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ORIGINAL ARTICLE

Anatomy of the posterior septal artery with surgical implications on the vascularized
pedicled nasoseptal flap
Xian Zhang, MD,1,3 Eric W. Wang, MD,2 Hongquan Wei, MD,1 Jin Shi, MD,3 Carl H. Snyderman, MD, MBA,2 Paul A. Gardner, MD,1
Juan C. FernandezMiranda, MD1*
1

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 2Department of Otolaryngology, University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania, 3Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, Peoples Republic of China.

Accepted 16 May 2014


Published online 21 July 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23775

ABSTRACT: Background. The purpose of this study was to define the


anatomic characteristics of the posterior septal artery related to the
design of the vascularized pedicled nasoseptal flap.
Methods. The course and branching pattern of the posterior septal artery
and its relationship with landmarks and other regional arteries were
studied in 26 vascular latex-injected head sides.
Results. The posterior septal artery is divided into 2 septal branches
within the sphenoidal segment, which occurred either close to the sphenopalatine foramen (65.4%) or at the posterior border of the nasal septum (34.6%). The inferior branch was frequently dominant (61.5%). The

INTRODUCTION
The vascularized pedicled nasoseptal flap (PNSF) is the
workhorse for reconstruction during endoscopic endonasal
surgery of the skull base. Since its introduction in 2006
by Hadad et al,1 the use of the PNSF has reduced the
overall rate of postoperative cerebrospinal fluid leak after
endoscopic endonasal surgery to a level comparable to
conventional skull base surgery.2 Understanding the
course of the posterior septal artery allows for optimal
design of incisions for the PNSF while minimizing inadvertent injury. The nasal septum receives its blood supply
from 3 main groups of arteries. In general, the superior
septum (olfactory region) is supplied by the anterior and
posterior ethmoid arteries from the internal carotid system, whereas the respiratory portion, a larger part of the
nasal septum, is supplied by the branches of the sphenopalatine artery, namely, the posterior septal artery. Anteriorly, branches of the facial artery contribute to the
anterior nasal septum at Kiesselbachs plexus. To date,
however, little has been written on the course, branching
pattern, and anatomic variations of the posterior septal
artery, especially from a reconstructive point of view.
This is important for primary endoscopic endonasal surgery, as well as patients with prior surgery involving the

*Corresponding author: J. C. FernandezMiranda, Department of Neurological


Surgery, University of Pittsburgh School of Medicine, 200 Lothrop Street, PUH
B-400, Pittsburgh, PA 15213. E-mail: fernandezmirandajc@upmc.edu

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dominant branch was always below the axial plane of the sphenoid
ostium. On the posterior nasal septum, the inferior branch may run
downward before coursing anteroinferiorly.
Conclusion. We identify 2 high-risk areas for the design of the vascularized PNSF, namely, at the inferior aspect of the sphenoid ostium and the
C 2014
junction of the posterior nasal septum and the choana arch. V
Wiley Periodicals, Inc. Head Neck 37: 14701476, 2015

KEY WORDS: anatomy, endoscopic endonasal approach, nasoseptal


flap, reconstruction, skull base

nasal septum or sphenoid sinus. Here, we present an anatomic study of the posterior septal artery with emphasis
on the anatomic characteristics related to the surgical
design of the vascularized PNSF.

MATERIALS AND METHODS


This anatomic study was completed at the Surgical
Neuroanatomy Laboratory of the Department of Neurosurgery and the Center for Cranial Base Surgery at the
University of Pittsburgh School of Medicine, and the
Neuroanatomical Laboratory of Nanfang Hospital at
Southern Medical University in Guangzhou, Guangdong,
Peoples Republic of China. A total of 14 preserved and
latex-injected adult human heads were microsurgically
dissected. Two sides of 2 specimens had been dissected
for other purposes previously, and could not be used for
this study.
A total of 26 sides (14 right and 12 left) were dissected
under an operating microscope (original magnification 3
610). The pterygopalatine fossa was dissected to expose
the internal maxillary artery, the origin of the posterior
septal artery. The course, branching pattern, and variations of the posterior septal artery were investigated by
removing the mucosa of the sphenoid surface and nasal
septum while preserving the submucosal tissues and the
vessels. After photodocumentation, the specimen was cut
in a sagittal plane at the level of the sphenopalatine foramen for measurement purposes. Vernier calipers were
used to take the following measurements: the diameter of

