but is also commonly used to increase volume in hands (where you can end up using a lot of it, increasing the cost/price). Typical usage is between a half to 2 or more syringes. Like with other facial fillers, the effects on Radiesse on the body will take for as long as 10-12 months. An average cost for a Radiesse treatment is around $900, with a range of $400-$1200. Most procedures are on the chin and cheeks.

Patient satisfaction seems to be around 83%. Adverse reactions include ashes, loss of volume swelling, and lumping. These, as with others, are generally attributable to poor technique or over-treatment.

BELOTERO

Similar to Radiesse, Belotero targets the nasolabial folds and the lines around the mouth. Although, there are some physicians that have used it to target dark circles and lines under the eyes.

It is possible to get multiple treatments for Belotero as well. The filler lasts around to 6 months, maybe up to a year. Although some patients may have shorter filler effects. The treatment costs around $625.00, with a range of $200-$1350.

Patient reviews (from a well known patient site) tended to be slightly higher than Radiesse which is interesting but not terribly informative. It worked well for patients who had their under eye lines treated, on their lip lines, crows' feet, tear troughs, and glabellar area. Complaints include bruising, swelling, and bumpiness.

SCULPTRA

Sculptra is a liquid based injectable that also targets the above mentioned treatments for lines. The use for the filler has been used for those who have lost weight and want to treat lines.

Primary treatment areas for Sculptra are temples and jowls and there's some increase in the after-care instructions including daily 'face massage' of the treatment areas. Repeat treatments may need to be administered after four to six or four to eight weeks, depending on the patient's results from the first treatment. (Always better to under-treat and have them come back than over-treat and have them unhappy.)

Price of treatment is around $1900, with a range of $150-$3800. Selling price of Sculptra to physicians is estimated around $750-$800. According to some physicians Sculptra retains on the face for around 6 to 24 months.

Sculptra seems to hover around a 90% patient satisfaction rate. Among the reviews on one website, 21% reported lumping and adverse reactions (which seems high).

JUVEDERM

Juvederm is one of the most popular volume enhancing fillers in the market. The target areas are lips, cheeks, and lines and wrinkles. A technique to administering the filler on the cheek is creating circles around the target area (similar to a Venn Diagram). Aside from the cheeks, lips are also a popular treatment region.

Juvederm products have a selling price of around $350-$1000. Cost of treatment is around $550, ranging from $250-$990. Treatment lasts from 6 to 12 months.

In looking into patient feedback, only Juvederm received more than 90% positive rate from patients across different review websites. Many are also doing returning treatments after their results. Common complaints for the filler are sagging and swelling under eyes and lips.

KYBELLA

We thought we'd take a look at something outside of fillers with Kybella since it's main usage is to remove the fat under the chin. Multiple treatments are done to achieve the expected result. Like with all the treatments here, Kybella can be done quickly. In administering Kybella, the box comes with a temporary tattoo guide which should be stuck under the chin. (We don't have personal experience with this so would appreciate ayone's thoughts from the community.)

Physicians buy a vial of Kybella at around $600. As for prices, Kybella has a range of $600-$2500 for a treatment, with an average of $1375.

The treatment is well received with an 87% positive rating on one website. Swelling is normal with the treatment after a few days. The treatment had boosted patient self-esteem. Negative reviews are few so far, some had mentioned they saw no change prior to treatment and should have opted Liposuction over injections.

Read the sister post on pricing of Botox, Xeomin & Dysport.

Pricing & Costs

There are a lot of physicians who enter the market at the low end of pricing in order to attract new patients (very successfully since this is essentially a commodity now) but if your prices don't include enough just to break-even, you’re heading for trouble. Medical businesses are expensive to run and it's more true than ever that a dollar saved is a dollar earned. All vendors are not all pricing fillers the same and it can cost you literally thousands of dollars a month right off the top-line profit if you're not getting the best deal from your local pharmacy or the manufacturer. Depending upon where you are in the world you might want to do a little research and find out if you can get a better deal.

