In the world of plastic surgery, misconceptions may lead to irrational requests or outcomes not appreciated by patients. Those who manage aesthetics should always listen and recognize the variability of cultural identities, desires, attitudes, anxieties and uncertainties of the patient. Emerging from a diversity of cultures and its transforming trends, the scope of cosmetic surgery and its practice reflect not only the individual’s personality, but also the culture as a whole. When counseling an individual, one has to recognize that even in groups of seemingly identical social or cultural standards; there are subtle differences in expectations. To illustrate the potential for inaccuracy of ethnic profiling in the field of plastic surgery authors quote their own work on Asian subjects and facial beauty and resort to experience of others. To reaffirm their opinion and to exemplify how sometimes “fine” differences in the perception of beauty exist, an original study that evaluates the preferences among selected groups of Latina women in respect to buttock aesthetics has been included. This dissertation will focus on how cultural factors influence beauty perception; strengthen the fact that beauty is in the eye of the beholder and how variable differences exist even between small subgroups.
It is another typically busy day in the operating suite; bright lights and cold temperature invade the space. The staff is focused on their assigned, routine tasks. I watch as new patients head into the operating rooms naturally anxious about their surgery, while others have already completed their surgeries and are being transferred to the recovery unit. The schedule is on time; there are no delays so far. I am in the lounge using the computer, trying to finish some work, while waiting for the next case to start. I noticed one of the surgeons ordering a variety of large breast implants to be available for an upcoming augmentation case. Nothing unusual, but it definitely caught my attention for a few minutes. The sales‐representative inquired if the surgeon would need any smaller size implants for the case; his response, while it may hold some truth, was shocking to me, “Only the bigger ones, she is Latina… they all want big breasts.” Unfortunately, he as many other surgeons implement ethnic profiling and stereotypes to erroneously define their patient’s preferences. This “template” type of approach to cosmetic surgery is a misconception, and may erroneously lead to imposition of surgeon’s predilection and a surgical approach. Unlike society’s submission to fashion trends, any surgical intervention for beautification is, by far, more than consequential. Anatomical alterations may be irreversible and therefore listening and acknowledging each patient’s wishes as well as understanding their expectations is an integral part of the management of each case. We all have different tastes, likes and dislikes, which affect our definition and perception of beauty. This is one of the reasons why exploration of cultural profiling and its role in plastic surgery today is addressed in this chapter.
For some, statements such as “beauty is in the eye of the beholder” and “perception of beauty that is in the eye of the beholder” are clichés. However, in plastic surgery, central to patient management, procedure planning, and execution is the recognition that everyone has a different perception of beauty. Implications of this perception and related research range from practical everyday activities (e.g., ability to get a job) to the artistic, political, and philosophical realms. For plastic surgeons, trends and perceptions of beauty characteristics (especially extreme) that become favored and those that tend to fade away provide challenging practice templates for daily work. The exact neural mechanisms of beauty perception are unclear; it is known that surroundings and one’s mood (including professional) may have a direct effect on visual processing (Figure 1).
Beauty? What is really beautiful? How do we determine beauty? Who decides if a specific feature is beautiful? These age‐old questions in reality do not have an absolute answer. “Beauty is in the eye of the beholder”—it seems very precise. Beauty is an evolving term that is influenced by culture, geography, ethnicity, age, and art among others. What we today consider beautiful, would perhaps not be accepted somewhere else in the world or at a different time in history. In addition to opinion, different cultural stimuli further shape these judgments. The concept of beauty has never been definitive and will never reach an absolute. Beauty will continue to transform in similarity to fashion trends. Over the centuries, as the concept of beauty continues to evolve, the only fact that remains true is that society will continue to strive to conform to what their environment considers attractive.
Attractiveness affects our social perception and interactions in various ways. The fascination with beauty penetrates society worldwide. The desire to look and feel beautiful involves all races, ages, genders, and nationalities. It is believed that good‐looking individuals are more fortunate and given more opportunities. Some say that less effort is required from them compared to their less attractive counterparts to achieve the same goals (e.g., job promotions, salary increase, better schedules, etc.) This perception drives individuals of all backgrounds and ethnicities to try and fit into what society accepts as beautiful with the goal to merit more opportunities, be accepted and respected.
