COSMETIC

Diced Cartilage Grafts in Rhinoplasty Surgery:Current Techniques and Applications

Rollin K. Daniel, M.D.

Newport Beach, Calif.Background: The author has used diced cartilage grafts in nasal surgery formore than 30 years. However, the number of cases and the variety of techniqueshave increased dramatically over the past 6 years.Methods: The author uses three methods of diced cartilage in rhinoplastysurgery: diced cartilage, diced cartilage wrapped in fascia (with fascia then sewnclosed), and diced cartilage covered with fascia (with the recipient area coveredwith fascia after graft placement). The constructs are highly varied to fit thespecific defect. Pieces of diced cartilage without any fascia can be placed inpockets in the peripyriform area, radix, or alongside structural rib grafts.Results: Over a 2-year period, the author treated 546 rhinoplasty cases in which79 patients (14 percent) had a total of 91 diced cartilage grafts. There were 34primary and 45 secondary operations involving the radix (n � 11), half-lengthgrafts (n � 14), full-length dorsum (n � 43), peripyriform (n � 16), infralobule(n � 4), and lateral wall (n � 3). All charts were reviewed for the 256 rhino-plasties performed in 2006 of which 30 patients had 35 diced cartilage grafts.With a median follow-up of 19 months (range, 13 to 25 months), two patientshad had revisions unrelated to their diced cartilage grafts. The three most commontechnical problems were overcorrection, visibility, and junctional step-offs.Conclusions: Diced cartilage grafts are a valuable addition to rhinoplasty surgery.They are highly flexible and useful throughout the nose. Their use simplifies oneof the greatest challenges in all of rhinoplasty—dorsal augmentation. Complica-tions have been relatively minor and their correction relatively simple. (Plast.Reconstr. Surg. 122: 1883, 2008.)

Diced cartilage grafts in rhinoplasty surgeryenjoyed widespread popularity 70 yearsago1,2 but were largely replaced by silicone

after World War II. In 1968, the author saw dicedcartilage grafts used at Burian’s clinic in Pragueand continued to use them on an occasional basisfor 25 years. In certain cases, the diced cartilagewould be wrapped in fascia to contain the piecesand facilitate insertion.3 Based on Sheen’s4 bal-anced approach to rhinoplasty with its emphasison radix grafts, the author found that a significantpercentage of cartilage grafts in the radix becamevisible and thus fascia became the material ofchoice.5 In 2000, Erol6 presented his experiencewith diced cartilage wrapped in Surgicel (Ethicon,Inc., Somerville, N.J.). The author reviewed Erol’s

procedure in detail and elected to use it as a sub-stitute for routine fascia grafts for the radix andspecialized half-length radix/dorsal grafts. Twenty-two cases were performed over 4 months with me-ticulous adherence to Erol’s technique.7 Ultimately,all grafts consisting of diced cartilage wrapped inSurgicel absorbed, probably because of the for-eign body reaction generated by Surgicel. As fivecases required surgical revision, it was elected touse grafts consisting of diced cartilage wrapped infascia, which proved successful. Based on this ex-perience, the author began to perform a largenumber of diced cartilage grafts with fascia in theradix and half-length and full-length dorsal con-structs. The present article is a review of the au-thor’s current techniques and applications ofdiced cartilage grafts in rhinoplasty surgery.

From private practice.Received for publication February 22, 2008; accepted May20, 2008.Presented, in part, at the Annual Meeting of the RhinoplastySociety, in New York, New York, April 19, 2007.Copyright ©2008 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31818d2104

Disclosure: The author has no commercial associ-ations or financial interests that might pose or createa conflict of interest with information presented inthis article.

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SURGICAL TECHNIQUESThe author has evolved three different meth-

ods of using diced cartilage during rhinoplastysurgery: diced cartilage, diced cartilage wrappedin fascia, and diced cartilage covered with fascia(Fig. 1).

Diced CartilageAll types of cartilage (excised material, sep-

tum, concha, or rib) are diced into 0.5- to 1.0-mmpieces using no. 11 blades. To facilitate insertion,the grafts are packed into 1.0-cc tuberculin sy-ringe. The most common recipient site for plaindiced cartilage grafts is the peripyriform area incocaine, cleft, and asymmetric noses. In thick-skinpatients, diced cartilage grafts can be placed in theradix area. When a structural rib graft is per-formed, diced cartilage is packed loosely next tothe rib and molded to avoid any lateral step-off.