Warning: Everyone is getting bombarded with solicitations from companies in China promising the lowest cost. Do NOT buy any drugs or pharmacy products from China (or South East Asia, or Africa). These countries do not have the same regulations as the US, Canada, and the EU where regulatory safeguards are in place.

Monday
Mar062017

Pricing Dysport, Xeomin, & Botox in the Aesthetics Market

Can you make money on Botox? Should you switch to Xeomin? The newest information shows that facial fillers and injectables will continue to be the primary physician-based cosmetic treatment (and a primary source of revenue and patient flow).

With Botox, Dysport and now Xeomin targeting wrinkles, and Juvederm, Radiesse, Kybella, Scupltra, and Belotero for volume/fullness, injection based treatments are the initial treatment point of contact for most cosmetic clinics, even those run by surgeons.

With the prevalence of these treatments we thought we'd take a look at the current state of care in the US (the largest single market) since there are a number of new players that are making inroads and taking some market share from the biggest players.

First up; Botox, Dysport and Xeomin.

Botox, Dysport, and Xeomin primarily treat glabellar Lines and lateral orbital rhytids (crow's feet) but they've seen increasing usage around the mouth in some practices. (We do not recommend this unless you're extremely skilled since this can cause some serious problems if you paralyze someone's mouth.)

These treatments are restricted by licence although there have been a number of unlicensed individuals (like this horror story) where individuals were treating patients.

Let's take a look at each.

BOTOX

The big boy in the market, Botox or onabotiliniumtoxinA was approved for cosmetic use in 2002. Approved treatment areas are as follows: hyperhidrosis, migraines, and the neck and chin. It is not limited to those areas as there are other FDA Approved uses in the body (Blepharophasm, Strabismus, and Overactive Bladder). It is used off-label by some physicians to treat other areas.

In 5 major US Cities, the average price of a Botox treatment for a patient is around $400. Botox (10mu) is selling around $400-$525 according to some US physicians and based on pharmacy price but it's much cheaper outside the US. Units used differ depending on the treated area, with a recommended 20 Units for the Glabellar Area, 6 to 20 Units for the Forehead, 4 to 12 for the Crow's Feet.

Many patients find Botox as the most effective in making wrinkles disappear, most are satisfied with their treatments over time, with a 95% Satisfaction Rate among patients. Not all however are mostly satisfied with their procedure, because some have complained making their appearance worse, probably do to the fact that every patient with a new treatment becomes hyper-focused on the mirror. Still, don't be to quick to discount patient reported effects of unevenness, ptosis, and sagging.

According to Mukherjee (2015), Botox is expected to grow to $2.9 Billion by 2018 with the facial aesthetic market to balloon to more than $4 Billion, with the US contributing half of it. (Nice!)

DYSPORT

The teenager Dysport (abobotiliniumtoxinA) entered the market in 2009 and has actually been giving Botox (Allergan) a respectable competitor. In its early release, many were skeptical about its efficacy, strengthening Botox' popularity among patients (possibly do to it's lower cost). However, many studies have shown that Dysport is a fast acting injectable as compared to Botox.

Why choose Dysport over Botox?

In a double-blind study conducted in 2011, Botox and Dysport were used to test ninety patients. Dysport was the better choice to treat crow's feet in the study. The dosage used in the study had 30 Units for Dysport, while 10 only for Botox.

On average, Dysport treatment costs $360 for some major US cities we looked at for Botox. As for the selling price of Dysport to physicians, it is at around $475-$800. According to some physicians, for treatment of crow's feet at least 30 units is used to treat one side, 20-80 for the forehead, and 40-80 units for the glabellar.

Dysport can be an alternative to those who do not find Botox effective. Some prefer Dysport as their neuromodulator of choice due to its longer efficacy. It has been said that due to lesser proteins, Dysport can easily be accepted by the body.

It has proven itself to be a worthy competitor against Botox with a 93% satisfaction rate by Dysport users. On the other hand, it is not all met with praise since it can cause the same side effects to patients that Botox can.