“Ugly Betty” exemplifies this concept. This television show takes place in the “superficial” word of fashion, where image is everything. An outcast, Betty, a smart mind but unattractive girl, reveals her struggles trying to fit in. This soap opera, which originated in Colombia, has been successfully adapted into many countries and languages around the world. International versions of the show have maintained the appearance of Betty with mild changes to local perceptions of attractiveness of each region (Colombia, Mexico, USA, Croatia, Dubai and Egypt). This show has inspired many people to deal with body imaging and raise awareness about the impact of discrimination that women face based on their looks.
As different cultures and ethnicities relocate to other parts of the world, plastic surgeons are encountering very diverse patients who have been exposed to different ideal standards of beauty with unique motivations for accentuation or elimination of features considered non‐attractive (e.g., prominent ears). Clearly, each patient’s definition of beauty is the result of individual’s specific life experiences.
Even subtle details can interfere with patient interactions. Stereotyping is a mistake that we are all guilty of. Anyone involved in patient’s care can make such mistakes. One of the nurses told a new patient “Where in Russia are you from?” The patient surprisingly to her responded, “I’m not Russian, I’m Polish.” Well, she had assumed from her last name that the Russian connection was the case. No negative consequences resulted from that action; however, like painting a canvas, start with a blank background. Eliminate all judgments and ask specific questions that will guide you into the creation of an individual piece of art. Plastic and cosmetic surgery allows you to transform and to an extent, recreate in the best possible manner the patient’s wishes. As mentioned earlier, ethnicity plays an important role in defining concepts of beauty; however, it is reckless to assume that belonging to a certain ethnic background is a definite indication for specific beauty ideals. “When a patient comes in from a certain background and of a certain age, we know what they’re going to be looking for” . Assuming this type of attitude as a plastic surgeon will lead to unhappy patients. However, the surgeon has to be capable to describe to a patient elements to consider and be sensitive and sophisticated enough to at least enlist suggestions and the rationale behind them. Without awareness of different demographic and culture that characterize specific patients, guidance will be crippled.
Knowing your patient well and establishing a relationship in which the patient feels comfortable enough to express his or her wishes is the main key to success. I have been guilty of failing to recognize the broad diversity of beauty preferences. I remember a few years back meeting a young patient who had traveled from a different country to undergo breast reduction surgery. The size of her breasts had been affecting her social life and caused her to feel uncomfortable when interacting with other college kids. Meeting her provided me with new insights of a culture that I had not been familiar with before. This particular patient was beautiful with big black eyes, striking lashes, and gorgeous long black hair. She, however, did not feel comfortable and would camouflage her chest with oversized clothes. Her posture was also affected and she was constantly trying to cover her breast with her arms. Her body habitus was curvy with very large breasts that did not harmonize with the rest of her body. As I continued chatting with her, she mentioned that she wanted to be more active but felt restricted and embarrassed about her chest, which is a usual complaint of women with macromastia. I assumed that by decreasing her breast size, she would be able to participate in various exercise activities that so far she had not been able to enjoy. When I asked her what sports she was interested in practicing, she stated that she did not want to do any sports because that could cause her to lose weight. I was curious to learn the reasoning of her statement. She then described that in her culture, being larger in size was a sign of wealth and that she would never want to look skinnier. Those words and the insight into her perception of beauty helped me become more aware of the role of socioeconomics and its influence on standards of beauty.
