You will also have routine blood work. Parathyroid surgery scarring is not preventable, but Dr. Babak Larian of the CENTER for Advanced Parathyroid Surgery performs a minimally invasive parathyroidectomy (MIP) designed to reduce scarring in contrast to other parathyroid procedures. Thank you for stopping by to read my brief essay. Elsevier Point of Care. parathyroid glands through the mouth. Parathyroid surgery removes abnormal parathyroid glands that produce harmful levels of calcium in the blood. Scar in 2 weeks after minimally invasive parathyroidectomy in a 55 year-old female, Scar 2 weeks after parathyroidectomy, removal of the right superior parathyroid adenoma, in 57 year-old female, Scar in 1 year and 4 months after minimally invasive parathyroidectomy for left upper parathyroid adenoma in 50 year-old female, Scar in 2 weeks after minimally invasive parathyroidectomy in 55 year old female, Scar in 10 months after minimally invasive parathyroidectomy in 41 year old female, Scar in eight months after parathyroid exploration surgery with removal of the right upper parathyroid adenoma in 72 year old female, Scar in 2 weeks after the minimally invasive, outpatient parathyroidectomy for a large left lower parathyroid adenoma in 44 year old female with primary hyperparathyroidism, Scar in 2 weeks after the parathyroidectomy with removal of the right lower parathyroid adenoma in 61 year old female with primary hyperparathyroidism, Scar in 33 year old female in 16 months after minimally invasive parathyroid surgery, Scar in 2 weeks after minimally invasive parathyroidectomy (2 cm), Office Address: kidney stones. Clinical trials are invaluable in testing new treatments, drugs and technologies. September 2014 Also, keeping an incision as short as possible helps increase the chance that a scar will be virtually invisible following parathyroid surgery. September 2017 The operation used to involve exposing almost every structure in the neck to find the parathyroid glands. When the rise in blood calcium caused by primary hyperparathyroidism leads to symptoms, surgery is often needed to lower the amount of calcium in the body. The light is absorbed by blood vessels in the scar and may result in softer, lighter scars. The light is absorbed by blood vessels in the scar and may result in softer, lighter scars. Parathyroid glands. My neck is very small and he had no trouble finding the bad boys. They reduce the tension on the skin, which helps keep the scar small. These tests evaluate your heart and lung function. The left inferior parathyroid adenoma removed from the patient. But, advancements in endocrine surgery at Johns Hopkins allow our surgeons to provide a scarless alternative to this procedure. Thank you for sharing. pain after thyroid or parathyroid surgery. Accessed July 29, 2022. And I do understand being nervous. Usually by about 48 hours after surgery, the incision is sealed so that it is water tight. Lasers: Scars that remain pink and raised may respond to pulsed yellow dye laser therapy. Enter the email addresses of the people you want to share this page with. Michael R. Starks, M.D. Nobody had considered the blood calcium before. Slightly sore throat. June 2018 Many published. One question people ask about their parathyroidectomy scar is whether they can or should put some type of cream or ointment on it. An imbalance of PTH affects blood levels of calcium. I'm supposed to check in at 10:30am and the sestamibi test will be done prior to surgery which is supposed to be around 12:30. WebThe procedure is a minimally invasive technique to remove diseased thyroid or parathyroid glands without leaving any visible scars anywhere on your body. this entire story is not only informative.but unselfish..not that I am surprised! May 2014 Parathyroid Tumor Gallery We have also put together a photo gallery of some of the different parathyroid tumors Dr. Larian has removed during That means even if the dressing falls off, the skin will remain closed. After 3 of 4 enlarged parathyroid were removed, my outer scar was sealed with surgical glue. This content does not have an Arabic version. October 2017 Find primary and specialty care near you. Russell diagnosed Gwen with hyperparathyroidism caused by a parathyroid nodule. 2 weeks autodesintigrating plaster. 