Diced Cartilage Wrapped in FasciaThe simplest type of graft consisting of diced

cartilage wrapped in fascia is a radix/half dorsallength graft. The diced cartilage is placed withina sheet of fascia and then closed with 4-0 plaincatgut, similar to creating a “bean bag.” The tech-nique is more complex when a full-length dorsalgraft is required. The first step is to determine therecipient-site requirements. The actual length (25to 35 mm) and width (6 to 9 mm) are measured.The thickness will often vary from tapered (2 to 6mm with the thick end placed cephalically or cau-dally) to uniform (2 to 8 mm). In these cases, alarge sheet (4 � 4 cm) of deep temporal fascia isharvested through a 3-cm incision above the ear.The cartilage is compressed in the syringe and thehub cut off with a no. 10 blade. The fascia ispinned to a silicone block. The hubless syringe isplaced on the fascia, which is wrapped around thesyringe. A 4-0 catgut suture is used to close thefascia over the distal end of the syringe. A secondsuture is inserted next to the first and then arunning locking suture closes the fascia over thesyringe. In contrast to the previous “injectionmethod,” a construct graft is formed to the specificdimensions required by careful shaping on theback table. Any extra cartilage is “milked out” untilthe desired shape is achieved. The graft is slippedinto the recipient site using the percutaneous su-tures. Once in place, the caudal end of the fascialsleeve is closed off by suturing it to the underlyingcartilaginous vault. Additional sutures can beadded laterally to fix the construct to the cartilag-inous vault. These dorsal grafts are inserted as a

final step immediately before the closure. Obvi-ously, all dorsal modifications, osteotomies, andspreader grafts are performed first.

Diced Cartilage Covered with FasciaThis technique is used most frequently to aug-

ment the radix area. A piece of fascia (2 � 2 cm)is folded into a ball and fixed loosely with a 4-0plain catgut suture. The suture is placed under theradix skin exiting at the nasion and the fasciaguided into the recipient pocket. Then, a smallamount (0.1 to 0.3 cc) of diced cartilage is injectedbeneath the fascia resting against the bare bone ofthe radix area. The advantage of this approach isthat the diced cartilage fixes to the bone and thefascia eliminates palpability. Also, this techniquehas been used in selected secondary rhinoplastieswhere patients want a subtle “natural” correctionof their “surgical appearance.” A double-thicknessfascial graft is slipped into the dorsum and then asmall tapered amount of diced cartilage is placedfrom the rhinion to the supratip area as the laststep before skin closure.

CLINICAL SERIESAs previously stated, the author has used grafts

consisting of diced cartilage and diced cartilagewrapped in fascia for the past 30 years. However,it became a routine consideration in all rhino-plasty cases beginning in 2002. To determine thecurrent indications and revision rate using the tech-niques described in the preceding section, 546consecutive procedures performed over a 2-yearperiod (2006 to 2007) were reviewed (Table 1).Diced cartilage grafts were used in 79 patients witha total of 91 grafts used in six configurations: radix(n � 11), half-length (n � 14, with seven in radix-dorsum and seven in the dorsum-supratip), full-length dorsum (n � 43), peripyriform (n � 16),infralobule (n � 4), and lateral wall (n � 3).Thirty-four procedures were primary operationsand 45 were secondary operations or nasal recon-structions. The types of graft were as follows: dicedcartilage (n � 27), diced cartilage covered withfascia (n � 21), and diced cartilage wrapped infascia (n � 43). Radix grafts were performed intwo configurations: diced cartilage covered withfascia in most cases, but diced cartilage only wasused in two male patients with very short hair toavoid any risk of a visible temporal scar. All radixgrafts were performed in primary rhinoplasties. Incontrast, full-length dorsal grafts were used in alltypes of rhinoplasty cases. Diced cartilage wrappedin fascia was particularly effective for dorsal aug-

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Fig. 1. Operative technique. (Above, left) Diced cartilage before injection into the peripyriform area. (Above, right) Dicedcartilage covered with fascia before placement in the radix area. (Center, above) Preparation of a tapered full-length graftconsisting of diced cartilage wrapped in fascia. (Center, below) Preparation of a full-volume, full-length graft consistingof diced cartilage wrapped in fascia. (Below) Insertion of the above graft consisting of diced cartilage wrapped in fasciaconstruct for dorsal augmentation in an Asian rhinoplasty.