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FIGURE 1. Origin, sphenoidal bifurcation and branches of the posterior septal artery. Note that the posterior septal artery originates as a bifurcation
(A and B) or trifurcation (C and D) of the sphenopalatine artery. The posterior septal artery bifurcates in the sphenoidal segment either lateral (A
and C) or medial (B and D) to the sphenoid ostium. Nonseptal branches of the posterior septal artery can arise from the main stem (near the asterisk in AD) or septal branch (A and C) of the posterior septal artery. Usually, the inferior posterior septal artery is the dominant branch of the sphenoid bifurcation (A). However, the superior branch can be equal to (B and C) or larger than (D) the inferior one. Black asterisk: posterior septal
artery; black arrow: common stem giving rise to the pharyngeal, vidian, and the foramen rotundum arteries; C: choana; ION: infraorbital nerve; MA:
maxillary artery; MT: middle turbinate; PLNA: posterior lateral nasal artery; ST: superior turbinate; white arrow: pharyngeal artery; white arrowhead: sphenoid ostium.

the posterior septal artery and its main septal branches,


the distance between the inferior aspect of the sphenoid
ostium (or the arch of the choana) and the main stem (or
septal branch) of the posterior septal artery, and the shortest distance between the posterior edge of the nasal septum and the inferior septal branch of the posterior septal
artery.
During the microscopic dissection, photographic documentation of the posterior septal artery was also carried
out endonasally using rod lens endoscopes (Karl Storz,
4 mm, 18 cm, Hopkins II; Karl Storz EndoscopyAmerica, Culver City, CA). Vascular casts of 2 heads made
previously for teaching purposes were used for photodocumentation and for illustration of the study findings.

RESULTS
Origin of the posterior septal artery
In this study, the sphenopalatine artery is defined as the
terminal segment of the maxillary artery where the maxillary artery bifurcates into the sphenopalatine artery and
descending palatine arteries. The sphenopalatine artery
then divides into the posterior lateral nasal artery and posterior septal artery. The posterior septal artery originated

from the sphenopalatine artery within the pterygopalatine


fossa in all cases (26 sides; 100%). In 24 sides (92.3%),
the sphenopalatine artery bifurcated into the posterior lateral nasal artery and posterior septal artery (Figures 1A
and 1B), whereas in 2 sides (7.7%), there was a trifurcation (Figure 1C and 1D). In the latter 2 sides, the third
branch of the trifurcation was either the palatosphenoidal
artery (Figure 1C) or a common stem giving rise to the
palatosphenoidal, vidian, and foramen rotundum arteries
(Figure 1D).

Course and segmentation


The course of the posterior septal artery can be divided
into 3 segments: pterygopalatine, sphenoidal, and septal
(Figure 2). The pterygopalatine segment is embedded in
the substance of the fat filling the pterygopalatine fossa.
The sphenoidal segment starts when the posterior septal
artery passes through the sphenopalatine foramen and
then runs on the anterior wall of the sphenoid sinus
between the sphenoid ostium and choana to reach the
posterior border of the nasal septum. The posterior septal
artery bifurcated into a superior and an inferior branch
within the sphenoidal segment (sphenoidal bifurcation) in
all specimens in this study. The last segment, the septal
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FIGURE 2. Schematic drawing of the course and segmentation of


