ORIGINAL ARTICLE

Correction of the Soft Tissue Pollybeak

Using Triamcinolone Injection
Matthew M. Hanasono, MD; Russell W. H. Kridel, MD; Norman J. Pastorek, MD;
Mark J. Glasgold, MD; R. James Koch, MD

Objective: To describe the technique for correction of
the soft tissue pollybeak deformity using intralesional in-
jection of triamcinolone acetonide.
Methods: We discuss our philosophy, regimen, and tech-
nique for treatment of the soft tissue pollybeak using tri-
amcinolone injection. We include results from a series
of 173 patients who underwent rhinoplasty performed
by one of us (N.J.P.).
Results: Triamcinolone was injected at 1 week after
surgery in 127 patients (73%). A second injection was
performed in 92 (72%) of the 127 patients at 4 weeks
after surgery. One hundred eight (85%) of the 127
patients had an acceptable result, as judged by the sur-
geon, with good supratip definition. Nineteen (15%) of
the 127 patients had a less than optimal result, with
residual supratip fullness, as judged by the surgeon.
There were no complications caused by triamcinolone
injection.
Conclusions: Because revision surgery is difficult and
may be associated with complications, intralesional tri-
amcinolone injection is the first-line treatment for the
soft tissue pollybeak deformities caused by subdermal scar-
ring. Should intralesional steroid injection fail to satis-
factorily treat the deformity, revision rhinoplasty can sub-
sequently be performed.
Arch Facial Plast Surg. 2002;4:26-30

From the Division of
Otolaryngology–Head and
Neck Surgery, Stanford
University Medical Center,
Stanford, Calif (Drs Hanasono
and Koch); the Department of
Otolaryngology–Head and
Neck Surgery, Division of
Facial Plastic Surgery,
University of Texas Health
Science Center, Houston
(Dr Kridel); the Department
of Otolaryngology–Head and
Neck Surgery, Cornell
University Medical Center,
New York, NY (Dr Pastorek);
and The Glasgold Group,
Highland Park, NJ
(Dr Glasgold).
T
HE POLLYBEAK deformity is
one of the most common
complications of rhino-
plasty.1-3 It is a convexity of
the nasal supratip relative
to the rest of the nose. This deformity is
colloquially known as pollybeak because
the lower two thirds of the nose takes on
the convex profile of a parrot’s beak. The
pollybeak is not due to transient postop-
erative edema but represents a persis-
tent, unattractive fullness that distorts the
dorsal profile and obscures the tip.
While the pollybeak may be the re-
sult of technique, it may also be an un-
predictable complication for even the most
experienced surgeons. The causes of pol-
lybeak include inadequate resection of su-
pratip structures, most commonly the dor-
sal septal cartilage or the cephalic margins
of the lower lateral cartilages; loss of tip
support; or, paradoxically, excessive car-
tilage resection in the supratip region that
results in subcutaneous scar tissue forma-
tion, often in conjuction with thick nasal
tip skin.1-5 If excess cartilage is the cause,
the condition is called a cartilaginous
pollybeak, and simple trimming of this
cartilage will solve the problem. With loss
of tip support, a cartilage strut or tip graft
can be placed to correct or disguise the
deformity.
A more difficult problem is the pol-
lybeak deformity that occurs paradoxi-
cally as a result of overresection of the lower
dorsal cartilaginous septum and/or the ce-
phalic margins of the lower lateral carti-
lages in the area of the supratip. This de-
formity usually occurs in combination with
For commentary
see page 31
thick nasal skin, resulting in inadequate
skin contraction and excessive dead space
between the skin and the septal border,
which fills with scar tissue and results in
a supratip fullness. The patient who re-
quires revision rhinoplasty with major alar
and septal cartilage resections to correct a
cartilaginous pollybeak deformity is also
at risk for formation of dead space that may
fill with scar tissue and result in a soft tis-
sue pollybeak.1

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 TECHNIQUE
A 1-mL tuberculin syringe with a 30-gauge needle is used.
The triamcinolone should be shaken well, as it comes in
suspension rather than as a solution. The technique of ad-
ministering triamcinolone can be performed as 2 separate
lateral supratip injections or as a single midline supratip
injection in which the needle is redirected to the left and
right sides (Figure 1).
