Facial Chemical Peels

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Facial Chemical Peels

  1. 1. Facial Chemical PeelsFacial Chemical Peels Jean Paul Font, MDJean Paul Font, MD David C. Teller, MDDavid C. Teller, MD Grand Rounds PresentationGrand Rounds Presentation Department of OtolaryngologyDepartment of Otolaryngology University of Texas Medical Branch atUniversity of Texas Medical Branch at GalvestonGalveston March 18, 2007March 18, 2007
  2. 2. HistoryHistory Egypt - first evidence ofEgypt - first evidence of exfoliants useexfoliants use – Sun-damaged skin was aSun-damaged skin was a sign of lower rank insign of lower rank in societysociety – Sour milk- contain lacticSour milk- contain lactic acid, an alpha-hydroxy acidacid, an alpha-hydroxy acid commonly used todaycommonly used today Turks - use fire toTurks - use fire to produce a thermalproduce a thermal exfoliationexfoliation
  3. 3. HistoryHistory 1882 P.G Unna, German dermatologist1882 P.G Unna, German dermatologist described resorcinol, salicylic acid, phenol,described resorcinol, salicylic acid, phenol, trichloroacetic acidtrichloroacetic acid 1903 Mackee began using phenol for acne1903 Mackee began using phenol for acne scarring (Chairman of dermatology at NYU)scarring (Chairman of dermatology at NYU) 1961 Baker and Gordon presented a peel1961 Baker and Gordon presented a peel formula with one patient with a 3 month followformula with one patient with a 3 month follow up, became the standard formulaup, became the standard formula 1966 Baker published results in 250 patients1966 Baker published results in 250 patients
  4. 4. AgingAging Define as the process ofDefine as the process of system's deteriorationsystem's deterioration ((Hanbook ofHanbook of the Biology of Agingthe Biology of Aging 2006)2006) Facial skin changes is one ofFacial skin changes is one of the most apparent examples ofthe most apparent examples of agingaging
  5. 5. HistologyHistology Actinic changes - photochemical effects of solarActinic changes - photochemical effects of solar radiation exposureradiation exposure – Disorderly arrangement of epidermisDisorderly arrangement of epidermis – Degeneration of the elastic networkDegeneration of the elastic network – Mottled pigmentationMottled pigmentation – Lymphocytic infiltrationLymphocytic infiltration – Decrease in collagenDecrease in collagen – Flattening of the dermal-epidermal junctionFlattening of the dermal-epidermal junction – Epidermal cell atypiaEpidermal cell atypia – Increased melanocytes, but they were unevenlyIncreased melanocytes, but they were unevenly distributed and contained variable amounts of melanindistributed and contained variable amounts of melanin
  6. 6. Peel Skin HistologyPeel Skin Histology Chemical burn of the epidermis and the outerChemical burn of the epidermis and the outer dermisdermis
  7. 7. Peel Skin HistologyPeel Skin Histology First 2 to 5 days - Regenerates from follicularFirst 2 to 5 days - Regenerates from follicular and eccrine duct epitheliumand eccrine duct epithelium
  8. 8. Peel Skin HistologyPeel Skin Histology Fresh, orderly, organized epidermisFresh, orderly, organized epidermis
  9. 9. Peel Skin HistologyPeel Skin Histology At 2 weeks - newAt 2 weeks - new collagen formationcollagen formation begins and maybegins and may continue up to 1 yearcontinue up to 1 year – New bands of dermisNew bands of dermis 2- to 3-mm-thick2- to 3-mm-thick – Thin, compact, parallelThin, compact, parallel collagen bundlescollagen bundles arranged horizontallyarranged horizontally along the epidermal-along the epidermal- dermal matrixdermal matrix
  10. 10. Peel Skin HistologyPeel Skin Histology Other changesOther changes – Melanocytes contain fine, evenly distributedMelanocytes contain fine, evenly distributed melanin granulesmelanin granules – Impaired melanin synthesis with a generalizedImpaired melanin synthesis with a generalized bleaching effectbleaching effect – Decrease lymphocytic infiltrationDecrease lymphocytic infiltration
  11. 11. Treat cutaneous lesionsTreat cutaneous lesions Replace atypicalReplace atypical keratinocytes with normalkeratinocytes with normal epidermal cellsepidermal cells Kligman concluded thatKligman concluded that chemical peel reduced thechemical peel reduced the development of newdevelopment of new neoplasmsneoplasms Litton decreased the rate ofLitton decreased the rate of appearance of precancerousappearance of precancerous and early cancerous lesionsand early cancerous lesions after a phenol chemical peelafter a phenol chemical peel