the posterior septal artery. I, pterygopalatine segment; II, sphenoidal segment; III, septal segment; black arrow: the origin of the
posterior septal artery; black arrowhead, the sphenoidal bifurcation of the posterior septal artery; dotted ovals, the 2 areas where
the sphenoidal bifurcation of the posterior septal artery most frequently occurs; 1, palatosphenoidal artery; 2, superior turbinate
artery or vidian artery; 3, superior turbinate artery; 4, mucosal
branch; 5, branch anastomosing with the posterior ethmoid
artery; 6, branch anastomosing with the anterior ethmoid artery;
7, branch anastomosing with the dorsal nasal artery; 8, branch
anastomosing with the superior labial artery; 9, branch anastomosing with the greater palatine artery; 10, branches anastomosing with the posterior lateral nasal artery at the nasal floor; C,
choana; DPA, descending palatine artery; MA, maxillary artery;
PLNA, posterior lateral nasal artery; SPA, sphenopalatine artery;
SO, sphenoid ostium; ST, superior turbinate. [Color figure can be
viewed in the online issue, which is available at wileyonlinelibrary.com.]

segment, is composed of the terminal septal branches of


the posterior septal artery, which form a dense arterial
network that supplies the inferior two thirds of the nasal
septum and a large part of the nasal floor.

Patterns of sphenoidal bifurcation


According to its relationship with the sphenoid ostium,
we classified the sphenoidal bifurcation into a lateral type
(17 sides; 65.4%; Figures 1A and 1C and Figure 3A) and
medial type (9 sides; 34.6%; Figures 1B and 1D and Figure 3B). Interestingly, the site of sphenoidal bifurcation
was not equally distributed along the course of the sphenoidal segment of the posterior septal artery. It occurred
in close proximity to either the sphenopalatine foramen or
the junction between the sphenoidal and septal segments
of the posterior septal artery (Figures 1A and 1B and Fig-

ure 3). The inferior branch was typically the largest


branch of the bifurcation (16 sides; 61.5%; 8 in each
side; Figure 1A and Figure 3A), whereas the superior one
dominated in 6 sides (23.1%; 4 in the right side and 2 in
the left; Figure 1D and Figure 3B). In 4 sides (15.4%; 2
in each side; Figures 1B and 1C), the diameter of the
superior branch was equal to that of the inferior one. The
diameters of the main stem and the branches of the posterior septal artery, and the distances between the posterior
septal artery or its branches and the surrounding landmarks are shown in Table 1. No side difference was
found in these measurements.

Prebifurcation branches
We define the portion before the sphenoidal bifurcation
as the main stem of the posterior septal artery. There
were 4 possible branches leaving the main stem of the
posterior septal artery, including the palatosphenoidal
artery (18 sides; 69.2%; Figure 1A), the vidian artery (1
side; 3.8%), the superior turbinate artery (10 sides;
38.5%; Figures 1A1D), and the mucosal branch supplying the choana and anterior wall of the sphenoid sinus
(17 sides; 65.4%; Figures 1B and 1D). The former two
originate from the pterygopalatine segment of the posterior septal artery. The superior turbinate artery, when arising from the main stem of the posterior septal artery,
frequently leaves the posterior septal artery at the level of
the sphenopalatine foramen. It is important not to misidentify the origin of the palatosphenoidal artery with the
sphenoidal bifurcation of the posterior septal artery, particularly in cases where the palatosphenoidal artery is
equal to or larger than the dominant septal branch of the
sphenoidal bifurcation, as we observed in 2 of our
specimens.
The origin of palatosphenoidal artery in this study
included the posterior septal artery (18 sides; 69.2%), the
posterior lateral nasal artery (3 sides; 11.5%), and the terminal sphenopalatine artery (2 sides; 7.7%). In 3 sides
(11.5%), the palatosphenoidal artery was not found.

Postbifurcation branches
In this study, nonseptal branches from the postbifurcation posterior septal artery were present only in those
with lateral type bifurcation. Under these circumstances,
the superior branch of the posterior septal artery consistently gave rise to the superior turbinate artery. Small

TABLE 1. Measurements of the diameters of and distances between some landmarks and the posterior septal artery and its branches.
Measurement

Main stem of the posterior septal artery*


Superior branch of the posterior septal artery*
Inferior branch of the posterior septal artery*
Dominant septal branch of the posterior septal artery*
Nondominant septal branch of the posterior septal artery*
Sphenoid ostium main stem or superior branch of the posterior septal artery
Arch of choana main stem or inferior branch of the posterior septal artery
Posterior nasal septum inferior branch of the posterior septal artery
* Diameter.

