use of rigid external distraction device in …...zygomaticomaxillary fracture extending to molar...

$: Use of Rigid External Distraction Device in …...zygomaticomaxillary fracture extending to molar teeth, an anterior left maxillary sinus wall fracture, and a left infraorbital rim$
Copyright @ 200 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.8

Use of Rigid External Distraction Device inTreatment of Complex Maxillofacial Fractures

Halil Ibrahim Canter, MD, M. Emin Mavili, MD, Gokhan Tuncbilek, MD, A. Emre Aksu, MD

Ankara, Turkey

Collapse of maxillofacial skeletal structures aftertrauma results in inadequate anteroposterior pro-jection and increase in facial width with deformedfacial aesthetics and various functional problems.After successful use of rigid external distractor fortreatment of congenital facial hypoplasia, they havebeen used for treating more complex craniofacialanomalies. Six patients with posttraumatic orbito-zygomaticomaxillary deformity weremanagedwithintraoperative and/or postoperative use of rigidexternal distractor device. All the patients main-tained the early postoperative aesthetic and func-tional results in their follow-up period. All patientsthat the device kept applied in postoperative periodtolerated the device. There were no complicationsrelated to use of rigid external distractor. Rigidexternal distractor device is a useful instrument inmanagement of traumatic facial deformities and canbe used (1) in controlled traction for reduction ofimpacted bony segments, (2) as external fixator todecrease the number of plates for fixation, (3) toovercome the soft tissue tension over bony struc-tures to enable the use of smaller screw-platesystems, and (4) for fine adjustment of bonysegments after operation depending on the needsof the case demonstrated with postoperative controlcomputed tomographies.

Key Words: Maxillofacial trauma, rigid externaldistractor

Collapse of maxillofacial skeletal structuresafter trauma results in inadequate antero-posterior projection and increase in facialwidth. Beside deformed facial aesthetics,

this bony collapse gives rise to various functionalproblems, such as malocclusion or open bite.1 Acareful analysis of these patients and accuratereassessment of the positions of the maxillarybuttresses are the keys both in acute repair of thecomplex midfacial fractures and the secondaryreconstructions of posttraumatic deformities of theinadequately treated complex orbitozygomaticomax-illary deformities.

Open reduction with rigid internal fixation is thepreferred method of choice for treatment of acutecomplex midfacial fractures, whereas conventionalosteotomy and bone grafting are usually necessaryfor correction of secondary deformities of inade-quately treated posttraumatic cases. Although use ofdistraction osteogenesis in maxillofacial deformitiesfrom old facial bone fractures has been recentlyreviewed,2 advantages of use of distraction osteogen-esis needs further discussion in terms of surgicaltechnique and mechanism of action. In addition, wereport the favorable results of this technique in bothacute and secondary deformities of complex mid-facial fractures.

PATIENTS AND METHODS

Four male and 2 female patients aged from 16 to46 years (mean 29.5 years) with posttraumatic

orbitozygomaticomaxillary deformity were man-aged with intraoperative and/or postoperative useof rigid external distractor device (RED System; KLSMartin L.P., Tuttlingen, Germany). Demographicdata of the patients were summarized in Table 1.

Patient 1

A 30-year-old male patient was admitted after atraffic accident with nasoethmoid and a rightzygomaticomaxillary fracture extending to molarteeth, an anterior left maxillary sinus wall fracture,and a left infraorbital rim fracture (Figs 1A, B).

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From the Department of Plastic and Reconstructive Surgery,Hacettepe University Faculty of Medicine, Samanpazari, Ankara,Turkey.

Address correspondence and reprint requests to Halil IbrahimCanter, MD, Acibadem Health Group, Acibadem BakirkoyHospital, Department of Plastic and Reconstructive Surgery,Halit Ziya Uzakligil Cad. No: 1, Bakirkoy 34140 Istanbul, Turkey;E-mail: [email protected]

None of the authors has any financial interest in the products,devices, or drugs mentioned in this article.