The depth of injection should be in the subcutaneous
tissue. If blanching is seen, the injection is in the dermis,
and the tip of the needle should be directed deeper. Injec-
tion of triamcinolone into the dermis can result in cuta-
neous atrophy. As is standard practice in intralesional in-
jection techniques, the surgeon should attempt aspiration
with the syringe first to ensure that the needle tip is not
within a blood vessel. This cannot be overemphasized, as
injection of triamcinolone into a blood vessel can have haz-
ardous consequences for the patient (see the “Comment”
section). Aspiration before injection may also facilitate the
diagnosis and treatment of a seroma that is masquerading
as a soft tissue pollybeak in the early postoperative phase.
A splint may be placed back on the nose in thick-
skinned individuals after the first injection and left in place
for approximately 1 week. The splint should fit well with
adequate pressure over the supratip but should not ex-
tend onto the domal area or cover the tip region. Patients
should be informed that the supratip area may look swol-
len for several days. They are assessed every 4 weeks after
injection, and subsequent injections are administered based
on the tissue response. Restraint must be used in the de-
cision to repeat an injection to prevent overtreatment and
the consequent atrophy that may produce a saddle nose or
irregular skin deformity. Generally, no more than 4 to 6
injections are administered over time.
The amount of triamcinolone used varies depending
on whether the intent is preventative or curative. In the pa-
tient with thick nasal skin and a cartilaginous pollybeak
deformity who is at risk for developing a soft tissue
For this soft tissue type of pollybeak, revision rhino-
plasty with resection of the scar and debulking of the su-
pratip subcutaneous tissue is often followed by taping and
splinting to prevent recurrence. However, this technique
may be ineffective in thick-skinned individuals and must
be performed with utmost care so as not to perforate
through the skin or devascularize the dermis from below
and cause tissue necrosis. Many rhinoplastic surgeons have
successfully been able to avoid such revision surgery by
sequential injection of the corticosteroid triamcinolone ace-
tonide into the supratip scar tissue.6-10 The literature, how-
ever, contains only brief mention of the use triamcino-
lone, and to date there has been little comparison or
quantification of the treatment regimens used by various
surgeons.
RESULTS
A retrospective review of the experience of one of us
(N.J.P.) with rhinoplasty was performed. One hundred
seventy-three rhinoplasties were performed over a 13-
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pollybeak, triamcinolone acetonide at a concentration of
10 mg/mL is typically used at the conclusion of surgery as
a preventive measure. Such an injection is not adminis-
tered when the technique of open rhinoplasty is used to
prevent spread of triamcinolone over the entire dorsal re-
gion of the nose. One of us (R.W.H.K.) assesses patients at
2 weeks after surgery for potential soft tissue pollybeak de-
formity and, if evident, will inject 0.1 to 0.2 mL of triam-
cinolone acetonide at a concentration of 10 mg/mL (1 to 2
mg). Subsequent injections in the same quantity are then
administered every 4 weeks as needed using either the 10-
or the 40-mg/mL suspension, based on the response to the
prior injection. The total amount of triamcinolone used is
guided by the response of the deformity, which varies from
patient to patient. In referral cases in which a soft tissue
pollybeak has already formed from previous surgery, 0.1
to 0.2 mL of triamcinolone acetonide at a concentration of
40 mg/mL (4-8 mg) is injected (Figure 2).
Another one of us (N.J.P.) begins injections earlier in
the postoperative course to address incipient formation of
the soft tissue pollybeak. Evaluation of the supratip area is
performed 1 week after surgery. At that time, supratip full-
ness is visually assessed and the supratip area is palpated.
If there appears to be fullness or if there is blottable edema
of the supratip, a small amount of triamcinolone ace-
tonide, 0.1 mL of a 10-mg/mL suspension (1 mg), is in-
jected subcutaneously. The patient is seen again at 1 month
after surgery and another injection is administered at that
time if residual fullness is present.