Distance.

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Mean 6 SD, mm

Range, mm

1.56 6 0.32
1.04 6 0.34
1.11 6 0.25
1.25 6 0.24
0.89 6 0.23
4.96 6 2.32
6.72 6 2.64
11.28 6 3.28

1.122.46
0.501.88
0.561.52
0.841.88
0.501.52
0.9612.38
2.3412.64
5.8218.66

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FIGURE 3. Endoscopic view of the sphenoidal bifurcation of the posterior septal artery (right side). The sphenoidal bifurcation can be classified into
a lateral type (A) and a medial type (B). Black arrow, the sphenopalatine artery bifurcation; black arrowhead, the sphenoidal bifurcation of the posterior septal artery; C, choana; MT, middle turbinate; S, septum; SO, sphenoid ostium; ST, superior turbinate. [Color figure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]

mucosal branches to the surrounding area could be seen


arising from both the superior and inferior septal branches
(Figures 1A and 1C).
At the posterior attachment of the superior turbinate,
one or more superior turbinate arteries were constantly
present (Figures 1A1D). This artery arose from the superior branch of the sphenoidal bifurcation of the posterior
septal artery in 17 sides (65.4%), the main stem of the
posterior septal artery in 10 sides (38.5%), and the middle
turbinate artery of the posterior lateral nasal artery in 2
sides (7.7%).

ied (11 sides; 42.3%), this inferior artery ran downward


first along the posterior border of the nasal septum and
then anteroinferiorly (Figures 1A and 1B and Figure 4C).
In all of these cases, the inferior posterior septal artery
was the dominant branch of the sphenoidal bifurcation.
Among these, it was not infrequent to find (5 of the 11
sides) that the inferior artery made an S-shaped turn
before coursing anteroinferiorly (Figures 1A and 1B). The
shortest distance between the inferior artery and the posterior edge of the nasal septum is shown in Table 1. This
distance was <1 cm but >5 mm in 10 sides.

Septal segment: Course of the posterior septal arteries

Anastomosis among septal arteries

The superior posterior septal artery more frequently


divided into 2 septal branches in the sphenoidal segment
(4 sides; 15.4%) than its inferior counterpart did (1 side;
3.8%; Figure 3A). Therefore, at the beginning of the septal segment, the posterior septal artery had 2 branches in
22 sides (84.6%), 3 in 3 sides (11.5%); and 4 in 1 side
(3.8%).
Once on the nasal septum, both the superior and inferior posterior septal arteries pursue less variable courses.
The superior one frequently proceeds anteriorly in an
axial plane that is roughly parallel to the middle turbinate
(Figure 4B). There were only 3 of the 26 superior arteries
that coursed anterosuperiorly above the level of the sphenoid ostium, and all of them belonged to the nondominant
branch of the posterior septal arteries (Figure 4A). The
inferior one, however, courses anteroinferiorly toward the
incisive canal (Figures 4B4D). Some branches arising
from the inferior artery extend beyond the nasal crest of
the maxilla and further laterally to supply the medial part
of the nasal floor (Figure 4D). Of note, we encountered
significant variability in the course of the inferior posterior septal artery near the posterior border of the nasal
septum. In nearly half of the posterior septal artery stud-