3. Attractiveness then and now
Beauty has evolved through history and has been delineated by different eras. Starting with the Renaissance period (14th to 17th century), where standards of female beauty seemed to be associated with the more voluptuous bodies. Iconic artists as Leonardo Da Vinci, Michelangelo Buonarrotti, and Raphaello Sanzio da Urbino gave us insight into the characteristics of perceived beauty from this time. Not only the unique “Mona Lisa” but also the nude forms of Michelangelo’s Venus and Raphaello’s ‘The Three Graces” clearly depict the Renaissance’ sense of beauty. Baroque and neoclassic times were followed by the Victorian era (18th to early 19th century) in which art demonstrates a change in perception with the female body emphasized with a smaller waist. Charles‐Edouard Boutibonne’s work such as the painting for Queen Margherita of Savoy reflects this new perception. The roaring twenties (Post‐WW1) brought new awareness of beauty. Music, industrial growth, and the focus on movie stars transformed, yet again, what had previously seemed attractive. Beauty was now centered in less voluptuous bodies and a leaner boy look. Hollywood actresses and artist like Louise Brooks became an iconic symbol that influenced different aspects of beauty. In the Golden Age (1930s–1950s with the end of WW2) beauty standards transformed back to a more feminine look. Actresses Jean Harlow, Rita Hayworth, and Marlene Dietrich epitomize this trend. The mid‐twentieth century (1950s), brought in a new look with the hourglass figure. Movie stars such as Marilyn Monroe and Grace Kelly completely depict this new take on beauty. In the 1960s, thin bodies became fashionable, and the first supermodels were revered. Model Jean Shrimpton characterized and led this new look. The 1970s perpetuated the very thin look with Farah Fawcett being a strong example of this trend. Undoubtedly, Madonna characterizes the views of the 1980s followed by stars like Kate Moss in the 1990s. This brings us to today with the new millennium, where it seems more than ever that the emergence and influence from the major beauty trends combined with athletic influences are captivating the world, women like Shakira, Beyoncé, and Jennifer Aniston, among others.
The perception of beauty has transformed through time and across the globe during specific events in history. In the late 1400s and early 1500s, after Christopher Columbus made landfall in the New World, Indians who had not been exposed to any eastern culture were found to have a completely different perception of beauty. For instance, The Mayan concept of beauty was influenced by many of their religious beliefs. “Yum Kaxx,” the maize God, persuaded the Mayan’s attraction for an elongated head and the implementation of primitive procedures to modify physical aspects of their newborns (Figure 2).Trepanning, for example, was a process used by parents to flatten their newborn babies’ soft skull, facilitating their cranial transformation into elongated heads. Interestingly, cross‐eyed deformities have never been thought of as a particularly desirable trait in European culture but in ancient Mayan culture, being cross‐eyed was admired. In fact, like cranial shape modification, Mayans would also go to great lengths to make their children cross‐eyed during infancy. This was accomplished by dangling objects in front of a baby’s eyes until they were permanently crossed. Moreover, based on different sculptures and artifacts, it seems as if some of their ideal features included large noses, pointed teeth, and multiple piercings that completely contrasted from other influences of the time.
Time‐related changes are yet another example that clearly reflects the strong influence that specific trends have toward the perception of beauty, even in heavily “regulated” environments. Changes that occurred through time with the iconography of Joan d’Arc, who was supposed to be beautiful, exemplify, and support this opinion. With her canonization in 1920, religion‐dominated stereotypes of thinking build her image to be rather ascetic and far from attractive by today’s standards, yet fitting the principles of Catholic propagated image of beauty. However, numerous movies, known paintings and posters from as early as 1851, confirm her changing appearance and exemplifies how symbols and characteristics of beauty followed the public perceptions of magnificence and femininity, even while being “censored” by the church. Early images made in her lifetime were destroyed upon her being condemned as a witch, rendering them dangerous devil’s currency. However, two written sources on the life of Joan d’Arc remain. The first, “Process de Condemnation”, was a record of her trial during her conviction that consisted of the events that took place during her interrogation. The second, “Process de Rehabilitation,” was a record of her retrial that compiled testimonies of eyewitnesses who all had personally known Joan d’Arc. Interestingly, in these documents, she was described as a short, robust woman with black short hair who only wore men clothes. Contemporary portraits of her seem to contradict the written sources. In a few images, Joan d’Arc is portrayed as an average size woman with long red‐brown hair wearing armor. We may speculate that these images were created from the artist’s imagination influenced by the perception of beauty of the time. Contemporary films similarly expose different takes on her appearance. The 1999 American movie “The Messenger: The Story of Joan of Arc” greatly differs from the popular TV miniseries “Joan of Arc” where beautiful yet completely different looking females Milla Jovovich and Leelee Sobieski portray this 15th century legendary warrior and saint (Figure 3).
