Mannu GS, Sudul M, Bettencourt-Silva JH, et al. These investigators stated that in an era of evidence-based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. Level of Evidence = IV. breast augmentation with implant. They stated that in the light of these findings, contralateral reduction mammoplasty with histopathological evaluation in breast cancer patients offered a sophisticated tool to catch those patients whose contralateral breast needs increased attention. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Other just require 500 grams no matter what your height and weight. background: #5e9732; Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete (i.e., breast size stable over one year) when any of the following criteria (A, B, or C) is met: Macromastia: all of the following criteria must be met: In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Within this study population, 54.4% of patients were obese (BMI > 30 kg/m2), of which 1308 (28.8%) were Class I (BMI = 30-34.9 kg/m2), 686 (15.1%) were Class II (BMI = 35-39.9 kg/m2), and 439 (9.7%) were Class III (BMI > 40 kg/m2). The majority (87.7 %) of cases presented with accompanying mastalgia. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Gynecomastia is a very common concern of male adolescence. Plastic Reconstr Surg. He Q, Zheng L, Zhuang D, et al. } Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. 2006;118(4):840-848. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. A total of 182 thirty-day postoperative surgical complications were documented, but stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26). Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass right: 30px; Reduction mammoplasty for asymptomatic members is considered cosmetic. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. With approval from the authors institutional ethics committee and written informed consent, a total of 22 patients with 33 abnormally hyperplastic breasts were enrolled at the First Affiliated Hospital with Nanjing Medical University between June 2016 and September 2018. Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration hemorrhage) from overlying breast tissue; There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; Reduction mammoplasty (also spelled as 'mammaplasty') is likely to result in improvement of the chronic pain; Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as: Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants, Dermatologic therapy of ulcers, necrosis and refractory infection, Physical therapy/exercises/posturing maneuvers, Supportive devices (e.g., proper bra support, wide bra straps), Chiropractic care or osteopathic manipulative treatment. display: none; Copyright Aetna Inc. All rights reserved. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. 2009;19(3):e85-e90. An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an e-mail containing a link to a web-based survey. 2004;113(1):436-437. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . .strikeThrough { .strikeThrough { Annu Rev Med. Although the BRAVO study is described as a controlled study, the "control" group is obtained, not from the same cohort, but from a separate cohort of individuals recruited from newspaper advertisements and solicitations at meetings for inclusion in a study of the population burden of breast hypertrophy; 75 % of this control group were obtained from2 centers, but the characteristics of those2 centers were not described. Computed tomography scan of adrenal glands to identify adrenal lesions. In fact, according to the American Society of Plastic Surgeons, more than 46,000 breast reduction procedures were performed in 2019, a six percent increase compared to 2018; but in recent years, insurance companies have become more likely to deny coverage for this medically recommended procedure. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Socioeconomic Committee Position Paper. Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. Fischer S, Hirsch T, Hirche C, et al. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. Well-designed clinical trials provide reliable information about the effectiveness of an intervention, and provide valid information about the characteristics of patients who would benefit from that intervention. 1993;17(3):211-223. 2019;166(5):934-939. 2000;44(2):125-134. } 2014b;48(5):334-339. Reduction mammaplasty: An outcome study. J Plast Surg Hand Surg. Plast Reconstr Surg. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. Brown DM, Young VL. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. Arlington Heights, IL: ASPS; March 9, 2002. Aesthet Surg J. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. 1990;24(1):61-67. margin-top: 38px; Petty PM, Solomon M, Buchel EW, Tran NV. 2006;9(2):109-114. }. A total of 244 out of 1,628 patients with the average age of 23.13 years. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. The authors concluded that breast re-reduction can be performed safely and predictably, even when the previous technique is not known; and 4 key principles were developed: Language services can be provided by calling the number on your member ID card. Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. 2015;10(8):e0136094. The average amount of breast tissue removed ranged from 430 g per breast to 1.6 kg per breast, with increased body weight associated with an increased amount of breast tissue to be removed. /*margin-bottom: 43px;*/ PLoS One. Ann Plast Surg. The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. 2007;356(5):479-485. Ann Plast Surg. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. .newText { A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Also, there was no correlation between PR expression and 2D: 4D. There were only 2 studies of a total 25 patients that were considered as good in quality. 1999;103(6):1687-1690. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Anesthesia may be injected along with saline solution until the tissue is firm, and a suction cannula is used to extract fat from the breast. When seeking preauthorization for a breast reduction, your goal is generally twofold. Gynecomastia in patients with prostate cancer: A systematic review. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. Breast reduction surgery is considered cosmetic and not medically necessary for the following conditions: poor posture, breast asymmetry, pendulousness, problems with clothes fitting properly and nipple-areola distortion. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Sugrue and associates (2015) evaluated the current practice patterns of drains usage by plastic and reconstructive and breast surgeons in United kingdom (UK) and Ireland performing bilateral breast reduction (BBR). Resolution of idiopathic gynecomastia may take several months to years. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. Thus, more than 1/3of operative subjects selected for inclusion in the study did not complete it; most of the operative subjects who did not complete the study were lost to follow-up. Seitchik MW. The American Society of Plastic Surgeons' evidence-based clinical practice guideline on reduction mammoplasty (ASPS, 2011) states thatin standard reduction mammoplasty procedures, evidence indicates that the use of drains is not beneficial. A physician-supervised diet and exercise plan may be indicated in obese patients. margin-bottom: 38px; The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Level of Evidence = IV. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Mistry RM, MacLennan SE, Hall-Findlay EJ. A cohort study of breast cancer risk in breast reduction patients. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. In the case of reduction mammoplasty for relief of back, neck and shoulder pain, Aetna has considered this procedure medically necessary in women with excessively large breasts because it seems logical, even in the absence of firm clinical trial evidence, that this excessive weight would contribute to back and shoulder pain, and that removal of this excessive breast tissue would provide substantial pain relief, reductions in disability, and improvements in function. Reduction mammoplasty: Criteria for insurance coverage. Kasielska-Trojan A, Danilewicz M, Antoszewski B. Administration of Benefits and Transition Responsibilities Breast J. It is not intuitively obvious, however, that breast weight would substantially contribute to back, neck and shoulder pain in women with normal or small breasts. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . Aetna considers breast reconstructive surgery to correct skin should not be excised horizontally below the inframammary fold. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. All RCTs that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible. Risk of bias was assessed independently by 2review authors. color:#eee; ASPS clinical practice guideline summary on reduction mammaplasty. 1998;26(1):61-65. 2014a;34(3):409-416. The mean volume of tissue resected was 250 g (range of 22 to 758 g) from the right breast and 244 g (range of 15 to 705 g) from the left breast. 2008;121(4):1092-1100. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Gynaecomastia. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Plast Reconstr Surg. There are alsoseveral earlier, smaller studies that found reductions in symptoms and improvements in quality of life after reduction mammoplasty (Glatt et al, 1999; Bruhlmannand Tschopp, 1998; Blomqvist et al, 2000; and Behmand et al, 2000). 2017;35:157-161. If breast growth has been completed, breast reduction surgery is an option. Marshall and Tanner (1969)shows that the final stage of breast maturityoccurs about age 15 on average, but there is wide variation. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. Plast Reconstr Surg. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. This investigators stated that these studies should include data from older individuals affected by gynecomastia and utilize valid tools of psychological measurement in order to better quantify the effect; elderly patients affected by the disease have been over-looked in the current research; more data on this subject could improve the pre-operative evaluation of these patients and help identify the patients who will benefit from treatment. Hoyos AE, Perez ME, Dominguez-Millan R, et al. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. 2020 Sep 4 [Online ahead of print]. Schnur subsequently refuted the validity of the Schnursliding scaleand stated that thescale should no longer be used as a criterion for the determination of insurance coverage for breast reduction surgery (Nguyen et al, 1999). 2017;139(6):1313-1322. 1995;61(11):1001-1005. Laituri CA, Garey CL, Ostlie DJ, et al. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. As explained below, the studies used to support the arguments for the medical necessity of breast reduction surgery are poorly controlled and therefore subject to a substantial risk of bias in the interpretation of results. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? There were no restrictions on the basis of date or language of publication. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. To calculate body surface area (BSA) see:BMI and BSA (Mosteller) Calculator;orBSA (m2) = ([height (in) x weight (lb)]/3131)(denotes square root), BSA (m2) = ([height (cm) x weight (kg)]/3600)(denotes square root). 01/04/2023 In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. Tang CL, Brown MH, Levine R, et al. Breast Concerns of Adolescents. 1997;100(4):875-883. 2 . Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold in and of themselves are not considered medically necessary indications for reduction mammoplasty. bottom: 20px; padding-bottom: 4px; Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? 2013;71(5):471-475. The author concluded that the current level of evidence on this subject was very low and future studies, examining the impact of the surgical intervention for gynecomastia on psychological domains, are greatly needed. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . For the first update of this review, these investigators searched the Cochrane Wounds Group Specialised Register (searched March 4, 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid Medline (2012 to March 3, 2015); Ovid Medline (In-Process & Other Non-Indexed Citations March 3, 2015); Ovid Embase(2012 to March 3, 2015); and EBSCO CINAHL (2012 to March 4, 2015). Ann Plast Surg. background-color:#eee; Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. N Engl J Med. padding: 15px; } Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. color: red!important; Surgeon. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g., infection, other wound complications, pain, and length of hospital stay [LOS]). Arlington Heights, IL: ASPS; May 2011. Aetna considers molecular susceptibility testing for breast and/or epithelial ovarian cancer ("BRCA testing") medically necessary once per lifetime in any of the following categories of high-risk adults with breast or epithelial ovarian cancer (adapted from guidelines from the U.S. Preventive Services Task Force (for Gynecomastia in patients with prostate cancer: Update on treatment options. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Marshall WA, Tanner JM. Criteria for reduction mammoplasty surgery from the American Society of Plastic Surgeons (ASPS, 2002; ASPS, 2011) states, among other things, that breast weight or breast volume is not a legitimate criterion upon which to distinguish cosmetic from functional indications. Plast Reconstr Surg. There were 18 out of 415 studies eligible to review. High-risk lesions (atypical ductal hyperplasia [ADH], atypical lobular hyperplasia [ALH], and lobular carcinoma in situ [LCIS]) were revealed in 37 (11.7 %), and cancer in 6 (1.9 %) patients. Grooving where the bra straps sit on the shoulder. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. Only 8 (9.9 %) patients did not have a complete resolution following tamoxifen therapy, of which 2 underwent subsequent surgical resection of their symptomatic gynecomastia. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an out-patient; however, this was not statistically significant (p = 0.07). Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Third, reliable evidence is especially important for pain interventions, because of the waxing and waning nature of pain and the susceptibility of this symptom to placebo effects and other biases that may confound interpretation of study results. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. Mayo Clin Proc. Collis N, McGuiness CM, Batchelor AG. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . Aesthetic Plast Surg. Plast Reconstr Surg. Endocrinol Metab Clin North Am. Gynecomastia: A systematic review. The health burden of breast hypertrophy. Level of Evidence = IV. Plast Reconstr Surg. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Breast reduction outcome study. Bertin ML, Crowe J, Gordon SM. Variations in pattern of pubertal changes in girls. background-color: #cc0066; Emiroglu M, Salimoglu S, Karaali C, et al. Am J Infect Control. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. position: fixed; 1998;41(3):240-245. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Howrigan P. Reduction and augmentation mammoplasty. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). color: red The authors (Nguyen et al, 2004) argue, based primarily on the results of the ASPS-funded BRAVO study (described below), that (with a single exception) no objective criteria for breast reduction surgery are supportable, including criteria based upon the presence of particular signs or symptoms, requirements based upon breast size or the amount of breast tissue removed, any minimum age limitations, any limitation based upon maximum body weight, requirements for a trial of conservative therapy, or the exclusion of certain procedures (liposuction). This conclusion is based primarily upon the Breast Reduction Assessment of Value and Outcomes (BRAVO) study, which is described in several articles (Kerrigan et al, 2001; Kerrigan et al, 2002; Collins et al, 2002). Surgical treatment of gynecomastia: Complications and outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Current concepts in gynaecomastia. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. The authors specified the value of these study results was in the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. @media print { Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. Plastic Reconstr Surg. Autorino R, Perdona S, D'Armiento M, et al. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated insection I above. Plast Reconstr Surg. z-index: 99; No data were provided on loss to follow-up. Med Decis Making. Reduction mammaplasty: The need for prospective randomized studies. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. Qu S, Zhang W, Li S, et al. Follow-up ranged from 2 months to 3 years. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. Kerrigan CL, Collins ED, Kim HM, et al. Ann Plast Surg. --> Well-designed trials are especially important in assessing pain management interventions to isolate the contribution of the intervention from placebo effects, the effects of other concurrently administered pain management interventions, and the natural history of the medical condition. 2006;30(3):309-319. Fischer JP, Cleveland EC, Shang EK, et al. Plast Reconstr Surg. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. A systematic search of the published literature was performed. Plast Reconstr Surg. } Sood R, Mount DL, Coleman JJ 3rd, et al. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Plastic Reconstruct Surg. 2001;76(5):503-510. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. Plast Reconstr Surg. Initial breast reconstruction including augmentation with implants 15771-15772 (when specific to breast), 19325, 19340, 19342, C1789 Fat grafting (alone, or with implant based feminization) 15771, 15772 *Note: CPT 19318 (breast reduction) includes the work necessary to reposition and reshape the nipple . Chadbourne EB, Zhang S, Gordon MJ, et al. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. Aesthetic Plast Surg. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; 1998;101(2):361-364. Major complications (1.6 %) included unilateral hematoma and localized infection. color: white; } } Kerrigan CL, Collins ED, Striplin D, et al. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. 2005;55(3):227-231. Setala L, Papp A, Joukainen S, et al. Moreover, these researchers stated that further studies are needed within the common gynecomastia population managed by plastic surgeons to examine the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients. 1999;103(1):76-82; discussion 83-85. Behmand et al (2000) reported on the results of a questionnaire pre- and post-surgery in 69 subjects from a single practice who underwent reduction mammoplasty. #backTop { A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. Mental health care professionals may be consulted to address psychological distress from gynecomastia. The authorsleave the reader with the conclusionthat decisions about the medical necessity of breast reduction surgery in symptomatic women should be left entirely to the surgeon's discretion. color: #FFF; Arlington Heights, IL: ASPS; 2011. They investigated effects of age on 30-day surgical outcomes for reduction mammoplasty with a goal of improving patient care, counseling, and risk stratification on 3537 patients. Narula HS, Carlson HE. In other patients, excess skin and nipple and areola relocation are necessary. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. A population-level analysis of bilateral breast reduction: does age affect early complications? Breast asymmetries: A brief review and our experience. Breast pumps. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. 1998;49:215-234. 2010;45(3):650-654. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Breast. The Mammotome procedure represented another novel therapeutic option for gynecomastia. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. The investigators found that comorbid conditions increased across obesity classifications (p < 0.001), with significant differences noted in all cohort comparisons except when comparing class I to class II (p = 0.12).
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