Numerous anastomoses exist between the branches of


the different groups of septal arteries (Figures 4A4D).
The posterior septal arteries anastomose with the posterior
ethmoid artery posterosuperiorly, the anterior ethmoid
artery and septal branch of the dorsal nasal artery anterosuperiorly, the greater palatine artery and septal branch of
the superior labial artery anteroinferiorly, and branches of
the posterior septal artery inferolaterally (Figure 4C).
Meanwhile, numerous anastomotic channels can also be
seen between branches of the posterior septal arteries
(Figures 4A4C).
The size of these anastomotic channels varies significantly. The most prominent anastomoses are those linking
the posterior septal artery and the anterior ethmoid artery,
or the different branches of the posterior septal artery (Figure 1B and Figures 4A4D). In some specimens, the anastomotic channels were so large that it formed an arterial
loop or the postanastomotic artery is even larger than its
proximal segment in caliber (Figure 1B and Figure 4C).
At the nasal floor, the arterial network is characterized
by a sagittal-plane channel located at the center of the
nasal floor connecting multiple coronal-plane channels
between the medial and lateral nasal walls (Figure 3D).
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FIGURE 4. Distribution and anastomotic features of the septal branches of the posterior septal artery. The posterior septal arteries can give off
branches before reaching the posterior edge of the nasal septum (A, viewed from the superoposterior). On the nasal septum, the superior artery
proceeds anteriorly at the level of middle turbinate, whereas the inferior one runs anteroinferiorly toward the incisive canal (B). Numerous intraarterial and inter-arterial anastomoses exist on the nasal septum with the most prominent channels present around and within the Kiesselbachs
area (AD). A sagittally oriented anastomotic artery (black arrowheads) located at the center of the nasal floor connects the nasal floor branches
arising from the septal artery medially and conchal artery laterally. Black arrow, greater palatine artery; green arrow, superior labial artery; purple
arrow, posterior ethmoid artery; red arrow, dorsal nasal artery; yellow arrow, anterior ethmoid artery.

DISCUSSION
In this study, we have found that the posterior septal
artery constantly bifurcates in its sphenoidal segment with
a higher prevalence at the lateral position close to the sphenopalatine foramen than at the posterior border of the nasal
septum. This is probably why some authors reported that
there were 2 posterior septal arteries.3 In addition, these 2
septal arteries in the lateral type of bifurcation can branch
again before reaching the posterior end of the nasal septum,
which explains the variable number of branches at the posterior border of the nasal septum in different reports.46

Implication on the traditional pedicled nasoseptal flap


During the routine harvesting of the PNSF, 2 parallel
and 1 vertical incision are made. In brief, injection with
local anesthetic with epinephrine in the submucoperichondrial plane is performed in a similar manner to a septoplasty. Subsequently, the incisions are made with a
needle tip monopolar cautery on a low setting. The superior incision extends from the sphenoid ostium medially
and anteriorly on the nasal septum approximately 1 cm
below the olfactory sulcus. The inferior incision begins at
the midpoint (12 oclock position) of the choana and
curves medially along the posterior edge of the nasal septum. This incision then turns anteriorly at the junction of
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the nasal floor and septum. The 2 incisions are connected


anteriorly and the flap is then elevated from the underlying cartilage and bone using a Cottle elevator.
Based on the current findings, it is worthy to note that
there are 2 high-risk areas where improperly placed incisions may injure the vascular pedicle (Figure 5A). In this
study, the superior septal branch of the posterior septal
artery on the anterior surface of the sphenoid sinus and
the posterior part of the nasal septum can be very close to
an imaginary line corresponding to the level of sphenoid
ostium. To minimize the risk of vascular injury, the posterior superior incision should not venture lower than the
level of the inferior aspect of the sphenoid ostium. The
other site is at the junction of the posterior edge of the
nasal septum and the arch of the choana. As shown in our
study, the proximity of the main stem (or the dominant
inferior branch) of the posterior septal artery to the arch
of the choana and the posterior edge of the nasal septum
in some individuals raises the concern that an inferior
incision that is placed too high on the anterior surface of
the sphenoid sinus or at the posterior border of nasal septum may compromise the main blood supply to the flap.
Before making the superior mucosal incision, the natural
ostium of the sphenoid sinus should be identified. The inferior portion of the superior turbinate is resected if it
obstructs visualization of the sphenoid ostium or, if

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FIGURE 5. The original (A),


modified (B and C), and our current (D) methods of preparing
the rescue pedicled nasoseptal
flap (PNSF). The black dashed
line represents the incision
made for preparing the PNSF.
The black shaded areas are
dangerous sites where an
improper incision may injure
the vascular pedicle. IT, inferior
turbinate; MT, middle turbinate;
S, septum; ST, superior turbinate. [Color figure can be
viewed in the online issue,
which is available at wileyonlinelibrary.com.]