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mentation in ethnic primary rhinoplasties, bothAsian and African American individuals. Second-ary cases were quite varied, but thin skin chal-lenges were common. In 10 cases, a septal saddlenose deformity was present, with six attributable tococaine and four to prior functional septoplasty.Because the goal of this article is to discuss currenttechniques, a single year was selected to determineapplications and revisions. For the calendar year2006, 30 patients of 256 consecutive rhinoplastycases were reviewed in-depth. Thirty-five diced car-tilage grafts were used, and there was a medianfollow-up of 19 months (range, 13 to 25 months).Two cases had been revised, with neither requir-ing modification of their diced cartilage grafts.One had a fascial graft to a persistent lateral cruraconcavity. The other patient had a severe post-traumatic paranasal deformity requiring columel-lar correction and hydroxyapatite to the maxilla.Interestingly, two patients in 2006 had a revisionof their graft consisting of diced cartilage wrappedin fascia performed during 2005. In both cases,visible contour deformities were the indication.One of the cases is shown in case 2.

CASE REPORTS

Case 1: Dorsal Full-Length for SecondarySaddle Nose

A 52-year-old woman presented 30 years after a primaryrhinoplasty (Figs. 2 and 3). In addition to a visible nasal de-formity, both vestibules were highly constricted, restricting hernasal respiration. The operation consisted of the following: (1)harvest of cartilaginous portions of the eighth and ninth ribs,(2) septoplasty including a septal brace for the unstable caudalseptum, (3) insertion of bilateral composite conchal grafts tothe vestibules, (4) a unilateral left low-to-low osteotomy, (5)insertion of bilateral spreader grafts, (6) tip reconstruction ofprior total alar resection using a crural strut and tip graft,8,9 and(7) dorsal reconstruction with a graft consisting of 0.8 cc ofdiced cartilage wrapped in fascia. At 3 years, the dorsum has

maintained a very normal appearance with a 6-mm-high aug-mentation.

Case 2: Dorsal Full-Length for SecondaryRhinoplasty

A 55-year-old woman presented for a secondary rhinoplasty(Figs. 4 and 5). Because of the severity of her deformity and aprior septoplasty, a rib graft reconstruction was recommended.However, she wanted a smaller procedure performed concur-rently with a subperiosteal face lift being performed by a col-league. It was emphasized to her that the nose could be made“better” but that she really needed a rib reconstruction. Even-tually, a small operation using conchal cartilage was decided onand consisted of the following: (1) a crural strut from remainingseptum, (2) a tip graft of conchal cartilage, (3) a 0.7-cc dicedcartilage wrapped in fascia full-length dorsal graft, and (4) acombined nostril sill/alar wedge resection (Fig. 6).

At 1 year, the patient and surgeon agreed that a rib graftwould indeed have been better. The second-stage operationconsisted of the following steps: (1) the cartilaginous portionsof the eighth and ninth ribs were harvested; (2) the nose wasopened and the intact graft consisting of diced cartilagewrapped in fascia was removed; (3) spreader grafts and a septalstrut of rib were inserted; (4) a crural strut and double-layershield shape tip graft were added; (5) the graft, consisting ofdiced cartilage wrapped in fascia, was trimmed on its under-surface and along the left side before being reinserted; (6)small, 3.5-mm nostril sill excisions were made; and (7) a semi-rigid graft consisting of excised diced cartilage wrapped infascia was inserted as an additional tip graft. At 1 year after therevision, the nose appears markedly improved and the patientconsiders her nose to be “straight but playful.”

DISCUSSIONAdoption of any new grafting technique will

require answers to three questions: What are itsadvantages that would cause one to replace mycurrent techniques? What are its problems andhow do you solve them? Is it safe and does it worklong term?