XEOMIN

The new kind on the block. Among the three neuromodulators, Xeomin contains only incobotulinumtoxin A, resulting in some calling Xeomin the 'Naked Botox'. It has no proteins which both the two prior injectables contain, and it requires no refrigeration. Many observe that Xeomin has the slowest onset among the toxins, with results appearing 3-4 days after treatment.

In administering Xeomin, the needle is smaller and the injections are a few centimeters away from each other (less pain?). It also uses only around 10-25 units for one side for crow's feet treatment, 10-15 for the forehead, and 20 for the glabellar. Merz retails a bottle of Xeomin at $466, with some pharmacies selling it at a lower cost around $260 - $300. On average, the treatment of Xeomin to patients is around $355.

Xeomin showed great results for frown lines for most patients, but it's often rated slightly lower by patients in terms of satisfaction. This may be due to actual results, but it's also likely that differing injection techniques by new clinicians who have previous experience with Botox and Dysport, as well as less patient name recognition could be the cause.

As part of this series we're going to do some internal surveys and research into pricing and satisfaction across physicians. If you'd like to be involved and/or have access when we release these results, please make sure that you sign up as a member.

Read the sister post to this on filler injections pricing and satisfaction for clinicians.

Sunday
Mar052017

New Concierge Startups Could Devastate The Cosmetic Medicine Market

Futuristic new startups in concierge medicine could really put the screws to competitors as they expand their offering.

Silicon Valley is rife with startups looking to disrupt all aspects of healthcare, moving from traditional approaches to entirely new delivery systems and business models. The result is a number of new, well financed competitors that don't have the baggage of traditional methodologies and can easily adopt new methodologies and could bury existing competitors. Here are a couple of examples.

Forward is a new tech concierge medical start-up San Francisco that is focusing on reinventing the primary care clinic. With something of a clean look that founder Adrian Aoun describes as something aking to an Apple store crossed with Star Treks next generation sick bay. Physicians have access to some really cool gizmos, from a wall-sized screen to visualize and show patient data to automated speach recognition that transcribes converstaions in real time and adds them to patient records. Patients can get their prescritions filled in the on-site pharmacy and can text staff around the clock (with 30 second response times).

But the biggest value is not the glass and white walls, it's the removal of trivial tasks that prevent clinicians from operating at the top of their license. According to a 2016 study in the Annals of Internal Medicine, physicians spend more than half of their time on paperwork, compared to a measly 27% interacting with patients. (Read the study here)

Forward is using technology to ruthlessly elimiate waste and improve physician productivity while also delivering what patients are asking for with whiz-bang tools. They currently don't taken insurance - although they have plans to change that - and charge patients $149/month all in.

Of course Forward is joining a number of other primary care and concierge competitors.

One Medical is another that already has a number of locations. It's not quite as technically cool but it's also getting traction by delivering what patients want  - same day appointments, online access, and 24/7 virtual care - at the even more affordable price of $149 per year.

And that brings us to telemedicine and what's happening there.

Read the 2015 Telemedicine Report from Medical Spa MD

In a poll asking dermatologists if they were to use telemedicine in their practice, 41.84% were opposed to the idea of adopting it. Only 38.1% were in favor in using telemedicine, but that may be changing.

In a study by Wilson and Maeder (2015), teledermatology has produced positive outcomes with user satisfaction and uptake, and hopeful in the idea of improvements with healthcare. Another study mentions the benefits of using teledermatology, which could serve as an educational tool.

Despite study findings about telemedicine’s ability to diagnose illnesses, it is still met with resistance. In another study referenced by the authors, it seems that while it can screen and diagnose illnesses, it faced a challenge with an accuracy. Bashur et al., (2015) also suggest the same finding that inaccuracy could be a common challenge when using teledermatology.

According to the Wall Street Journal, the American Telemedicine Association expected the number of physicians using telemedicine to rise approximately 30% more. Healthmine has conducted a poll saying that out of 1500 physicians, only 15% employed telemedicine.