The Table summarizes the regimens used by several
authors. Note that more recent reports have recom-
mended smaller dosages than those used by Rees6 and Mahe
et al,7 who were among the first to describe the technique
in detail and had very successful results. Also, Holt et al1
recommend an injection of 5 mg of triamcinolone ace-
tonide into the supratip region every 3 to 6 weeks until the
edema is resolved. Cook and Guida4 recommend treating
the soft tissue pollybeak with 10-mg/mL triamcinolone ace-
tonide injections monthly beginning 1 month after sur-
gery until the deformity resolves.
month period. The patients (139 women and 34 men)
ranged in age from 15 to 78 years. One hundred nine-
teen patients underwent primary rhinoplasty (91 women
and 28 men), and 54 patients underwent revision rhi-
noplasty (48 women and 6 men). These rhinoplasties were
performed with the cartilage delivery technique in pa-
tients who demonstrated adequate tip support before sur-
gery. An external splint was placed at the conclusion of
surgery and was removed in 1 week, at which time the
supratip was visually assessed and palpated. Postopera-
tive follow-up lasted a minimum of 6 weeks.
Triamcinolone acetonide (10 mg/mL) was injected
subcutaneously into the supratip region per the au-
thor’s protocol at 1 week after surgery in 127 patients
(73%). The group included 84 (70%) of 119 primary rhi-
noplasties and 43 (80%) of 54 revision rhinoplasties.
Ninety-two (72%) of the 127 patients required a second
injection with triamcinolone acetonide at a concentra-
tion of 25 mg/mL at 4 weeks after surgery. The decision
to treat with triamcinolone was made by the surgeon
(N.J.P.).
WWW.ARCHFACIAL.COM
 One hundred eight (85%) of the 127 patients who
received injections had an acceptable result, with good
supratip definition, as judged by the surgeon. Nineteen
(15%) of the 127 patients had a less than optimal result,
with residual supratip fullness, as judged by the sur-
geon. There were no permanent complications from the
injections in any of the patients in this series.
COMMENT
Triamcinolone acetonide is commercially available as an
injectable suspension in concentrations of 10 and 40 mg/
mL, but it can be diluted to lesser concentrations with ei-
Figure 1. Placement of subcutaneous intralesional triamcinolone acetonide
injection for soft tissue pollybeak deformity.
A B
Figure 2. A, Presurgical photograph of a 22-year-old woman who underwent rhinoplasty, chin augmentation, and submental liposuction. B, Photograph taken
7.5 weeks after surgery demonstrates early formation of a soft tissue pollybeak, which was treated with triamcinolone acetonide at that time. C, Photograph
taken 7 months after surgery. D, Posttreatment photograph taken 9.5 months after surgery shows resolution of the soft tissue pollybeak.
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ther 1% lidocaine hydrochloride or normal saline. The pack-
age insert states that triamcinolone acetonide at a
concentration of 10 mg/mL (Kenalog-10; Bristol-Myers
Squibb Co, Princeton, NJ) is intended for intradermal and
intra-articular use. Intradermal applications include treat-
ment of a wide range of disorders, including keloid scars,
discoid lupus erythematosus, necrobiosis lipoidica dia-
beticorum, lichen planus, psoriatic plaques, granuloma an-
nulare, and lichen simplex chronicus. Triamcinolone ace-
tonide at a concentration of 40 mg/mL (Kenalog-40; Bristol-
Myers Squibb Co) is intended for intramuscular and intra-
articular use. We describe herein subcutaneous intralesional
rather than intradermal injection of triamcinolone ace-
tonide at concentration doses of up to 40 mg/mL.
Intralesional injection of keloid and hypertrophic
scars with triamcinolone was first described in the 1965
by Maguire.11 Triamcinolone is used in hypertrophic and
keloid scars as both a primary treatment and prophylac-
tically after surgical scar excision to prevent recur-
rence.12,13 Significant action of the agent is discernible in
tissues for up to 6 weeks.14 Darzi et al12 reported symp-
tomatic relief in 72% and complete flattening in 64% of
keloid and hypertrophic scars injected with triamcino-
lone. It has therefore been recommended as a first-line
treatment for small keloids.