Advantages and DisadvantagesThere are at least 10 advantages of diced car-

tilage grafts when compared with the range ofgraft material used in rhinoplasty surgery. First, itis autogenous material and thus rejection is not anissue. In contrast to cadaver fascia, cartilage, orAlloDerm (LifeCell Corp., Branchburg, N.J.),these grafts are viable and remain so from the timeof insertion onward as confirmed histologically.10

Second, the graft is easily prepared. One only hasto compare the surgeon having to meticulouslyshape a costal chondral graft as opposed to beinghanded a syringe filled with diced cartilage by thenurse. Third, all types of cartilage can be used,including excised material from the alar carti-lages, dorsum, or septum. One does not have toharvest the perfect 35 � 8-mm piece of septalcartilage for a solid dorsal graft. The latter is often

Table 1. Diced Cartilage Grafts

No.

Series (2006–2007)Rhinoplasties 546Patients with grafts 79 (14%)No. of grafts 91

Type of graftDiced cartilage 27Diced cartilage covered with fascia 21Diced cartilage wrapped in fascia 43

Recipient siteRadix 11Dorsum/half length 14Dorsum/full length 43Peripyriform 16Tip/infralobule 4Lateral wall 3

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impossible in secondary cases. Fourth, the graftcan be made into a wide range of shapes to fitvarious recipient sites. Dorsal grafts can be virtu-ally any length or thickness. Fifth, the grafts aremalleable, which allows for fine adjustments bothintraoperatively and up to 10 days postoperatively.Sixth, the entire grafting process is relatively sim-ple and easy to learn and can be performedquickly (�15 minutes), which differs markedlyfrom most other dorsal grafts. Seventh, there is nopossibility of warping and no need for foreignbodies (Kirschner wires). Eighth, the graft ishighly resistant to infection, as opposed to allo-grafts of silicone or Medpor (Porex Surgical,

Newnan, Ga.). Ninth, revisions are very minor andeasily corrected by shape shaving with a knifeblade. Minor irregularities can be reduced usinga percutaneous no. 16 needle in the examinationroom. Tenth, there has been no evidence of ab-sorption in over 200 cases performed since 200211

with a mean follow-up of 3 years.The only inherent disadvantage of this tech-

nique is that diced cartilage grafts are not struc-tural grafts. The history of dorsal grafts in rhino-plasty using various types of rib grafts was reviewedin a prior publication by the author dealing withdiced cartilage grafts.7 When used for dorsal aug-mentation, grafts consisting of diced cartilage

Fig. 2. Case 1. This secondary rhinoplasty patient’s saddle nose was augmented with a 6-mm-thick, full-length graft consisting of diced cartilage wrapped in fascia. (Left) Preoperative views.(Right) Appearance 3 years postoperatively.

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wrapped in fascia are highly effective in augmen-tations 1 to 8 mm thick, virtually any length, andwith a highly variable shape. Grafts consisting ofdiced cartilage wrapped in fascia become semi-rigid, with fibrous tissue filling the interstices inbetween the diced cartilage pieces. When struc-tural support is required, the author often relieson a “composite reconstruction” approach.12 Es-sentially, the two components consist of a deepfoundation layer of spreader grafts and septalstrut overlaid with an aesthetic layer of columel-lar strut and diced cartilage wrapped in fasciafor dorsal augmentation. In severe cases of nasalcollapse as seen in the cocaine nose, I continue touse osseocartilaginous rib grafts braced to a col-umellar strut.13

Problem and SolutionsFrom a technical perspective, the three most

common problems have been overcorrection, vis-ibility, and junctional step-offs. Equally, each re-cipient site has specific needs. As a fundamentalprinciple, there is no absorption of the graft andtherefore overcorrection should not be per-formed. If overcorrection does occur, it can beeasily reduced by shaving the graft on its under-surface or reducing any lateral bulges using a knifeblade. A visible “pebbling” of the surface couldtheoretically occur but can be avoided by addingan additional covering layer of fascia, which wasperformed in one patient with steroid damageskin. Early on, junctional step-offs were seen withfull-length dorsal grafts in the radix and supratip

Fig. 3. Case 1. Additional preoperative (left) and 3-year postoperative (right) views.