1 The human body has four small, butterfly-shaped parathyroid glands, located in the neck. Parathyroidectomy (pair-uh-thie-roid-EK-tuh-me) is surgery to remove one or more of the parathyroid glands or a tumor that's affecting a parathyroid gland. When Gwen met with head and neck endocrine surgeon Jonathon Russell, M.D. Primary hyperparathyroidism. Luke is married and has two young children. WebBefore you see the surgeon, you may need to undergo a series of tests to evaluate your parathyroid glands. I did not have the mibi test, after all. This is especially true for parathyroid surgery. One year photo update (Nov. 2016) after surgery. Best Regards, Fran. There are no sutures to remove. Lyden ML (expert opinion). December 2017 Word of mouth? To close the skin, we use a dissolvable suture that does not need to be removed. As it heals, your parathyroidectomy scar will change from week to week, and month to month. You notice numbness or tingling in your face, lips or hands that isnt managed with your calcium supplement. https://www.uptodate.com/contents/search. There is essentially nothing that needs to be done with the incision after surgery. I often hesitate at my Hudson group site because it is less about Hudson.. lol.. but I know many would appreciate some common sharing. March 2018 Let us help you find an answer to your question. Yip L, et al. Most often you can take your routine medications with a sip of water. Designed to provide a unique, specialized learning experience. If you dont, your parathyroidectomy scar may be 5-6 inches in length! An aside, Robyn: I wanted to add that a release of stress for me involved being close to the hospital the day before and the next night after surgery. Insulin Patient with insulin pumps: Patients without insulin pumps: August 2021 I wrote a review on it, actually. Initially, the incision site will be covered with protective tape that helps prevent infection at the treatment site. Robyn, that is great news to read. Medication Guidelines. Or call Adult Specialties (800) 272-3666 or Pediatric Specialties (877) 607-5280. Yes, I do live far away (3 1/2 hours) and will have a relative with me. Im assuming arnica and stretching will deal with this, but its not nothing. When this happens, patients should try not to worry and understand that these side effects are common during parathyroid surgery recovery. Parathyroid gland problems requiring parathyroidectomy include. Patients may notice swelling around the treatment site in the weeks after parathyroid surgery. If you dont, your parathyroidectomy scar may be 5-6 inches in length! Traditional thyroidectomies and parathyroidectomies leave a visible scar in the middle of the neck. Though individual results may vary, most patients can expect results within the range of examples shown here. We recommend you take it off at 7 days following the operation. Mayo Clinic; 2021. Excess exposure to direct sunlight can make a parathyroid surgery scar darker in contrast to the skin around it, so keeping a scar out of sunlight up to one year following parathyroid surgery is recommended can help minimize its appearance. If a patient believes an infection is present at a parathyroid surgery treatment site, medical care is required to correct the issue as quickly as possible. Russell diagnosed Gwen with hyperparathyroidism caused by a parathyroid nodule. The calcium is necessary due to removal of the overactive gland and the remaining sleepy parathyroid glands. A very slight pulling sensation at scar. Lots of hugs to you Becky! WebVideo-assisted parathyroidectomy: The surgeon makes two small incisions in the neck. He also drew an ink-line on my neck prior to surgery. New knowledge driving discovery to advance the health of our communities. The parathyroid glands lie behind the thyroid. But I have been very fatigued for the past few years and other issues kept appearing that could have been explained by other causes. Generally, the scar is less than 2 centimeters in length. Then the hunt stared for the cause, which has taken 17 months to the day! Try looking up a doctor, a clinic location, or information about a condition/treatment. Scar, 8 months after minimally invasive parathyroid surgery. lol Again, my very best to you. September 2016 I started to miss lint at fine detail. Bella, thank you visiting my website and reading the basic topic of healing progression on my scar. Get the Calcium-Pro parathyroid diagnosis app developed by our experts. I posted it at St. Joseph's but I have to seek out more sites to send the link to. Sometimes, one or more of your parathyroid glands can release (secrete) too much parathyroid hormone. After a parathyroidectomy, you are likely to go home with some calcium Hello, and Welcome!Like you, I have many life experiences, but unlike many, I want to write about mine, and others,in poem and story. We place a Steri-Strip, a small white bandage, that will fall off around 10-14 days. After 3 of 4 enlarged parathyroid were removed, my outer scar was sealed with surgical glue. The results are used to help confirm that all of the overactive glands have been removed. Choose from a three or four-year MD program at various campus locations, our anesthesiologist assistant, physician associate, or a number of dual degree programs. Scar in two weeks after a minimally invasive parathyroidectomy for a primary hyperparathyroidism in a 21 year-old female (the same patient as it