In detailed radiologic examination revealed thatthe left infraorbital rim fracture extended sagitally,and the medial segment of the fracture was displacedposteriorly. Right zygomaticomaxillary complex wasfractured into 2 major and several minor segments.The right major segment was displaced 1 cm poster-ior to the right lateral orbital wall (Figs 1CYF).Neither ophthalmological nor intracranial injurieswere detected on his physical and radiologic exam-inations in preoperative period.

Bilateral subciliary and right superior gingivo-buccal sulcus incisions were used to get access to thefractured fragments. On the right side, replacementof the depressed zygomaticomaxillary segment wasnot possible with conventional techniques. Suchanatomical alignment of the right infraorbital rimwas achieved with titanium plate and screws, andsegmental fractures were converted to a pyramid-like 1 major segment, in which the infraorbital rimwas the base and molar teeth were the apex. Three2-0 surgical steel wires were passed through cornersof the pyramid and using percutaneous routes; theywere connected directly to the distraction units of aRED II external distractor (Figs 1GYJ). On the leftside, a 2-0 surgical steel wire was passed through themedial segment of the sagittal fracture line, and via apercutaneous route, it was connected to the distrac-tion unit of the RED II external distractor. As a result,3 distractor units were connected to the upper barand 1 distractor unit was connected to the lower barof the external distractor. Reduction of the segmentswas realized with intraoperative distraction. Distrac-tion was applied to all of the wires consecutively.Segments were distracted until the anatomical con-tours were achieved. The right lateral wire wasdistracted for 10 mm, right medial wire was dis-tracted for 7 mm, and the left medial wire wasdistracted for 6 mm. Medial canthoplasty wasperformed, and nasal fractures were fixed withintranasal packing and external nasal splinting.

Steel wires connected to the fracture segments werefixed to the distraction units in a tense position.Intermaxillary fixation was applied to guarantee thenormoocclusion (Figs 1KYN).

No distraction was performed during the post-operative period, but the whole unit acted as asuspension device to zygomaticomaxillary-nasalregion. No complication was seen in the postopera-tive period, and patient was discharged from thehospital at the fifth postoperative day. Externaldistractor, wires, and intermaxillary fixation rem-ained in place for 2 weeks, and the removal of thesystem was performed as an outpatient procedure(Figs 1OYP).

Patient 2

A 20-year-old female patient was admitted for anacute maxillofacial trauma after suicidal attempt,which was implemented by jumping from a height.History affirmed that, first, she hit the legs to theground, then both of her legs were broken, andfinally, she hit her face to her knees. Therefore, themain traumatic force to face was obliquely orientedfrom down to up and from anterior to posterior(Figs 2A, B).

Radiologic examination revealed multifrag-mented Le Fort II fracture of the naso-ethmoidaland medial maxillary fractures of both sides andright mandible parasymphysial oblique fracture. Leftmaxillozygomatic fracture line was extending obli-quely from left pterigomaxillary junction up to theradix nasi passing through the left orbital floor.Alveolar process of maxilla was mainly attached toleft maxillary segment and separated from rightmaxillary segment by an oblique fracture extendingfrom the base of right aperture priformis to thepterigomaxillary junction. Lateral wall of rightaperture priformis was fractured and displaced asseparate bone fragment (Figs 2CYE).

Due to influence of the upward directed force,the vertical length and projection of the face wereshortened by the displacement of the fracturedsegments to the maxillary sinuses, especially on theleft side of the face. Neither ophthalmological norintracranial injuries were detected on her physicaland radiologic examinations in preoperative period.

A custom-made rigid intraoral splint that wasattached to maxillary teeth and a bracket to the teethwere applied by Orthodontic Department in pre-operative period.

Bilateral superior gingivobuccal sulcus incisionsand right superior gingivobuccal sulcus incisionwere used to get access to the fractured fragments.