What does this mean for cosmetic / aestheitic practices?

These new startups are going to be under increasing pressure to find ways to generate revenue Forward, for example, has already raised $30m from venture capitalists and needs to get to a value of more than $100m to raise additional funding.

The likely result is that they, like others before them, will see that cosmetic medicine is primarily a cash fee-for-service business that will need little additional investment to add. Since these new competitors are built to deliver such extrodinalry patient satisfaction it will be more than just a little challenging for stand-alone clinics to compete.

Of course their success is not yet assured and they could implode if they can't meet their revenue needs.

If they can, there will be a period of adoption but they will be riding the wave of transformative care that is coming.

Sunday
Mar052017

A Brief Overview on Cannulation Techniques For Fillers

Physicians have used cannulas to inject fillers as an alternative to needles.

Blunt-tip cannulas prevent the pricking on the veins. In addition, it is found that cannulas are more effective and safer for some patients. In one study, it is found that microcannulas lessened the incidence of tissue injury (Salti and Rauso, 2015). Dr. Sabine Zenker presents her techniques in using cannulas on the sagged lateral cheek areas and lips.

Many physicians have used the same method as cannulas have been seen as more effective and safer compared to needles. The author’s techniques are limited to the upper lateral and the lips.

Their technique for the lateral cheek is gentle molding, which would give an optimal result. The author recommends a linear threading method proceeding with a fan-shape that would help with cannulating from the entry point, the Zygomatic Arch.

As for the lips, the Zenker addresses it with “multiple boli” starting from the center eventually going laterally. In enhancing the lips, a lateral technique is also utilized. Thread volume is little, which allows correcting of the lips. The author reminds that there is a risk of overcorrection in this area.

So how else have authors used cannulas in their studies?

The authors have presented some cannulation techniques and recommendations on how to administer these injections. With cannulas, downtime has lessened significantly (Luthra, 2015). In addition, the author noted that patients returned for augmentation or enhancing procedures.

According to Arsiwala, when injecting with large-volume fillers, a cannula is more effective as opposed to the traditional needle. In Hedén’s (2016) study, which focuses on the nose, cannulas that are 25-G or wider lessens any risk to the vessel, in addition using thin cannulas reduces risk with intra-arterial injection. Montes, Wilson, Chang, and Percec (2016) recommend using a cannula for the upper eyelid to achieve ideal results.

Loghem, Yutskovskaya, and Werschler (2015) focuses on the danger zones and injection areas for cannulas. The authors suggest a multi-level approach (linear threading) when doing a brow lift and to avoid overcorrection to look masculine. In line with Zenker’s work, the researchers suggest to utilize a two-point cannula method when approaching the Zygomatic area.

To read more about the author’s techniques find out more about it here: https://www.prime-journal.com/indication-specific-cannula-treatment/

For the injection techniques by Loghem, Yutskovskaya, and Werschler, check it out here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295857/

Tuesday
Feb142017

Dr. Susan Stuart - La Jolla Plastic Surgery & Dermatology, CA

Dr. Susan Stuart values education and training to progress and become unique in the field of aesthetics in our interview with the dermatologist.

Dr. Susan Stuart - La Jolla Plastic Surgery & Dermatology, CAName: Dr. Susan Stuart
Clinic: La Jolla Dermatology
Locations: La Jolla and San Diego
Website: https://www.lajollaskin.com/

What can you tell us about your staff and methods to hiring staff?

We have a very close staff who have been with us for many years. We all strive to give all our patients the best care because our staff were carefully chosen and share our mission. We have weekly wrap around meetings where we discuss each upcoming case to make sure all issues are addressed and treatment plans are fully implemented. We have frequent staff meetings where everyone provides input into how we can improve the patient experience. Frequent retreats allow us to create team building and improve morale. We just had a wonderful retreat where the staff enjoyed an afternoon of competitive bowling in a trendy downtown alley...

Click to read more ...

Tuesday
Feb072017

The State of Aesthetic IPLs & Lasers

In the last few years there's been an explosion of new IPLs and cosmetic lasers.