is shown on a prior picture). A cancerous tumor is a rare cause of primary hyperparathyroidism. Scar improves with time, and the final result is generally evident 6 months after surgery. For example, careful incision placement helps lower the risk of a large scar after parathyroid surgery; the incision is usually in the lower neck and in the line of neck crease. Less people ask about the actual healing process of their parathyroidectomy scar, but it is still important. Scar, 2 weeks after a minimally invasive, VIDEO-ASSISTED (with camera) parathyroid surgery, an approach from the left side. Patients may notice swelling around the treatment site in the weeks after parathyroid surgery. I think it was a job well done, inside and out by Dr. Michael Starks; Tracy Bennett, PA-C of St. Joseph General Surgery and the excellent care at St. Joseph Hospital, Bangor, Maine (Conducted by the Felician Sisters). This usually lasts only a few days or a few weeks after surgery. January 2016 getting shorter! Depending on the results of the blood work, you may need to take additional calcium supplementation for a short period of time. Your glands must have been quite enlarged for him to feel them. If you can swing it, I would do two nights because of your long drive. A blood test to measure parathyroid hormone typically is done during surgery. We know there is a lot of information on the site and it can be A general anesthetic will prevent you from feeling pain during the operation. Surgery is supposed to be midday. A MIP is also fast, safe, and delivers a cure rate of 97%. Log in to make an appointment. WebScarless Thyroidectomy and Parathyroidectomy. Scar improves with time, and the final result is generally evident 6 months after surgery. Staying out of sunlight and applying sunblock when going outdoors are two ways to achieve this. Lasers: Scars that remain pink and raised may respond to pulsed yellow dye laser therapy. January 2018 Fax (732) 536-0919, Multidisciplinary Endocrine Oncology Clinic, Familial medullary thyroid cancer syndromes:MEN 2A, MEN2B, FMTC. Mayo Clinic; 2021. If the gland wont be there, then we dont need to expose or look there. You may be able to leave the hospital the same day as the surgery. This is typically discussed with your surgeon during your clinic visit. Apply sunblock with a sun protection factor (SPF) of 35 or higher in the mornings for at least two months as well. The only thing we would recommend is Vitamin E, but even then it is hard to tell which patients used Vitamin E and which ones did not. Individual results may vary. April 2014 Through collaboration with the brightest minds in science and medicine MCWs Centers are at the forefront of discovery and innovation. Contact me.Feel free to leave a comment. Take care! Sometimes, one or more of your parathyroid glands can release (secrete) too much parathyroid hormone. 901 West Main Street Enhancing learning, research, patient care and the health of the community. In many instances, the scar also fully heals after surgery, so it has minimal impact on appearance. I felt I had excellent care. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. Thank you Dr. Michael Starks, Tracy Bennett PA-C, and the fantastic St. Joseph Hospital, Bangor, Maine. A large parathyroid adenoma 6g, 3.3 cm x 2 cm (removed from the patient pictured left). After 3 of 4 enlarged parathyroid were removed, my outer scar was sealed with surgical glue. Once again, this is where our approach makes the difference. Make a donation. This surgery leaves no visible scar since there is no incision on the outside of the neck. We did get a hotel (at a hospital discount) for the night before and the day of the surgery. pain after thyroid or parathyroid surgery. Parathyroid surgery is used to treat hyperparathyroidism (HPT). But more importantly, there isnt much room for improvement for our parathyroid incisions. The parathyroid glands help regulate calcium and phosphorous blood levels. As a general rule, you will be asked not to eat or drink anything after midnight the night before surgery. Endoscopic parathyroidectomy: The surgeon makes two or three small incisions in the front of neck and one cut above the collarbone. Your health care provider may advise that you take calcium after surgery to prevent low calcium. November 2016 This raises the levels of calcium in the blood. Parathyroidectomy: Recovery and Next Steps Elsevier; 2018. https://www.clinicalkey.com. Cleveland Clinic is a non-profit academic medical center. The camera is inserted through one incision and the surgical instruments are inserted through the other incision. The camera is inserted through one incision and the surgical instruments are inserted through the other incision. November 2014 Thyroid, Parathyroid, and Adrenal. When they stop working properly, parathyroid surgery removes the abnormal glands