Table 1. Demographic Data of the Patients

Age, yr Gender

Cause of

Trauma

Acute Versus

Chronic

Use of RED

In Treatment

46 Male Traffic accident Acute Intraoperative reduction and

postoperative fixation

20 Female Suicide attempt Acute Intraoperative reduction

16 Female Suicide attempt Acute Intraoperative reduction

42 Male Traffic accident Acute Intraoperative reduction

35 Male Traffic accident Acute Intraoperative reduction and

postoperative fixation

18 Male Traffic accident Chronic Support of postoperative

fixation

USE OF RED IN COMPLEX FACIAL FRACTURES / Canter et al

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Fig 1 A, Preoperative anterior view of the patient. B, Preoperative submental view of the patient; note the depression ofthe right malar area. C, Fracture lines are clearly seen on the right and left zygomaticomaxillary areas in the preoperativeanterior view of three-dimensional computed tomography (3D CT) of the patient. D, Preoperative right lateral view of 3DCT of the patient. E, Preoperative left lateral view of 3D CT of the patient. F, Posteriorly depressed fracture segments areclearly seen on both sides in the preoperative axial view of 3D CT at the level of infraorbital rims. G, Peroperative anteriorview of the patient with RED II device. RED II device was assembled, and suspension from 4 sites was performed. Threedistractor units were connected to the upper bar, and 1 distractor unit was connected to the lower bar. H, Peroperative rightview of the patient with RED II device. I, Peroperative left view of the patient with RED II device. J, Peroperative top view ofthe patient with RED II device. K, Postoperative anterior view of 3D CT of the patient. RED II device was assembled, andsuspension from 4 sites was performed. Titanium plate with 4 screws can be seen on the right infraorbital rim.L, Postoperative left view of 3D CT of the patient. M, Postoperative right view of 3D CT of the patient. N, Position of theposteriorly depressed fracture segments after reduction is clearly seen on both sides in the postoperative axial view of 3DCT at the level of infraorbital rims. Anatomical alignment of the both infraorbital rims was achieved. Note that one of thetraction wires can be seen on the right side. O, Postoperative anterior view of the patient 4 months after surgery.P, Postoperative submental view of the patient 4 months after surgery.

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 19, NUMBER 2 March 2008

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Peculiar minimal dissection was done to disturb thecontinuity of periosteal coverage over the fracturedsegments as minimal as possible. A 2-0 surgical steelwire was passed through a hole drilled on thezygomaxillary buttress of the left fractured bonysegment and connected directly to the distractionunits of a modified RED II external distractor afterboth ends of the wire were passed through the samehole of the overlying skin. Additional two 2-0surgical steel wires were attached to the hooks ofthe rigid intraoral splint (Figs 2FYH). The intraopera-tive traction from all applied wires was applied notonly to forward direction but also to downwarddirection, that is, exactly to the opposite direction of

the impaction force caused by the trauma. Controlledreduction of impacted segment was achieved by slowtraction of each applied wire by few turns ofdistractor units and waiting for some while betweeneach tractions to overcome the soft tissue restrain.Rigid fixation with plate-screw application was doneeasily after complete reduction of the fracturedsegment, which was still hold steady by the appliedRED II external distractor. Right nasomaxillarysegment was reduced by intranasal elevation withash septum straightening forceps and externalmanipulation.Minimally displaced obliquemandiblefracture was achieved by 3 bicortically appliedscrews. Maxillomandibular fixation was achieved

Fig 2 A, Preoperative anterior view of the patient. B, Preoperative top view of the patient; note the depression of the leftmalar area. C, Panfacial fracture lines on both sides of zygomaticomaxillary areas are clearly seen in the preoperativeanterior view of 3D CT of the patient. D, Preoperative left lateral view of 3D CT of the patient. E, Preoperative right lateralview of 3D CT of the patient. F, Peroperative anterior view of the patient with RED II device. RED II device was assembled,and suspension from 3 sites was performed. Two distractor units connected to the lower bar were attached to the intraoraltraction unit applied by orthodontics department preoperatively, and 1 distractor unit was attached to the upper obliquetitanium bar, which was designed and manufactured by author M.E.M. and added to the system to obtain different anglesof traction forces for precise reduction. G, Peroperative top view of the patient with RED II device. H, Peroperative obliqueview of the patient with RED II device. I, Postoperative anterior view of the patient 3 months after surgery. J, Postoperativeleft view of the patient 3 months after surgery. K, Postoperative right view of the patient 3 months after surgery.


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via brackets applied preoperatively. After externalcast application, halo device was removed.

No complication was seen in the postoperativeperiod, and the patient was transferred to physicalrehabilitation unit for her lower extremity fracturesat the third postoperative day. Maxillomandibularfixation was applied for 15 days (Figs 2IYK).