  12. 12. Patient SelectionPatient Selection "The ideal patient is a thin-skinned female"The ideal patient is a thin-skinned female with fair complexion and fine rhytids."with fair complexion and fine rhytids." Skin type and the amount of photodamageSkin type and the amount of photodamage presentpresent Fitzpatrick classified the skin typesFitzpatrick classified the skin types – Color and acute solar radiation responseColor and acute solar radiation response The Glogau classification based on theThe Glogau classification based on the degree of photoagingdegree of photoaging
  13. 13. Fitzpatrick ClassificationFitzpatrick Classification Fitzpatrick skin type I and type II are good candidatesFitzpatrick skin type I and type II are good candidates Type III and greater - increased risk pigment complicationsType III and greater - increased risk pigment complications TypeType ColorColor Tanning responseTanning response II WhiteWhite Always burns, never tansAlways burns, never tans IIII WhiteWhite Usually burns, tans less than averageUsually burns, tans less than average IIIIII WhiteWhite Sometimes burns mildly, tans about averageSometimes burns mildly, tans about average IVIV BrownBrown Rarely burns, tans more than average and with easeRarely burns, tans more than average and with ease VV Dark brownDark brown Very rarely burns, tans very easilyVery rarely burns, tans very easily VIVI BlackBlack Never burns, tans very easilyNever burns, tans very easily
  14. 14. Glogau classificationGlogau classification GroupGroup ClassificationClassification Skin characteristicsSkin characteristics PeelPeel II MildMild Little wrinkling or scarring and noLittle wrinkling or scarring and no keratoseskeratoses SuperficialSuperficial IIII ModerateModerate Early wrinkling, mild scarring, andEarly wrinkling, mild scarring, and sallow color with early actinicsallow color with early actinic keratoseskeratoses MediumMedium IIIIII AdvancedAdvanced Persistent wrinkling, discolorationPersistent wrinkling, discoloration with telangectasias and actinicwith telangectasias and actinic keratoseskeratoses MediumMedium IVIV SevereSevere Wrinkling—superficial to deepWrinkling—superficial to deep actinic keratoses ± skin canceractinic keratoses ± skin cancer Medium to DeepMedium to Deep
  15. 15. Aesthetic IndicationsAesthetic Indications RhytidsRhytids SpottySpotty hyperpigmentationhyperpigmentation Superficial acneSuperficial acne scarringscarring
  16. 16. Therapeutic IndicationsTherapeutic Indications Actinic keratosesActinic keratoses Superficial basal cellSuperficial basal cell carcinomascarcinomas Lentigo malignaLentigo maligna lentigineslentigines MelasmaMelasma (discoloration of skin(discoloration of skin caused by pregnancy)caused by pregnancy)
  17. 17. ContraindicationsContraindications RelativeRelative ContraindicationsContraindications – Darker skin typeDarker skin type (Fitzpatrick IV-VI)(Fitzpatrick IV-VI) – History KeloidHistory Keloid – History of herpes infectionsHistory of herpes infections – Cardiac abnormalitiesCardiac abnormalities – A history of diabetesA history of diabetes mellitus or previous facialmellitus or previous facial irradiationirradiation – Unrealistic patientUnrealistic patient expectationsexpectations – TelangiectasiasTelangiectasias – Anticipation of inadequateAnticipation of inadequate photo protectionphoto protection AbsoluteAbsolute ContraindicationsContraindications – Significant hepatorenalSignificant hepatorenal diseasedisease – HIV-positive patientHIV-positive patient – SignificantSignificant immunosuppressionimmunosuppression – Emotional instability orEmotional instability or mental illnessmental illness – Ehlers-Danlos syndromeEhlers-Danlos syndrome – Scleroderma or collagenScleroderma or collagen vascular diseasesvascular diseases – Accutane treatment (withinAccutane treatment (within 6–12 months before)6–12 months before)
  18. 18. Patient PreparationPatient Preparation History of herpes infectionsHistory of herpes infections – Prophylaxis with Valtrex or Acyclovir for 2 wksProphylaxis with Valtrex or Acyclovir for 2 wks Skin preparationSkin preparation – Vitamin A derivative therapy 4 weeks before theVitamin A derivative therapy 4 weeks before the procedureprocedure Speeds epidermal healingSpeeds epidermal healing Thins stratum corneumThins stratum corneum Increases the depth of a chemical peelIncreases the depth of a chemical peel – Stop sun exposure - 2 months before theStop sun exposure - 2 months before the procedureprocedure