producing harmful high-calcium blood levels. Just saying. Masks are required inside all of our care facilities, COVID-19 testing locations on Maryland.gov, The four parathyroid glands, each about the size of a grain of rice, are located behind the, Hormones from the parathyroid glands regulate blood levels of calcium and other minerals. Happy to hear it is over and done with, and you are feeling well. I felt more rested being in the area the night before. When they stop working properly, parathyroid surgery removes the abnormal glands producing harmful high-calcium blood levels. Luke was the chief of Endocrine Center at Tallahassee Memorial Hospital/FSU for 4 years until joining the "Dream Team" in Tampa. https://www.asahq.org/madeforthismoment/anesthesia-101/types-of-anesthesia/general-anesthesia/. 5-Star-Rated. Thyroid nodules were checked and deemed ok at this time. Testing may include an ultrasound, a sestamibi scan and/or a CT scan. WebScar Gallery Minimally Invasive Parathyroid Surgery All incisions are closed using the same meticulous technique, identical to that used by plastic surgeons. Prior to having surgery, a series of general screening tests are done to make sure you are healthy for surgery. Scar, 2 weeks after a parathyroidectomy for parathyroid hyperplasia with removal of 3 and parathyroid glands, and simultaneous total thyroidectomy for multinodular goiter with findings of a micropapillary thyroid carcinoma. hope u are able to post this on a medical or surgical site so others may benefit. Parathyroid Adenoma or Parathyroid Hyperplasia. General anesthesia. Parathyroid Tumor Gallery We have also put together a photo gallery of some of the different parathyroid tumors Dr. Larian has removed during Hardening of scar tissue after parathyroid surgery tends to reach its peak level at about three weeks after treatment. If you experience these symptoms, please notify the office. WebScar in 2 weeks after pararathyroidectomy with removal of 3.5 cm (2 and inches) parathyroid adenoma in 60-year-old female (see parathyroid adenoma that was removed on the prior picture) Scar in two weeks after minimally invasive parathyroidectomy with excision of the left upper parathyroid adenoma in 66-year-old female June 2015 Longer periods of time may be needed if the scar remains red and elevated. Other syndromes associated with thyroid cancer: New Jersey Parathyroid Center at Jersey Shore University Medical Center, Endocrine Surgery at Jersey Shore University Medical Center, Primary Hyperparathyroidism in children and adolescents, Familial hypocalciuric hypercalcemia (FHH). We work closely with partners to redefine health beyond healthcare and with a bold vision of achieving health equity for all. Longer periods of time may be needed if the scar remains red and elevated. Even so, the incision is continuously remodeling to get to the final strength until about six months after surgery. These tests provide useful information to the surgeon about your parathyroid glands. I'd be curious to know what country you are from? This is the easiest question to answer, and likely the biggest difference between very experienced and high-volume surgeons and those surgeons who do not specialize in parathyroid surgery. Generally, the scar is less than 2 centimeters in length. If you know of any, please go ahead and share the link. A single copy of these materials may be reprinted for noncommercial personal use only. Whenever possible, incisions are placed along natural skin lines. If anyone has or is having any type of medical issues after any type of surgery, I would strongly suggest that you speak to your local medical doctors/centers/specialists/surgeons and if needed seek a second opinion. So be warned! This surgery leaves no visible scar since there is no incision on the outside of the neck. I did not use special creams. However, steps can be taken to limit the size of a parathyroid surgery scar and ensure it naturally blends into a patients neck skin. You will also have some blood work checked. Surgeons made these large incisions for parathyroid surgery for 75 years, but sadly many of surgeons still do this. December 2016 Your parathyroid glands are part of your endocrine system. I am very glad to have connected with you and look forward to hearing of your progress. All went very well. WebScarless Thyroidectomy and Parathyroidectomy. I will amend my piece with a 6 month update. I noticed a new type of fatigue on top of my hypothyroidism about 11 years ago, but Id fought so hard for thyroid replacement I didnt dare say something was wrong. Thank you for the quick response. If your surgeon uses anything other than dissolvable sutures, run out of their office! The drive is an easy one to St. Joes. Accessed July 29, 2022. SO feel free to share. Goldblum JR, et al. A low calcium level is typically a short term problem treated