While that's generally good for clinics - inducing some competition and pricing/sales pressure - it can be a problem trying to find the right system to invest in.

READ: Cosmetic IPL & Laser Reviews & Comparisons Forums

In 2011, Dermatologist Dr. Goldman wrote a journal article about using what kind of laser should be used for the practice. In the present, there are devices that have multiple modalities and treatment options, you can have a single laser device instead of two or more. These devices are now made convenient for physicians and practitioners.

Lasers are steadily gaining traction in the aesthetic field. Many aesthetic devices have been launched, and various companies continue to upgrade their devices or create breakthroughs. Physicians are able to choose devices, which is suitable for their practice, as there are many ranging from skin rejuvenation to fat melting to even vaginal rejuvenation. At the same time, not everything has been met with praise, as lasers have its downsides for the patients or the physicians or practice itself. Thus, it is best that physicians and practitoners practice laser treatments with care.

Multiple treatments are common in many practices. More and more aesthetic companies are making more integrated systems with multiple modalities. Alma, Sciton, and Cutera are some of the aesthetic laser companies that have begun or launched a multiple modality device for one’s practice. No studies have been made about the efficacy of using multi-modality systems, but the technology is promising.

Having multiple modalities could mean multiple or combination treatment options. Effectiveness has been proven in several studies. Prior to multiple modality in a single device, physicians have been combining treatments.

Findings:

  • In a dermatologic setting, treatment of non-melamona skin cancer with laser and photodynamic therapy was proven successful and effective. Er:YAG and ALA-PDT had the most efficacy rate with 98.97%
  • Goldberg, 2012 suggests that IPL is better at removing hair considering it will be done with multiple sessions
  • As for skin rejuvenation, an alternative to fillers would be repeated Erbium:YAG laser mini-peels (El-Domyati et al., 2013), leaving patients with an average of 88% satisfaction rate after the treatment.

Lasers remain to have some controversy over lawsuits filed by patients and complications brought about by its usage. One common issue faced by practices is negligence or mishandling by a non-physician administering the laser procedure. Several state laws allow non-physician practitioners, so long as the doctor is present in the practice. However, unhappy patients experieince some adverse side effects possibly due to poor handling and patient screening.

Training is important to avoid any of this concerns to rise and be the cause of lawsuits. According to E. Victor Ross, dermatologist, vigilance is key when administering laser treatment.

In 2016, a study was published by Dr. Gary Chuang, noting that fumes were present in a laser hair removal system. There are 13 carcinogenic compounds present in the laser hair removal plume. It is a cause for alarm as it could affect the respiratory systems of those performing the procedure and those receiving it. The researchers suggest that better ventilation systems and protection would help prevent any further issues.

Aside from this finding, Laser Service Solutions provides us with a list of common issues with laser devices. Technical issues like LCD screens and circuit boards should not be taken lightly. Other problems include: water issues, calibration, and handpieces.

It is expected that despite issues and problems, aesthetic laser procedures will still rise according to several market research reports.

REFERENCES:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390232/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3376014/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4632833/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100114/
http://dermatologytimes.modernmedicine.com/dermatology-times/news/laser-fundamentals?page=0%2C1
http://jamanetwork.com/journals/jamadermatology/article-abstract/2532614
https://www.laserservicesolutions.com/most-common-aesthetic-laser-issues/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390232/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3376014/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4632833/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100114/http://dermatologytimes.modernmedicine.com/dermatology-times/news/laser-fundamentals?page=0%2C1http://jamanetwork.com/journals/jamadermatology/article-abstract/2532614https://www.laserservicesolutions.com/most-common-aesthetic-laser-issues/

Tuesday
Feb072017

Dr. Michael Law - Michael Law MD and Blue Water Spa, NC

Dr. Michael Law shares about his experience in aesthetic medicine, and how he runs his clinics with wife Kile in our interview with the Plastic Surgeon.