The exact mechanism by which steroids reduce scar-
ring has not been fully elucidated. Corticosteroids de-
crease fibroblast proliferation and inflammatory re-
sponses.13 This action results in decreased collagen and
glycosaminoglycan synthesis with decreased tissue fibro-
sis.15 Corticosteroids also inhibit collagenase inhibitors,
resulting in increased collagen degradation.13,15 Prophy-
lactic and early treatments should therefore have a greater
clinical effect, as they are associated with both decreased
scar proliferation and increased degradation. Later, revi-
sion treatment may have less effect, because it takes place
after the period of scar proliferation and is associated
C D
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 Triamcinolone Regimens Recommended by Various Authors for Treatment of the Soft Tissue Pollybeak
Source, y Triamcinolone Acetonide, Dosage
6
Rees, 1971 0.2-0.5 mL of 10 mg/mL (2-5 mg)
Mahe et al,7,8 1974 and 1979 0.25-0.5 mL of 40 mg/mL (10-20 mg)
Guyuron et al,9 2000 0.1-0.2 mL of 40 mg/mL or
0.2-0.4 mL of 20 mg/mL (4-8 mg)
Gruber,10 2000 0.1-0.2 mL of 10 mg/mL (1-2 mg)
mixed with an equal volume of
lidocaine hydrochloride
Present study
N.J.P. 0.1 mL of 10 mg/mL (1 mg)
R.W.H.K. 0.1-0.2 mL of 10 mg/mL (1-2 mg)
with increased scar degradation alone. Because of the dual
activity of triamcinolone before scar proliferation, early in-
jection requires less agent. Our method therefore re-
quires a lower concentration (10 mg/mL) of triamcino-
lone acetonide for intraoperative and early postoperative
treatments and a higher concentration (40 mg/mL) for re-
vision cases with curative rather than preventive intent.
The major risk of treatment with triamcinolone in-
jections is subcutaneous atrophy.12 The rate of subcuta-
neous atrophy in hypertophic and keloid scar treatment
reported by Darzi et al12 was 4%. Because triamcinolone
remains active in the tissue for 4 to 6 weeks, reinjection
should probably not take place before this period because
there may be a higher accumulation of corticosteroid than
desired. Other potential complications include depigmen-
tation, telangiectasia formation, necrosis, and ulcer-
ation.13,14,16 Rarely, symptoms of Cushing syndrome have
been reported but are usually reversible.17,18 A recent re-
port described an occurrence of complete and irreversible
blindness resulting from steroid injection into the dorsum
of the nose to treat subcutaneous scarring.18 Presumably,
the blindness was caused by a microembolus of injected
suspension that led to the occlusion of retinal or choroi-
dal vessels. To our knowledge, there have been no other
reports of blindness associated with steroid injection of
the nasal dorsum, but blindness has been described as a
complication of nasal turbinate steroid injection.19
We know of no studies that have quantitatively evalu-
ated the systemic effects of intralesional injection of tri-
amcinolone for the pollybeak deformity. Mabry20 found
that slight systemic absorption was evident 3 days after
intraturbinal injection with 40 mg of triamcinolone ace-
tonide for nasal turbinate hypertrophy, with some de-
pression of plasma cortisol lasting up to 1 week in 4 (30%)
of the 14 patients studied. Cortisol values, however, were
not lower than normal limits at any time, and no adre-
nal suppression was apparent after repeated injections.
If steroid injections do not fully correct the pol-
lybeak deformity, revision surgery can be performed. The
scar tissue is excised, and a compressive tape and nasal
dorsal splint are applied. The compressive tape should
be maintained for at least 3 weeks. If the cartilaginous
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First Treatment
After Surgery Repeated at
Not stated 1- to 2-wk intervals as needed
Not stated 3 wk if needed
4 wk 4-wk intervals (3 injections
maximum)
4-6 wk 1- to 2-wk intervals as needed
1 wk 4 wk after surgery with 0.1 mL of
25 mg/mL (2.5 mg) if needed
2 wk 4 wk using 0.1-0.2 mL of 10 mg/mL
or 40 mg/mL (1-2 mg or 4-8 mg,
respectively) depending on
results of previous injection
(4-6 injections maximum)
septum or the dorsal borders of the upper lateral carti-
lages are too high, they can also be trimmed during sur-
gical revision. Augmentation of the upper dorsum may
be needed in patients with very thick supratip skin in or-
der to create a straight-appearing dorsal line. Tip grafts
may also be used to refine and protect the tip above a
thick supratip that will not respond to therapy.
Dorsal autologous grafts can also be used when the
illusion of supratip fullness is caused by excessive high
dorsal resection when the remaining nasal skin does not
shrink down. Prophylactic triamcinolone injections can
be administered at the time of surgery and during the
recovery period according to the protocol we have
outlined. Revision surgery should be delayed for at least
6 months after the initial surgery.