In the current world, the fascination with the media and the capacity for globalization of culture and fashion trends has allowed an evolving international concept of beauty between continents. However, based on current experience from the practice of cosmetic surgery, it is clear that local preferences still remain strong. Is media powerful enough to influence perception of others? Can the use of specific products or brands make you feel and project a higher level of attractiveness? Well, hearing a 12‐year old girl in a Victoria’s Secret store telling her mother that she wanted to carry the bag because it would make her look prettier was shocking. The comment initially made me laugh but then, I wondered if this statement could hold any truth. A recent study revealed that consumers often prefer and choose specific brands in an effort to affirm and enhance their sense of self and as a result to create a more positive self‐image . Indisputably, we all recognize the effect that branding and media have in our minds. For example, hearing “Victoria’s Secret” will most likely make you think about an attractive, thin, blond woman wearing sexy clothes. “Hugo Boss” will make us think about a tall, good‐looking elegant male. All over the world, a brand’s goal is to build an appealing personality to attract consumers and enhance the way they view themselves. But not everyone gains the same things from a product. Two types of self‐theories were identified and described: the incremental and the entity theory . Incremental theorists believe that their personal qualities can be improved or enhanced by their own efforts. Conversely, entity theorists do not believe they can improve their personal qualities on their own and adopt signals to project improved qualities to others. The former study concluded that implicit self‐theories carry a big influence on consumer self‐perceptions, specifically the entity theorists. So can these same self‐theories apply to the world of plastic and cosmetic surgery? It all seems familiar and recognition of these clues may open insight into the individual goals’, self‐perception and surgery expectations.
Many aesthetic research studies focus on finding characteristics that are considered attractive, but do they hold true? As we noted earlier, these same characteristics may eventually evolve into complete opposites. Other studies have focused on determining differences among “similar groups”. Answering the question—What does the patient find attractive?—can clearly provide the plastic surgeon with information to minimize a generalization of their patients and improve surgeon‐patient interactions and outcomes. The question arises whether surgeons and patients are on the same page with what they consider “attractive”. Do surgeons from different areas of the world have similar perceptions when it comes to different body parts? A study, which explored this matter, confirmed that the perception of beauty has multiple influences and revealed interdependence between variables such as country of residence, sex, age, occupation, and aesthetic perception . In this study, an online survey was distributed to both plastic surgeons and laypersons worldwide in an effort to assess lip attractiveness. The study gathered over 1000 responses from 35 different countries and concluded that surgeon’s preferences on lip attractiveness varied depending on their practice location. Additionally, it revealed that laypersons living in the same area as surgeons did not share the same aesthetic preferences.
In order to explore profiling of patients, our group conducted a study to test the hypothesis that there are meaningful differences in perception of beauty even between seemingly similar generations with the same ethnicity and culture. In this study, preferences for facial cosmetic surgery among Asian women were investigated . It may have seemed based on geographical location that women of similar background would share the same views on beauty. However, significant differences in preferred beauty features were identified specifically for the periorbital region.
To further survey these geographical influences, a similar study involving yet a different ethnical group was undertaken. It was created to test the common stereotype that Latina women have similar opinions when it comes to buttock shape and its alteration or enhancement with cosmetic surgery. The interest in the topic evolved because it was noted that a growing number of patients from all ethnic groups continue to request this type of cosmetic surgery in the United States. Specifically, increased interest in the ideal buttocks has led to higher demand and inquiry for these aesthetic procedures. Between 2002 and 2003, a reported increase of 533% of gluteal augmentation procedures was reported by the American Society for Aesthetic Plastic Surgery . Latinas are the leading consumers of aesthetic surgery among US minority groups . Media has a strong influence in creating a consistent prototype when it comes to Latina women and their aesthetic preferences.
Although beauty ideals are subjective among individuals and continue to change between cultures and ethnic backgrounds, different ways to evaluate the gluteal region have emerged. Examination of the current literature identified specific features that describe the ideal buttocks. The hourglass female figure appears to be the preferred and ideal shape. A waist‐to‐hip ratio (WHR) of 0.7 was established and described to support this idea . Other defining features that stood out as consistent features of beauty include the anteroposterior projection, the length of infra‐gluteal fold, the presence of supra‐gluteal fossettes and the upper inner‐gluteal sacral junction “V‐zone” . Similarly, it was recognized that there are two relationships formed by the infra‐gluteal to inner thigh and the sacral height to gluteal crease length as important contouring zones . Furthermore, four different body frame types have been widely described as critical features that dictate specific interventions when planning buttock aesthetic surgery. An extensive search for gluteal aesthetic improvements has occurred since 1960 and led to the evolution of more advanced techniques and products with improved aesthetic results.