Patient 3

An 18-year-old male patient was admitted forreconstruction of left zygomaticomaxillary deformityresulted from tripot fracture after previous trafficaccident occurred 1 year ago. He could not beentreated for this particular problem in acute phasebecause of the associating closed head injurynecessitating intensive care follow-up. Preoperativephysical examination revealed left enophthalmos,decreased left malar projection, and decreased rangeof motion of temporomandibular joint of leftside (Figs 3AYC). Radiological examination wasconsistent with physical examination findings,demonstrating the enlarged left orbital cavity dueto inferolaterally depressed and healed zygomaticbone fragment, which was also restraining the fullrange of motion of the temporomandibular joint ofthat side (Figs 3D, E).

Left subciliary and left superior gingivobuccalsulcus incisions were used to get access to thedisplaced zygomatic bone fragment. All the connec-tions between the surrounding scarred soft tissueand the fractured segment were relieved with widedissection, and healed fracture lines were renovatedusing fine osteotomes to maximize the mobility ofdisplaced fractured segment. Considering the inabil-ity of microplate system to hold the bone in reducedposition in anteroposterior dimension and thepossibility of miniplate system to be palpable under-neath the thin periorbital soft tissues, microplatesystem was used in conjugation with rigid externaldistraction system. A 2-0 surgical steel wire waspassed through one of the holes of the micropalateapplied to the infraorbital bone and connecteddirectly to the distraction units of external distractorafter both ends of the wire were passed through thesame hole of the overlying skin. The wire was

Fig 3 A, Preoperative anterior view of the patient. B,Preoperative submental view of the patient; note thedepression of the left malar area. C, Preoperative leftoblique view of the patient. D, Laterally and inferiorlydisplaced left zygomatic segment is clearly seen in thepreoperative anterior view of 3D CT of the patient.E, Preoperative left lateral oblique view of 3D CT of thepatient. F, Postoperative left lateral view of the patient.RED II device was assembled and used as a suspensiondevice to overcome the soft tissue stress over thereconstructed area. G, Postoperative anterior view of thepatient. H, Postoperative submental view of the patient. I,Postoperative anterior view of 3D CT of the patient.J, Postoperative left oblique view of 3D CT of the patient.K, Postoperative anterior view of the patient. L, Post-operative submental view of the patient. M, Postoperativeleft oblique view of the patient.


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tightened enough to overcome the soft tissue stress,which would otherwise bend themicroplate and leadto relapse of deformity (Figs 3FYH).

No distraction was performed during the post-operative period, but the whole unit acted as asuspension device. No complication was seen in thepostoperative period. Patient was discharged fromthe hospital the day after surgery. External distractorand wires remained in place for 2 weeks, andremoval of the system was performed as an out-patient procedure (Figs 3IYM).

RESULTS

A ll patients that the device was kept applied inpostoperative period tolerated the device. There

were no complications related to the use of rigidexternal distractor. All the patients maintained theearly postoperative aesthetic and functional resultsin their follow-up period.

DISCUSSION

Comminuted complex maxillofacial fractureswith loss of one or more of the buttresses of

the facial skeleton usually result in collapse of facialbony integrity, which is clinically presented asinadequate anteroposterior projection and increasein facial width. Reestablishment of both horizontaland vertical buttresses of facial skeleton should bedone with the utmost care in acute management ofthese complex facial fractures to avoid postoperativeaesthetics deformity and functional problems, suchas malocclusion, open bite, telecanthus, enopthal-mus, shortened or retruded nose, short palpebralfissure.1,3 Although the precise reduction and rigidfixation of the fractured bone segments woulddefinitely restore the facial integrity, it is not easyneither to reduce the impacted bone fragments nor tohold them in reduced position until rigid fixation isachieved with plates and screws. In addition,extensive surgical dissection done to expose thefractured segments and to prepare the bony seg-ments for plate application may jeopardize thevascularization of fractured segments and evenmay lead to complete devascularization, which thencompromise the bone healing process in postopera-tive period. Moreover, uncontrolled traction ofimpacted bones with bone holders, elevators, ortowel clamps for reduction is an uncontrolledsurgical maneuver that may end up with completedevascularization of that bony segment, especially ifthe comminuted bone segments are small. Controlledreduction of the bony segments is so important that itcontributes to the success of reconstruction. Even if

the devascularized bone segments can still be used asautografts to fill the defect, one cannot guarantee thatthe early postoperative reconstruction will lastduring the process of bone healing and creepingsubstitution of all these bone grafts.