with calcium supplements. Generally, the scar is less than 2 centimeters in length. If you are suffering from hyperparathyroidism, schedule your consultation with the best parathyroid surgeon Dr. Babak Larian. The photos below will show a healing progression of my scar over a three month period, starting from October 20, 2015, the day of the surgery, to January 16, 2016, three months after surgery. After surgery, you may have a scar at the base of your neck. Scar improves with time, and the final result is generally evident 6 months after surgery. I see you are outside of the London (UK) area. All rights reserved. Did you already have this test? supplements until the remaining normal parathyroid glands wake up and If the remaining glands are underactive, you may have low calcium levels. Depending on your history, you may also need an EKG, chest x-ray, and/or stress test. Fairer-skinned individuals generally have lighter-colored scars than individuals with darker complexions. Lal G, Clark OH. There are many things that determine how visible a scar is, from length and direction to tension to skin tone. My travel time one way was 2 hours. Scar, 2 weeks after a minimally invasive parathyroidectomy with a removal of the right lower parathyroid adenoma. I have my first major blood test in April for my upcoming 6 month follow-up. They are located behind the thyroid at the bottom of the neck. You will also have routine blood work. Diabetes medications: The doctor may order imaging and laboratory tests, such as: Ultrasound, sestamibi nuclear medicine scan, computed tomography (CT) or magnetic resonance imaging (MRI) to visualize the parathyroid glands and surrounding areas, Blood test(s), urinalysis, bone density screening, Examination of the vocal cords and their function using an instrument called a laryngoscope. Surgical management of hyperparathyroidism. He received his formal training in endocrine surgery at Yale University where he worked closely with Dr Tobias Carling. My very best to you Robyn Smith with your pending surgery. Vitamin E can help speed healing, and sunblock can lighten the appearance of scars. The most important reason we chose this is the same reason we dont use glue. Care following thyroidectomy and parathyroidectomy. Day 2 is horrendously sore, and swollen and bruising is emerging. They produce parathyroid hormone, which plays a role in regulating the body's blood level of calcium and phosphorus. or to our office, and get back to you as soon as we can. Whenever possible, incisions are placed along natural skin lines. January 2019 If hoarseness doesn't improve, you may need to have your vocal cords examined. https://www.uptodate.com/contents/search. Find more COVID-19 testing locations on Maryland.gov. Secondary hyperparathyroidism develops as a result of another medical condition, most often kidney disease. WebScar in 2 weeks after pararathyroidectomy with removal of 3.5 cm (2 and inches) parathyroid adenoma in 60-year-old female (see parathyroid adenoma that was removed on the prior picture) Scar in two weeks after minimally invasive parathyroidectomy with excision of the left upper parathyroid adenoma in 66-year-old female The skin is closed with sutures or glue. In general, over the counter, anti- But then again, he is very experienced. Too little calcium can cause bone problems, depression, fatigue and other symptoms, while too much calcium can result in problems such as kidney stones, muscle spasms and nerve pain. We do not endorse non-Cleveland Clinic products or services. Keeping your home area private, if you do live far you might consider staying at a local hotel. WebHealth care providers perform thyroidectomy to treat thyroid disorders. At The CENTER for Advanced Parathyroid Surgery we are dedicated to providing our patients with individualized care and treatment plans to give them rapid relief from the devastating effects of hyperparathyroidism. All the best. Hi Becky. In: Minter RM, Doherty GM. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. and staff will continue their great service under this name. In some cases, you may need to stay overnight in the hospital. I was in PT for nearly a year. The surgery is performed laparoscopically through small incisions on the inner surface of your lower lip without any external neck incisions. It doesnt take much to be able to see the glands and remove the problem glands. No incision looks great immediately after surgery. I don't have stones, thank God. Surgeons can access the parathyroid glands through an incision at the front of the neck, or through the mouth (scarless procedure). Between 1-2 weeks, the incision will have a majority of its final strength. A note on Penobscot Surgical Care: Effective February 29, 2016 Penobscot Surgical Care will be professionally managed by St. Joseph Hospital. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, (http://endocrinediseases.org/parathyroid/surgery_overview.shtml), Visitation, mask requirements and COVID-19 information. April 2017 Post-treatment care instructions typically offer the following recommendations: Why vitamin ointments and sunblock? All scars heal, and parathyroid surgery scars are no different. There are several surgical approaches that can be used for parathyroidectomy. If you develop primary hyperparathyroidism before age 50, your health care provider may suggest you have surgery even if you don't have any symptoms. We deliver effective, minimally invasive treatments in a caring environment. January 2015 Parathyroidectomy: Recovery and Next Steps As I said above, after six months, your incision shouldnt be visible unless someone is deliberately looking for it. A job well done! New York, NY: McGraw-Hill; 2014. Read our Parathyroid Blog! Clinical Overview: Hyperparathyroidism. I was diagnosed after my nephrologist saw a trend of elevated blood calcium and he felt it was most likely the cause of my recent diminished kidney function. By following post-treatment instructions, patients can minimize scarring, as well as avoid potential complications. I thought my aches and fatigue, tendonosis (break down of tissue) et al were due to aging (64) and a rather poor spinal column which now I think was losing more calcium leading to some painful days. Def. You should ask your surgeon about your incision, because many surgeons arent worried about how the incision will look. | Phone: (813) 972-0000 | Fax: (888)-481-1487, Copyright 1996-2023 | All rights reserved. You will also have routine blood work. Refractory hyperparathyroidism and indications for parathyroidectomy in adult dialysis patients. I feel ever grateful for my excellent care starting at my local health clinic Eastport Health Care, and then the referral to Dr. Henderson which led me to Dr. Starks. *The content/images on this website are not a guarantee of individual results. You may have of numbness, tingling or cramping if your calcium level gets too low. I was surprised I had hyperplasia. When this happens, patients should try not to worry and understand that these side effects are common during parathyroid surgery recovery. In some cases of minimally invasive surgery, you may need only local anesthesia, so you're awake during the procedure. Parathyroidectomy: Recovery and Next Steps Traditional thyroidectomies and parathyroidectomies leave a visible scar in the middle of the neck. I would love that. Medications on Discharge July 2016 Statesir Cancer Center, All were enlarged (hyperplasia). When they stop working properly, parathyroid surgery removes the abnormal glands producing harmful high-calcium blood levels. Though individual results may vary, most patients can expect results within the range of examples shown here. These include cancer, noncancerous enlargement of the thyroid (goiter) and overactive thyroid (hyperthyroidism). There are some great stories here! Your scar will be most visible for the first 1-2 months after surgery, improve significantly over 2-3 months, and gradually fade over the next 6-9 months. The only treatment for primary hyperparathyroidism is surgery to remove the abnormal glands. I guess they are never really sure what they will find until they are in there. I am eager to get to the other side of this but am understandably nervous. You may receive medicines to reduce nausea and vomiting (antiemetics). I think it was do to the anesthesia, a common occurrence. These range from an antibiotic ointment like polysporin to vitamin E oil to scar reduction creams like Mederma. We have also put together a photo gallery of some of the different parathyroid tumors Dr. Larian has removed during minimally invasive parathyroid procedures. While the most important aspect of parathyroid surgery is getting a cure, we frequently get asked as many questions about the incision and scar as we do about the surgery. WebScar Gallery Minimally Invasive Parathyroid Surgery All incisions are closed using the same meticulous technique, identical to that used by plastic surgeons. You may need this surgery if one or more of your parathyroid glands makes too much parathyroid hormone (hyperparathyroidism). This surgery leaves no visible scar since there is no incision on the outside of the neck. When surgery is performed by a parathyroid expert, minimal scarring occurs. Whenever possible, incisions are placed along natural skin lines. The sestamibi test is a bit exhausting in that you must stay very still as they scan. I will try to remember to post those results here. You can shower the day after surgery, and you dont need to cover your incision or keep it dry. Jameson JL, et al. October 2018 You will no longer have high calcium levels in your blood.
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