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areas. The radix junction can be corrected witheither a separate radix graft of fascia or using the“fascial toque” recommended by Kelly et al.14 Thesupratip step-off occurred from milking out toomuch diced cartilage from the graft to achieve animmediate intraoperative supratip break. Postop-eratively, as the skin sleeve tightened, the step-offbecame more apparent. This supratip step-off canbe easily avoided by leaving the graft longer. Cor-

rection can be performed postoperatively with ei-ther a fascial graft or diced cartilage, dependingon the severity. If minor, the depression can beconcealed with an injectable filler. Visible edges orprominences are easily shaved off. Ultimately, theprimary challenge is avoiding edges and irregu-larities, which is accomplished by building asmooth “construct” on the back table before in-sertion and then molding in situ as necessary.

Fig. 4. Case 2. For this secondary rhinoplasty patient, a rib graft reconstruction was recommended (left, preoperative views). Thepatient opted to have a smaller “cosmetic fill” of the dorsum performed with a graft consisting of diced concha wrapped in fascia.After the first operation, the problems of a graft consisting of diced cartilage wrapped in fascia are visible, including a slightprominence on the left side and small supratip depression (center). One year later, a formal rib reconstruction was performed. Thegraft, consisting of diced cartilage wrapped in fascia, was removed, shaped, and reinserted. The patient is shown at 2 years after theoriginal operation (right). The histology of the patient’s diced cartilage wrapped in fascia graft is shown in Figure 6.

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Fig. 5. Case 2. Additional views of the patient shown in Figure 4.

Fig. 6. Case 2. The graft, consisting of diced cartilage wrapped in fascia, was removed at 1 year after insertion. (Above, left) Thediced cartilage wrapped in fascia graft is a semirigid solid and can be bent. (Above, right) The lateral prominence was shavedoff with a no. 15 blade before reinsertion. One can easily see the diced cartilage pieces with interspersed fibrous tissue. (Below,left) Hematoxylin and eosin staining demonstrates well-preserved architecture and normal progression of chondrocytes. (Be-low, right) Trichrome stain showed normal chondrocyte staining (blue: cartilage matrix; red: nuclei).

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Viability and Intermediate-Term ResultsThe author and his colleagues have performed

extensive histologic testing of human grafts con-sisting of diced cartilage wrapped in fascia anddiced cartilage grafts obtained at the time of re-vision surgery.10 Similar tests were performed onexcised portions of the graft consisting of dicedcartilage wrapped in fascia temporarily removedfrom the patient in case 4. Hematoxylin and eosinstaining demonstrated matrix that was intenselybasophilic, with a high density of cells. Thetrichrome stain demonstrated basophilic nucleiwithin lacunae and normal blue staining matrix.Glial fibrillary acid protein staining was positive,indicating normal regenerative potential. Onecould conclude that the cartilage in diced carti-lage and diced cartilage wrapped in fascia grafts isactively growing. On several occasions when graftsconsisting of diced cartilage wrapped in fasciawere modified in situ, the fascia was always foundto be intact, easily separated from the nasal softtissue envelope, but adherent to the underlyingdiced cartilage. Also, the cartilage grafts, whetherdiced cartilage or diced cartilage wrapped in fas-cia, appear as a semisolid mosaic with small dicedpieces easily visible. Importantly, the fascia is to-tally viable and highly vascularized, perhaps serv-ing as a neoperichondrium.10 Because the viabilityof the construct is critical, the use of AlloDerm orxenografts as a wrapper is not recommended.