  19. 19. Chemical Peel DepthsChemical Peel Depths SuperficialSuperficial – Epidermal lossEpidermal loss MediumMedium – Injury to superficialInjury to superficial dermisdermis DeepDeep – Mid-dermal injuryMid-dermal injury
  20. 20. Chemical PeelChemical Peel Frosting - keratin proteinFrosting - keratin protein denaturationdenaturation – Level I - erythema withLevel I - erythema with streaky surface whiteningstreaky surface whitening – Level II - white-coatedLevel II - white-coated frosting with erythemafrosting with erythema showing throughshowing through – level III - solid whitelevel III - solid white enamel frosting with little orenamel frosting with little or no background of erythemano background of erythema (penetration through the(penetration through the papillary dermis)papillary dermis)
  21. 21. Superficial PeelsSuperficial Peels Necrosis of the epidermisNecrosis of the epidermis Healing time from 1 to 4 daysHealing time from 1 to 4 days Improve pigmentary irregularitiesImprove pigmentary irregularities Improve minor surface changesImprove minor surface changes Fresher appearance to facial skinFresher appearance to facial skin
  22. 22. Superficial PeelsSuperficial Peels Different SolutionsDifferent Solutions – 10% to 20% Trichloracetic10% to 20% Trichloracetic acid (TCA)acid (TCA) – Jessner's solutionJessner's solution (resorcinol, 14 g; salicylic acid, 14 g;(resorcinol, 14 g; salicylic acid, 14 g; lactic acid, 14 mL; ethanol, 100 mL)lactic acid, 14 mL; ethanol, 100 mL) – Glycolic acid (50% to 70%)Glycolic acid (50% to 70%) Level I frostingLevel I frosting PostoperativePostoperative – Mild cleanser, moisturizersMild cleanser, moisturizers and sunscreensand sunscreens Glycolic acid can be usedGlycolic acid can be used to peel skin of all skinto peel skin of all skin types with minimal risktypes with minimal risk
  23. 23. Medium PeelMedium Peel Necrosis of the epidermis & inflammation withinNecrosis of the epidermis & inflammation within the papillary dermisthe papillary dermis Improvement of skin texture in moderateImprovement of skin texture in moderate photodamaged skin (grade II Glogau)photodamaged skin (grade II Glogau) Removes of epidermal or superficial lesionsRemoves of epidermal or superficial lesions – Actinic keratosesActinic keratoses – Repair mild rhytidesRepair mild rhytides – Improve pigmentary dyschromiasImprove pigmentary dyschromias – Improve depressed scarsImprove depressed scars
  24. 24. Trichloracetic acid (TCA)Trichloracetic acid (TCA) TCA approaching 50% or higher were used toTCA approaching 50% or higher were used to achieve injury to the superficial dermisachieve injury to the superficial dermis At this concentration TCA is unreliable andAt this concentration TCA is unreliable and associated with a higher incidence ofassociated with a higher incidence of complications (complications (pigmentary dyschromia, textural change, andpigmentary dyschromia, textural change, and even scarringeven scarring)) Combination of products improves theCombination of products improves the absorption of the lower concentration of TCAabsorption of the lower concentration of TCA without the associated complicationswithout the associated complications – Solid CO2 freezing with trichloracetic acid 35%Solid CO2 freezing with trichloracetic acid 35% – Jessner's solution + 35% TCAJessner's solution + 35% TCA – Glycolic acid 70% plus 35% TCAGlycolic acid 70% plus 35% TCA
  25. 25. Medium PeelMedium Peel BrodyBrody – First developed solid CO2 applied with acetone to the skinFirst developed solid CO2 applied with acetone to the skin – Freezing technique break the epidermal barrier for a more evenFreezing technique break the epidermal barrier for a more even and complete penetrationand complete penetration MonheitMonheit – Jessner's solution destroyed the epidermal barrier by breakingJessner's solution destroyed the epidermal barrier by breaking up individual epidermal cellsup individual epidermal cells ColemanColeman – 70% glycolic acid before the application of 35% TCA.70% glycolic acid before the application of 35% TCA. – Results similar to that of Jessner's solutionResults similar to that of Jessner's solution Deeper penetration of the 35% TCA and a more evenDeeper penetration of the 35% TCA and a more even application of the peeling solutionapplication of the peeling solution Phenol 88% by itself will give a medium-depth peelPhenol 88% by itself will give a medium-depth peel