Dr. Michael Law - Michael Law MD and Blue Water Spa, NC

Name: Michael Law MD
Clinics: Michael Law MD/Aesthetic Plastic Surgery and Blue Water Spa
Location: Raleigh, North Carolina
Website: www.bluewaterspa.com, www.michaellawmd.com

Brief Bio:

Michael Law MD is a plastic surgeon certified by the American Board of Plastic Surgery. He received his M.D. degree at Emory University, where he graduated magna cum laude, second in his class of over 100 graduating physicians, and was inducted into Alpha Omega Alpha. He elected to pursue a rigorous ten-year training program that includes general surgery residency at the University of California Los Angeles (UCLA), plastic surgery residency at the University of Southern California (USC), and a plastic surgery fellowship at USC. His ten years of formal training following medical school amount to twice that of some plastic surgeons.

How did you get started with plastic surgery?

I knew I wanted to be a surgeon since childhood. I elected to become a plastic surgeon for several reasons: for the creativity required for practice of reconstructive surgery, for the procedural and anatomic variety of surgeries performed, and perhaps most of all for the opportunity to be artistic in my life’s work.

I practiced plastic surgery in Beverly Hills for several years after completing my surgical residency and fellowship. While there, I started working with aestheticians. I realized early in my practice that good skin care was a great compliment to aesthetic plastic surgery. When I made the decision to move to...

Click to read more ...

Monday
Jan302017

Why You Should Review Injecting Techniques

Injectables are one of the many popular non-cosmetic procedures. Around 45% of the aesthetic/cosmetic procedures done in 2015 in the US was injectable procedures. It ranks high as an alternative to cosmetic surgery, and it is expected to rise in the coming years. These procedures have received praise by many patients. However, there is a constant need for reminder on injecting dermal fillers and botulinum toxin on patients. It is all in the [method of] injection, declares all practitioners. Additionally, some studies and researchers have emphasized the importance of administering procedures.

Some patients have reported that they have issues with fillers, which have caused adverse side effects like disfiguration of the face and vision loss. These side effects should serve as reminders to practitioners.

In the latest study by Scheuer, Sieber, Pezeshk, Campbell, Gassman, and Rohrich (2017) the authors present how to minimize problems in administering soft tissue filler injections. The authors suggest to inject slowly with small doses. In addition, a serial puncture technique is best in high risk areas. They cover six regions, which are considered danger zones.

Even with experience, physicians and certified injectors could still make mistakes in administering these injections. Thus, physicians must remember these safety concerns and administering of injections.

 Brow and Glabellar Region

  • Digital injection must be applied.
  • The authors recommend that intradermal injections must be done for this area.
  • Blindness and tissue loss are common serious side effects in this region.

Temporal

  • The measures of the danger zones in this area are 2.5 mm lateral and 3.0 mm superior to the peak of the brow (Scheuer, Sieber, Pezeshk, et al., 2017).
  • Deep and superficial injections can be done in this area,
  • The adverse side effect when injecting in this area is blindness.

Infraorbital

  • Practitioners should refrain from injecting deeply
  • Authors suggest to inject laterally and pushed medially
  • Tissue necrosis is an adverse side effect in this region

Lips/Commissure

  • On the commissure, the linear crosshatching method in injecting is safe.
  • Injections done in either lips must be done superficially with around 3mm deep.
  • Tissue necrosis is a serious side effect in these regions.

Nasolabial Fold

  • Intradermal injections can be administered as well injected in the preperiosteal plane.
  • Injections on the deep and superficial subcutaneous and dermal areas in the nasolabial fold are safe
  • On the alar base, only intradermal injections should be administered.

Nose

  • Fillers should be injected deeply and greater than 3mm.
  • As suggested by the authors, any injections done on the tip and dorsum should be in the preperichondrial and preperiosteal planes.
  • Tissue necrosis and visual loss are some of the adverse side effects.

To learn more about the injection techniques, you can watch the video provided by the authors here: http://journals.lww.com/plasreconsurg/Pages/videogallery.aspx?videoId=972&autoPlay=true

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