necessary, for access. Because the main stem of the posterior septal artery or its branch frequently courses medially
under the lower end of the superior turbinate, as shown in
Figure 3, the resection should be carried out with caution.
Therefore, the cut of the attachment of the superior turbinate lower than the sphenoid ostium should not go too
deep; otherwise the vascular pedicle would be injured.
The palatosphenoidal artery is also called palatovaginal
artery or pharyngeal branch of the maxillary artery and is
traditionally regarded as a branch of the pterygopalatine
segment of the maxillary artery.7,8 However, we found that
this artery actually arises from the posterior septal artery in
the majority of cases. This is an important consideration
when the vascular pedicle needs to be fully mobilized to
maximize the reach of the flap or to allow for an ipsilateral
transpterygoid approach; in such cases, the palatosphenoidal artery must be sectioned to achieve this goal.

Implication on the rescue pedicled nasoseptal flap


A potential limitation of the vascularized PNSF is that
the vascular pedicle of this flap may be sacrificed during
a sphenoidotomy and/or posterior septectomy. Therefore,
the decision to prepare a nasoseptal flap rests on the esti-

mated risk of a significant intraoperative cerebrospinal


fluid leak. For those cases in which a leak is not expected
but at times encountered, a rescue flap technique was
introduced to preserve the option of a vascularized reconstruction.9 In this method, the superior incision is limited
to the anterior sphenoid and posterior septum and the vascular pedicle is displaced inferiorly (Figure 5A). During
surgery, however, injury to the pedicle may occur from
the passage of instruments and the use of powered instrumentation. Two modified techniques were introduced
recently to overcome this drawback. In the method
described by Otto et al,10 the posterior half of the inferior
incision used in the traditional PNSF is added (Figure
5B), enabling further downward displacement of the flap
pedicle. Kim et al,11 in contrast, advocated a curvilinear
superior incision from the sphenoid ostium that curves
downward to a level of one-half to one-third of the lower
height of the middle turbinate over the vomer (Figure
5C). These authors proposed that this technique could not
only provide similar levels of sellar floor exposure, but
also preserve more olfactory mucosa.
With respect to the probability of preserving the vascular pedicle, our anatomic data indicate that there is a difference between these 2 modified techniques. In our
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study, the superior posterior septal artery was the largest


branch of the sphenoidal bifurcation in more than one
fifth of dissections, and its main stem crossed anteriorly
parallel to the long axis of the middle turbinate. From an
anatomic point of view, an anteroinferior curvilinear incision has the risk of sectioning a dominant superior posterior septal artery. However, the clinical study by Kim
et al11 showed a high success rate of flap survival. This
discrepancy reflects the intrinsic weakness of a purely
anatomic study and warrants further clinical investigation.
The pedicled mucosal flap may have a strong potential to
survive, even with seemingly insufficient vascular supply.
Nevertheless, it is our policy to try to preserve the whole
vascular pedicle in every case. At present, we can often
preserve the pedicle to the PNSF without either of these
modifications. By simply making a relaxing incision
along the posterior nasal septum, a mucosal flap measuring approximately 1.5 cm 3 0.5 cm is removed at the
level of and medial to the sphenoid ostium (Figure 5D).
Thus, the pedicle can be mobilized inferiorly into the
nasopharynx without injury. Based upon the current anatomic data, resection of posterior septal mucosa can be
safely performed while allowing for preservation of both
divisions of the vascular pedicle. This adaptation is our
current technique. The benefits of this alteration include
increased visualization and access while minimizing soft
tissue retraction of the pedicle.

CONCLUSION
The current study has provided detailed information
concerning the anatomic characteristics related to the posterior septal artery, which is the main blood supply to the

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vascularized PNSF. This anatomic knowledge may be of


importance in the preservation and design of the vascularized PNSF for endoscopic endonasal surgery of the skull
base and other reconstructive needs.

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