Any discussion of intermediate-term resultsmust be taken within the context of a limitedfollow-up with regard to both duration (7 years)and percentage of follow-up. Perhaps the mostcritical subgroup to evaluate is full-length dorsalgrafts in primary Asian rhinoplasty cases. Begin-ning with the first Asian rhinoplasty performedusing grafts consisting of diced cartilage wrappedin fascia in 2003, 25 consecutive cases were stud-ied. To date, there has been only one revisionoperation, and that was an alar wedge scar cor-rection. However, the author’s critical aestheticassessment indicates that two patients had a su-pratip junctional step-off and one patient has ex-cessive prominence at the rhinion. To avoid theseproblems, I now prefer the back table constructmethod for grafts consisting of diced cartilagewrapped in fascia rather than the injectionmethod.15 Again, none of the dorsal grafts re-quired revision, nor was there any evidence ofabsorption. All dorsal grafts remain palpable.Based on recent experimental studies, it is con-firmed that diced cartilage does survive, provided

that it is minimally traumatized and placed in awell-vascularized recipient site.16–20

Rollin K. Daniel, M.D.1441 Avocado Avenue, Suite 308

Newport Beach, Calif. 92660rkdaniel@aol.com

ACKNOWLEDGMENTSThe author thanks Dr. Jay W. Calvert and Dr.

Costa-Iyer for the histological analysis.

REFERENCES1. Burian, F. The Plastic Surgery Atlas. New York: Macmillan,

1968.2. Denecke, H. J., and Meyer, R. Plastic Surgery of the Head and

Neck. New York: Springer-Verlag, 1967. P. 148.3. Daniel, R. K. Rhinoplasty: An Atlas of Surgical Techniques. New

York: Springer, 2002.4. Sheen, J. H., and Sheen, A. P. Aesthetic Rhinoplasty. St. Louis,

Mo.: Quality Medical, 1998.5. Daniel, R. K. Aesthetic Plastic Surgery: Rhinoplasty. Boston: Lit-

tle, Brown, 1993.6. Erol, O. O. The Turkish delight: A pliable graft for rhino-

plasty. Plast. Reconstr. Surg. 105: 2229, 2000.7. Daniel, R. K., and Calvert, J. W. Diced cartilage grafts in

rhinoplasty surgery. Plast. Reconstr. Surg. 113: 2156, 2003.8. Daniel, R. K. Rhinoplasty: A simplified, three-stitch, open tip

suture technique. Part I: Primary rhinoplasty. Plast. Reconstr.Surg. 103: 1491, 1999.

9. Daniel, R. K. Rhinoplasty: A simplified, three-stitch, open tipsuture technique. Part II: secondary rhinoplasty. Plast. Re-constr. Surg. 103: 1503, 1999.

10. Calvert, J. W., Brenner, K. B., DaCosta-Iyer, M., Evans,G. R. D., and Daniel, R. K. Histological analysis of humandiced cartilage grafts. Plast. Reconstr. Surg. 118: 230, 2006.

11. Daniel, R. K. The role of diced cartilage grafts in rhinoplasty.Aesthetic Surg. J. 26: 209, 2006.

12. Daniel, R. K. Rhinoplasty: Septal saddle nose deformity andcomposite reconstruction. Plast. Reconstr. Surg. 119: 1029,2007.

13. Daniel, R. K. Rhinoplasty and rib grafts: Evolving a flexibleoperative technique. Plast. Reconstr. Surg. 94: 597, 1994.

14. Kelly, M. H., Bulstrode, N. W., and Waterhouse, N. Versatilityof diced cartilage-fascia grafts in dorsal nasal augmentation.Plast. Reconstr. Surg. 120: 1654, 2007.

15. Daniel, R. K. Asian Rhinoplasty (Video). Alexandria, Va.: Amer-ican Academy of Facial Plastic and Reconstructive Surgery,2003.

16. Arslan, E., Majka, C., and Polat, A. The fate of diced cartilagegrafts of traumatized versus nontraumatized origin. AestheticPlast. Surg. 31: 365, 2007.

17. Brenner, K. A., McConnell, M. P., Evans, G., et al. Survival ofdiced cartilage grafts: An experimental study. Plast. Reconstr.Surg. 117: 105, 2006.

18. Buyuklu, F., and Cakmak, O. Histological analysis of humandiced cartilage grafts. Plast. Reconstr. Surg. 120: 348, 2007.

19. Camak, O., Bircan, S., Buyuklu, F., et al. Viability of crushedand diced cartilage grafts: A study in rabbits. Arch. Facial Plast.Surg. 7: 21, 2005.

20. Yilmaz, S. Diced cartilage grafts in rhinoplasty. Plast. Reconstr.Surg. 116: 678, 2005.

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