Our study was created to test the hypothesis that generalizing all Latinas in the same category of aesthetic preferences is inappropriate . The target group was Latinas born and raised in Central or South America but who were residing in the USA for at least 5 years at the time of survey. Three different countries were selected in a geographical manner to represent our study group. Three different zones were established: Central America, Eastern South America, and Western South America, which were represented by Mexico, Colombia, and Brazil, respectively. The investigation used a photomorph‐based survey, which included 12 questions. Three of the questions were pertinent to age, nationality, and interest in plastic enhancement surgery. The remaining nine questions were composed of multiple photographs contrasting different features of the ideal buttocks. The anonymized photographs were obtained from public files on the Internet and were edited to reveal a specific feature (Figure 4). None of these pictures resembled the original. The area of interest was isolated on each photograph to eliminate any bias from the overall appearance of the models. The nine features were identified in the literature to define anatomical details that contribute to attractive buttocks. These features are listed in Table 1 and were found to be essential during evaluation and planning an approach to enhancement surgery.
|1||Supra‐gluteal fossettes (SGF) (SGF)|
|2||Waist‐to‐hip ratio (WTHR)|
|3||Infra‐gluteal fold (IGF)|
|4||Antero‐posterior projection (prone) (APP‐p)|
|5||Frame shape (A: A‐shaped; S: square shaped; V: V‐shaped; R: round)|
|6||Antero‐posterior projection (profile) (APP‐pr)|
|7||Upper‐inner gluteal sacral junction (V‐zone)|
|8||Infra‐gluteal fold inner thigh relationship (diamond zone)|
|9||Sacral height to gluteal crease ratio (SH‐GCR)|
The survey was written in Spanish and Portuguese; it was distributed via social network and available for 5 days to female participants only. At the end of the 5 days, no additional surveys submitted were accepted. The identity of each participant was verified with the records form each personal profile in the social network. The study concluded that despite having similar backgrounds and influences, their buttock aesthetic preferences were not consistent. Even among women from the same country, differences were encountered. Regardless of nationality, each patient is an individual with unique predilections that have been influenced from specific life experiences, cultures, education, economics, and social surroundings. This is what contributes in shaping their perception of beauty. Consequently, plastic surgeons should be sensitive to different ethnic concepts of beauty and appreciate a range of values rather than assume what a specific culture or ethnicity prefers.
Not only Latina but also black women are believed to prefer large buttocks. I erroneously at one point believed that statement. During a regular clinic day, a real example was in front of my eyes. This memorable patient had suffered from erroneous stereotyping based on her race. She had previously undergone an enhancement procedure for her buttocks. Specifically, she had fat injections to improve her shape. Soon after talking to her, she started crying from frustration with the results obtained from the procedure. She explained that she just wanted a slight increase of the projection of her buttocks. However, communication and discussion of expectations were not successful. The surgeon who performed the procedure assumed that because of her dark skin, she wanted large and voluptuous buttocks and performed what he “thought” the patient wanted. A thorough discussion prior to signing informed consents for cosmetic procedures should emphasize expected outcomes and ambitiously approximate the patient’s goals for his or her appearance.
As one can imagine, buttock reshaping is not performed in the same manner for everyone. All surgical techniques are used in combination to achieve the desired results. Baseline exam of the patient and analysis of their buttocks are crucial prior to undertaking any intervention. Identification of physical features and the input from the patient will guide the plastic surgeon to the proper approach. It is important to recognize that physical features not only vary among females but also across gender and ages. For example, it has been demonstrated that male buttocks show fewer signs of atrophy and transformation with aging in comparison to females. The aging process is based on fat distribution, skin and tissue changes, volume and the effects of gravity . Proper analysis applies to every part of the body (Figure 5).
Our studies on facial and gluteal features are random examples on how profiling and stereotyping can lead to inaccurate assumptions in cosmetic surgery. They denote that scientific analysis can assist the surgeon in preoperative counseling. It also influences in learning and managing patient expectations and helps to optimize the choice in tools for beautification. The use of evidence‐based medicine to approach the design and execution of cosmetic surgery is practical and helpful in codification of technical guidelines (Figure 6).