  26. 26. Patient PreparationPatient Preparation Vigorous cleaning and degreasing areVigorous cleaning and degreasing are necessary for even penetrationnecessary for even penetration – Septisol and acetoneSeptisol and acetone – Debrided of stratum corneum and excessiveDebrided of stratum corneum and excessive scalescale A splotchy peel is usually the result ofA splotchy peel is usually the result of uneven penetration of peel solutionuneven penetration of peel solution because of residual oil or stratumbecause of residual oil or stratum corneumcorneum
  27. 27. Medium PeelMedium Peel TCA is painted evenlyTCA is painted evenly – Forehead to temple toForehead to temple to cheeks and finally to thecheeks and finally to the lips and eyelidslips and eyelids – Eyelids within 1 to 2 mm ofEyelids within 1 to 2 mm of the lower eyelid marginthe lower eyelid margin Amount of TCA deliveredAmount of TCA delivered is dependent on:is dependent on: – Number of applicationsNumber of applications – Degree of saturationDegree of saturation – Pressure applied to thePressure applied to the skinskin – Contact timeContact time
  28. 28. Medium PeelMedium Peel White frost appears completeWhite frost appears complete on the treated area within 30on the treated area within 30 seconds to 2 minutesseconds to 2 minutes Before re-treating an area oneBefore re-treating an area one should wait at least 3 to 4should wait at least 3 to 4 minutes before determining forminutes before determining for asymmetryasymmetry Eyelid skin and bonyEyelid skin and bony prominences have a highprominences have a high propensity for scarring (limitedpropensity for scarring (limited to a level II frosting)to a level II frosting) An assistant standby withAn assistant standby with sterile eye wash in case agentsterile eye wash in case agent spills into the eyespills into the eye
  29. 29. Jessner's TCA peel for moderate photoaging skin, Glogau level II. A, Preoperative view demonstrating rhytides, lentigenes, keratoses, and sallow skin. B, Jessner's solution applied to face. C, Full application 35% TCA with a level III frosting. D. Four days after chemical peel. E, Six months after chemical peel
  30. 30. Medium PeelMedium Peel Dark crusts peels off on day 5 to 7 thenDark crusts peels off on day 5 to 7 then erythema appears and soon fadeerythema appears and soon fade Repeat medium-depth chemical peelRepeat medium-depth chemical peel should not be performed for at least 1 yearshould not be performed for at least 1 year There is improvement of collagenThere is improvement of collagen thickness progressing over a 6- to 13-thickness progressing over a 6- to 13- month periodmonth period
  31. 31. Deep Chemical PeelDeep Chemical Peel Glogau III and IV photoaging skinGlogau III and IV photoaging skin – Deeper grooves and wrinklesDeeper grooves and wrinkles Deep peels are usually performed using theDeep peels are usually performed using the Baker-Gordon solutionBaker-Gordon solution – Phenol 88% 3 mL, Septisol 8 drops, Croton oil 3Phenol 88% 3 mL, Septisol 8 drops, Croton oil 3 drops, Distilled water 2 mLdrops, Distilled water 2 mL Septisol acts as a surfactant which results inSeptisol acts as a surfactant which results in more even penetrationmore even penetration Croton oil is epidermolytic enhancing theCroton oil is epidermolytic enhancing the absorption of phenolabsorption of phenol
  32. 32. Deep Chemical PeelDeep Chemical Peel Phenol >80%Phenol >80% – Keratin protein binds to the phenol creatingKeratin protein binds to the phenol creating large molecules preventing further penetrationlarge molecules preventing further penetration of the peel solutionof the peel solution Phenol <50%Phenol <50% – produce deeper penetration and moreproduce deeper penetration and more destruction than desireddestruction than desired
  33. 33. Tape OcclusionTape Occlusion Occlusion of theOcclusion of the peeling solution withpeeling solution with tape increases itstape increases its penetration creatingpenetration creating injury to the mid-injury to the mid- reticular dermisreticular dermis