It is preferable, however, to avoid surgery if pos-
sible. Subdermal dissection with resection of scar tissue
in revision surgery is difficult to perform and may lead to
complications. Irregular thinning, adhesions, telangiec-
tasias, vertical grooves, furrows, and possible skin loss may
result.2 In general, subcutaneous triamcinolone injection-
into the scar tissue is the preferred first-line treatment for
soft tissue pollybeak, as it is well tolerated and has mini-
mal risk of exacerbating the deformity. If the triamcino-
lone injections are not effective, surgical revision re-
mains a possibility for correction of the deformity.
Systemic steroids, such as dexamethasone, are used
by some rhinoplastic surgeons to decrease postopera-
tive eyelid and nasal edema as well as discomfort or
pain.21,22 It is not known whether use of systemic ste-
roids at the time of surgery may reduce the incidence of
the pollybeak deformity. Several other modulators of the
wound healing process are also currently being ex-
plored as intralesional or systemic treatment for keloids
and hypertrophic scars. These modulators include isotreti-
noin, interferon gamma, interferon alfa, and tamoxifen
citrate.23-25 For example, isotretinoin combined with tri-
amcinolone appears to significantly inhibit the growth
of keloid fibroblasts in cell culture.23 Whether these treat-
ments alone or in combination with triamcinolone in-
jection will prove to be effective treatment for the postrhi-
noplasty pollybeak remains to be seen.
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CONCLUSIONS
Because revision surgery is difficult and may result in com-
plications, subcutaneous intralesional triamcinolone in-
jection is the first-line treatment for the soft tissue pol-
lybeak deformity. The technique is straightforward,
and good results may be achieved. Subcutaneous injec-
tion into the scar tissue may be accompanied by infre-
quent adverse effects, most commonly subcutaneous at-
rophy; therefore, injections should be administered only
in the subcutaneous level of the supratip, where the over-
lying skin is thick. Should intralesional steroid injec-
tion fail to satisfactorily treat the deformity, revision rhi-
noplasty can still be performed 6 months after the initial
surgery.
Accepted for publication August 23, 2000.
This study was presented in part at the spring meeting
of the American Academy of Facial Plastic and Reconstruc-
tive Surgery (Combined Otolaryngological Spring Meet-
ings), Orlando, Fla, May 13, 2000.
Corresponding author and reprints: Russell W. H. Kridel,
MD, Facial Plastic Surgery Associates, 6655 Travis St,
Suite 900, Houston, TX 77030-1336 (e-mail: rkridel
@todaysface.com).
REFERENCES
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rhinoplasty. Otolaryngol Clin North Am. 1987;20:853-876.
2. Parkes ML, Kanodia R, Machida BK. Revision rhinoplasty: an analysis of aes-
thetic deformities. Arch Otolaryngol Head Neck Surg. 1992;118:695-701.
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tralesionally. JAMA. 1965;192:325-326.
12. Darzi MA, Chowdri NA, Kaul SK, Khan M. Evaluation of various methods of treat-
ing keloids and hypertrophic scars: a ten year follow up study. Br J Plast Surg.
1992;45:374-379.
13. Lindsey WH, David PT. Facial keloids: a 15-year experience. Arch Otolaryngol
Head Neck Surg. 1997;123:397-400.
14. Ceilley RI, Babin RW. The combined use of cryosurgery and intralesional injec-
tions of suspensions of fluorinated adrenocorticosteroids for reducing keloids
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15. Cohen IK, Diegelmann RF. The biology of keloids and hypertrophic scars and
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16. Ketchum LD, Cohen IK, Masters FW. Hypertrophic scars and keloids: a collec-
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17. Boyadjiev C, Popchristova E, Mazgalova J. Histomorphologic changes in ke-
loids treated with Kenacort. J Trauma. 1995;38:299-302.
18. Shafir R, Cohen M, Gur E. Blindness as a complication of subcutaneous nasal
steroid injection. Plast Reconstr Surg. 1999;104:1180-1182.
19. Mabry RL. Visual loss after intranasal corticosteroid injection: incidence, causes,
and prevention. Arch Otolaryngol. 1981;107:484-486.
20. Mabry RL. Evaluation of systemic absorption of intraturbinally injected triam-
cinolone. Otolaryngol Head Neck Surg. 1981;89:268-270.
21. Kittel H, Masing H. Corticosteroid therapy in rhinoplasty. Rhinology. 1976;14:
163-166.
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1998;40:490-493.

Call for Papers

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the other AMA journals. All aspects of the theme will be
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