4. Beauty, plastic surgeons: Are we unsettled?
Plastic surgery symposiums offer learning opportunities in the form of oral and poster presentations, as well as by interactions with other plastic surgeons. Some of these interactions have provided eye‐opening experiences during my training. Recently, while attending one of these events, the highlight of the night was listening to the introduction and speech given by the physician who had the honor of receiving the night’s “Lifetime Achievement Award.” It was fascinating to learn his story of success and multiple accomplishments, but undoubtedly, what I found outstanding was the fact that he was able to use his cultural and ethnic background and apply his surgical knowledge to the analysis of his patients. His career path and his own race inspired him to study hundreds of black noses from different cultures and create a classification system to aid other surgeons to understand the differences on this type of patient. His interest was motivated by the erroneous assessments he witnessed during his career when other plastic surgeons continued to apply the same general techniques to every patient regardless of their different features and incompatibility of the procedures .
Assessments and technical approaches to aesthetic body changes, not necessarily for pure beautification, but in a broader sense for the transformation of the patient’s image, should include patient age, ethnicity, characteristics, and flavor of desired type of attractiveness, fashion, etc. The assessment may require an isolated and comprehensive evaluation of “aesthetic units.” For example, the analysis of anatomically defined parts of the face (subunits) helps to isolate different components of beauty (or loss of it) and provides the surgeon data which can be utilized for the development of software to image and morph imaginary outcomes to determine how the patient perceives his or her beauty features and propose changes .
If one considers that cosmetic medicine and surgery are scientifically based, then consequently, an evidence‐based approach to cosmetic surgery requires objective data based on which recommendations are formulated from the assessment. On the other hand, if beauty is defined as a subjective notion; perceptions of the patient and experience of a surgeon, less hard‐core scientific evidence is needed at for the decision‐making process. The reality is that both subjective and objective factors are needed for successful cosmetic interventions. Intermingling subjectivism with objectivism, in different proportions, depending on both patient’s and surgeon’s preferences are fundamental for the connection between both parties and a successful surgery. Unexpectedly, to a degree, differences in the perception of beauty (subjective) between seemingly similar ethnic groups may be rooted in variable approaches based on how they celebrate bodies, personal wellness, and achievements (objective). For instance, in China, the new‐style
The need to mix subjectivism with objectivism brings relativism (the doctrine that knowledge, truth, and morality exist in relation to culture, society, or historical context, and are not absolute and constant) to cosmetic medicine and surgery. Standards of reasoning and justification, translated into guidelines of practice, will depend on time and place. Good or bad (it is relative and subject to changes with time), these are products of differing conventions, i.e., plastic surgery and dermatology publications, fashion, and frameworks of assessment. Therefore, the authority of the norm is confined to the context giving rise to it (e.g., beautiful, morally good, epistemically justified). Debates about relativism permeate the whole spectrum of philosophical sub‐disciplines: from ethics to epistemology, science to religion, political theory to ontology, theories of meaning and even logic, and now to the dilemma whether aesthetic surgery is a part of medical science. In the opening paragraph of this chapter an anecdotal example of inappropriate but unfortunately frequent subjectivism was brought up. The question whether cosmetic values and assessments are or are not part of medical science is of paramount importance and goes beyond the surgical locker room and certainly belongs in this chapter. For example, paradigm for body image stands behind “increasingly scientific” approaches to body dysmorphic disorder. Social perception and stereotyping have been important issues in social and cross‐cultural psychology over the centuries but plastic surgery pushed boundaries of concerns to an unprecedented level. Certainly, a plastic surgeon’s perspective on stereotyping and perception of beauty goes well beyond the componential approach to interpersonal social perceptions. Therefore, standards of reasoning should be studied, codified, and continuously adjusted. It is the author’s opinion that aesthetic surgery is a science, however with continuously changing paradigms. Our focused studies appear to affirm this notion .
Coco Chanel remarked that fashion is always of the time in which we live and “is not something that exists in dresses only”. Social media technology has changed the world; consumers of both fashion and cosmetic surgery are savvier than ever before and more comfortable with exploring the range of fashion, aesthetic medicine, and surgical options available. Emerging from our diverse culture, the fashion industry projects a symbolic system of society preferences that speak about current society’s personality. Beauty criteria and preferences—although related to fashion—appear to be more timeless where the impact of local microcosm and beliefs are stronger and entrenched with local traditions. The future of plastic surgery will continue to build bridges between art, ethnography, and science.
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