Distraction osteogenesis has been used increas-ingly as treatment of congenital facial hypoplasia.4Y6

Successful applications of distraction osteogenesiswith halo distraction device in maxillary skeleton fortreatment of severe maxillary hypoplasia associatedwith cleft palate patients have led to the applicationof halo distraction device to treat many morecomplex craniofacial anomalies.7Y12 In our clinic, weused rigid external distraction device extensively andmade several modifications to simplify its usage.13Y15

We even demonstrated that this device can be usedas external fixator after percutaneous reduction ofnoncomminuted zygomatic fractures with appropri-ate modification.16

We used the external distraction device inmanagement of more complex comminuted facialfractures. In complex midface fractures, fixing thefractured segments to each other may cause problemsin the maintenance of the facial projection. Fixatingthe fractured segments to the already fractured andimpacted nasoethmoid area and/or medial inferiororbital rims may not provide necessary support tofractured bone segments. In the first presented case,major bony segments were fixed to each other, andafter anatomical reduction, the whole midface wassuspended with an external distractor. In that sense,the external halo device was used as an externalfixator rather than an external distractor. Suspensionof themidface with an external distractor provides thedeficient support force, retains the fragments, andlessens the number of plate and screws. In addition,suspension of the midface with an external distractorenables the surgeon to adjust the position of themidface at the postoperative period, if necessary.

In second and third cases, the bony segmentswere impacted to the maxillary sinus, and both thevertical and the horizontal buttresses of the maxillawere disturbed. It was hard both to reduce theimpacted maxillary alveolar processes in controlledmanner and hold them in reduced position untilrigid fixation is achieved. In these patients, externaldistractor applied intraoperatively did not only makethe controlled traction of the impacted fracturedsegments possible but also took over the role of theassistant surgeon holding the bones in reducedposition until bone fixation achieved. In addition,halo device enables the use of principles of creep andstress relaxation in traction of the impacted fracturedsegments.17 This device holds the fracture fragments


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under constant tension (creep). Then soft tissuesrelax under that tension (stress relaxation) and allowfurther advancement of the bony segments to theiroriginal positions intraoperatively. In these patients,halo device was removed after rigid bony fixationwas achieved with rigid plate and screw fixation offracture segments.

In fourth and fifth cases, the nasoethmoidalfractures of facial skeleton were common. In thesepatients, we preferred to use the halo device both forcontrolled traction of midface for reduction offractured bony segments and for suspension andstabilization of reduced segments. These cases werealso managed with percutaneous application ofscrews and wires not to disturb the continuity ofperiosteal coverage over the fractured segments. Webelieve that undisturbed periostium layer over thebone fracture segments both helps the correctorientation of fractured segments during reductionwith percutaneous traction and makes the healing ofthese segments better postoperatively.16,18,19

In the last case, the wire was applied to themicroplate used for fixation of an old fracture after itsreduction. Apparently, the microplate was not strongenough to keep the reduced old fracture in appro-priate position under the soft tissue tension coveringthe fracture line when they were used alone.Miniplates, on the other hand, were too thick forthis anatomical localization. The advantage in usingexternal halo device is that it helped this microplatein resisting the soft tissue tension until soft tissuesrelaxes with biological creep.17 In that way, wemanaged the case with nonpalpable thin plate-screw system while preventing the relapse ofdeformity in anteroposterior dimension due to thesoft tissue tension.

One last advantage of the use of externaldistractor device in management of traumatic facialdeformities is that this device can bemodified as REDI, RED II, and RED III to adjust the vectoral pullingforces. Therefore, it is still possible to make same fineadjustments on the fractured bony segments inpostoperative period by distracting some segmentswhile keeping the others in place or even releasing tosome extend according to the prospering needs of thecase in postoperative computed tomographic scans.