  34. 34. Deep Chemical PeelDeep Chemical Peel Face is divided into six aestheticFace is divided into six aesthetic subunitssubunits – Forehead, perioral region,Forehead, perioral region, bilateral cheeks, nose, andbilateral cheeks, nose, and periorbital regionperiorbital region – 15-minute time interval between15-minute time interval between unitsunits White frost that is carried 2 to 3White frost that is carried 2 to 3 mm across the vermilion bordermm across the vermilion border Lower eyelids need to be treatedLower eyelids need to be treated to within 1 to 2 mm of the ciliaryto within 1 to 2 mm of the ciliary marginmargin Upper eyelid above supratarsalUpper eyelid above supratarsal foldfold
  35. 35. Deep Chemical PeelDeep Chemical Peel Erythema may take months to resolveErythema may take months to resolve Evaluated in 3 to 4 days to observe the amountEvaluated in 3 to 4 days to observe the amount of wound healing and residual crustingof wound healing and residual crusting Sun avoidance 6 weeks and minimize sunSun avoidance 6 weeks and minimize sun exposure for up to 6 months (Sunscreen with anexposure for up to 6 months (Sunscreen with an SPF of 3)SPF of 3) Splotchy hyperpigmentation (2 – 6 weeks)Splotchy hyperpigmentation (2 – 6 weeks) – Retin A, hydroquinone and triamcinolone may provideRetin A, hydroquinone and triamcinolone may provide an improvementan improvement
  36. 36. Deep Chemical PeelDeep Chemical Peel
  37. 37. Phenol ToxicityPhenol Toxicity Cardiotoxic & eliminated hepatic and renalCardiotoxic & eliminated hepatic and renal Monitored settingMonitored setting – Cardiac status, pulse-oximetry, and blood pressureCardiac status, pulse-oximetry, and blood pressure Volume loading with intravenous fluids before, during,Volume loading with intravenous fluids before, during, and after phenol peelingand after phenol peeling Botta advocates force diuresis (furosemide given 10 minBotta advocates force diuresis (furosemide given 10 min before phenol)before phenol) Waiting as much as 20 to 30 minutes between unitWaiting as much as 20 to 30 minutes between unit RecognizeRecognize – First - CNS stimulation,First - CNS stimulation, Tremors, hyperreflexia, and hypertension.Tremors, hyperreflexia, and hypertension. – Later - CNS depression, respiratory failure, hypotension, andLater - CNS depression, respiratory failure, hypotension, and cardiac arrhythmias ensuing rapidly.cardiac arrhythmias ensuing rapidly.
  38. 38. SequelaeSequelae – Pigmentary changesPigmentary changes – Persistence of rhytidsPersistence of rhytids – Prolonged erythemaProlonged erythema – Hypertrophic subepidermalHypertrophic subepidermal healinghealing – MiliaMilia – Skin pore prominenceSkin pore prominence – Increased prominence ofIncreased prominence of telangiectasiastelangiectasias – Darkening and growth ofDarkening and growth of preexisting nevipreexisting nevi ComplicationsComplications – Skin infectionSkin infection Herpes simplex virusHerpes simplex virus Pseudomonas organismsPseudomonas organisms Staphylococcus/StreptocoStaphylococcus/Streptoco ccus organismsccus organisms Candida organismsCandida organisms – EctropionEctropion – Cardiac arrhythmiasCardiac arrhythmias – Renal failureRenal failure – Facial scarringFacial scarring
  39. 39. HyperpigmentationHyperpigmentation
  40. 40. HypopigmentationHypopigmentation
  41. 41. Herpes outbreakHerpes outbreak
  42. 42. Candida infectionCandida infection
  43. 43. Pseudomonal infectionPseudomonal infection
  44. 44. ScarringScarring
  45. 45. ConclusionConclusion Chemical peeling is an technique that removesChemical peeling is an technique that removes superficial lesions and improves the texture of skinsuperficial lesions and improves the texture of skin Careful patient selection and education are crucial toCareful patient selection and education are crucial to both the patient's final result and his or her satisfactionboth the patient's final result and his or her satisfaction Learning the technique is a small part of the process;Learning the technique is a small part of the process; postoperative care and close patient follow-up arepostoperative care and close patient follow-up are equally importantequally important Clinical and histological changes are long-lasting (15 toClinical and histological changes are long-lasting (15 to 20 years) and may be permanent for some patients20 years) and may be permanent for some patients A complication can also be permanent!A complication can also be permanent!
  46. 46. ReferencesReferences Deborshi R. AblativeFacial Resurfacing Dermatologic Clinics. 23(3), July 2005Deborshi R. AblativeFacial Resurfacing Dermatologic Clinics. 23(3), July 2005 Gary D. M. MEDIUM-DEPTH CHEMICAL PEELS. Dermatologic Clinics. 19(3), July 2001Gary D. M. MEDIUM-DEPTH CHEMICAL PEELS. Dermatologic Clinics. 19(3), July 2001 Langsdon, P. Comparison of the Laser and Phenol Chemical Peel in Facial SkinLangsdon, P. Comparison of the Laser and Phenol Chemical Peel in Facial Skin Resurfacing.Resurfacing. Brody HJ. Chemical Peeling. St Louis, Mo: Mosby-Year Book; 1992:1-5Brody HJ. Chemical Peeling. St Louis, Mo: Mosby-Year Book; 1992:1-5 Brody HJ: Chemical Peeling and Resurfacing. St. Louis, Mosby, 1997, pp 109–110Brody HJ: Chemical Peeling and Resurfacing. St. Louis, Mosby, 1997, pp 109–110 Monheit GD: Advances in chemical peeling. Facial Plast Surg Clin North Am 2:5–9, 1994Monheit GD: Advances in chemical peeling. Facial Plast Surg Clin North Am 2:5–9, 1994 Monheit GD: The Jessner's-TCA peel. Facial Plast Surg Clin North Am 2:21–22, 1994Monheit GD: The Jessner's-TCA peel. Facial Plast Surg Clin North Am 2:21–22, 1994 Monheit GD, Zeitouni NC: Skin resurfacing for photoaging: Laser resurfacing versusMonheit GD, Zeitouni NC: Skin resurfacing for photoaging: Laser resurfacing versus chemical peeling. Cosmet Dermatol 10:11–22, 1997chemical peeling. Cosmet Dermatol 10:11–22, 1997 Rubin M: Manual of Chemical Peels. Philadelphia, Lippincott, 1995, pp 120–121Rubin M: Manual of Chemical Peels. Philadelphia, Lippincott, 1995, pp 120–121 Stegman SJ: A comparative histologic study of the effects of three peeling agents andStegman SJ: A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin. Aesthetic Plast Surg 6:123–135, 1982dermabrasion on normal and sundamaged skin. Aesthetic Plast Surg 6:123–135, 1982 Cummings: MANAGEMENT OF AGING SKINCummings: MANAGEMENT OF AGING SKIN.. Otolaryngology: Head & Neck Surgery, 4thOtolaryngology: Head & Neck Surgery, 4th eded,, 2005. Chapter 292005. Chapter 29 Tse Y, Ostad A, Lee HS, et al. A Clinical and histologic evaluation of two medium-depthTse Y, Ostad A, Lee HS, et al. A Clinical and histologic evaluation of two medium-depth peels: glycolic acid versus Jessner's trichloroacetic acid. Dermatol Surg. 1996;22:781-786peels: glycolic acid versus Jessner's trichloroacetic acid. Dermatol Surg. 1996;22:781-786 Kligman A.M. Long-term histologic follow-up of phenol face peel.Kligman A.M. Long-term histologic follow-up of phenol face peel. Plast Reconstr SurgPlast Reconstr Surg (1985) 75 : pp 652-659(1985) 75 : pp 652-659 Halaas YP Medium Depth Peels, Facial Plastic Surgery Clinics of North America,Halaas YP Medium Depth Peels, Facial Plastic Surgery Clinics of North America, 12(3):297-304, 200412(3):297-304, 2004

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