In conclusion, rigid external distractor device isa useful instrument in management of traumaticfacial deformities and can be used (1) in controlledtraction for reduction of impacted bony segments,(2) as external fixator to decrease the number ofplates for fixation, (3) to overcome the soft tissuetension over bony structures to enable the use ofsmaller screw-plate systems, and (4) for fine adjust-

ment of bony segments after operation depending onthe needs of the case demonstrated with post-operative control computed tomographies.

REFERENCES

1. Gruss JS, Van Wyck L, Phillips JH, et al. The importance of thezygomatic arch in complex midfacial fracture repair andcorrection of posttraumatic orbitozygomatic deformities. PlastReconstr Surg 1990;85:878Y890

2. Mitsukawa N, Satoh K, Morishita T, et al. Clinical applicationof distraction osteogenesis for traumatic maxillofacial defor-mities. J Craniofac Surg 2006;17:431Y437

3. Manson PN. Facial fractures. In: Goldwyn RM, Cohen MN,eds. The Unfavorable Result in Plastic Surgery. Philadelphia:Lippincott Williams & Wilkins, 2001;489Y519

4. Polley JW, Figueroa AA, Charbel FT, et al. Monobloccraniomaxillofacial distraction osteogenesis in a newbornwith severe craniofacial synostosis: a preliminary report.J Craniofac Surg 1995;6:421Y423

5. Polley JW, Figueroa AA. Management of severe maxillarydeficiency in childhood and adolescence through distractionosteogenesis with an external, adjustable, rigid distractiondevice. J Craniofac Surg 1997;8:181Y185

6. Polley JW, Figueroa AA. Rigid external distraction: itsapplication in cleft maxillary deformities. Plast Reconstr Surg1998;102:1360Y1372

7. Figueroa AA, Polley JW. Management of severe cleft maxillarydeficiency with distraction osteogenesis: procedure andresults. Am J Orthod Dentofacial Orthop 1999;115:1Y12

8. Swennen G, Colle F, De May A, et al. Maxillary distraction incleft lip palate patients: a review of six cases. J Craniofac Surg1999;10:117Y122

9. Hierl T, Hemprich A. Callus distraction of the midface inthe severely atrophied maxillaVa case report. Cleft PalateCraniofac J 1999;36:457Y461

10. Harada K, Baba Y, Ohyama K, et al. Maxillary distractionosteogenesis for cleft lip and palate children using an external,adjustable, rigid distraction device: a report of 2 cases. J OralMaxillofac Surg 2001;59:1492Y1496

11. Fearon JA. The Le Fort III osteotomy: to distract or not todistract? Plast Reconstr Surg 2001;107:1091Y1103

12. Krimmel M, Cornelius CP, Roser M, et al. External distractionof the maxilla in patients with craniofacial dysplasia.J Craniofac Surg 2001;12:458Y463

13. Mavili ME, Tuncbilek G, Vargel I. Rigid external distraction ofthemidface with direct wiring of the distraction unit in patientswith craniofacial dysplasia. J Craniofac Surg 2003;14:783Y785

14. Tuncbilek G, Mavili ME, Vargel I, et al. Midface distractionusing spring scale attached to rigid external device. PlastReconstr Surg 2004;113:1410Y1416

15. Mavili ME, Vargel I, Tuncbilek G. Stoppers in RED IIdistraction device: is it possible to prevent pin migration?J Craniofac Surg 2004;15:377Y383

16. Mavili ME, Tuncbilek G. Treatment of noncomminutedzygoma fractures with percutaneous reduction and rigidexternal devices. J Craniofac Surg 2005;16:829Y833

17. Canter HI, Jackson IT. Comment on ‘‘Closure of massiveabdominal wall defects: a case report using the abdominalreapproximation anchor (ABRA) system.’’ Ann Plast Surg2007;58:590

18. Mavili ME, Canter HI, Tuncbilek G. Treatment of noncom-minuted zygomatic fractures with percutaneous screw reduc-tion and fixation. J Craniofac Surg 2007;18:67Y73

19. Mavili ME, Canter HI. Closed treatment of frontal sinusfracture with percutaneous screw reduction. J Craniofac Surg2007;18:415Y419


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