Management of recurrent pinna haematoma following rugby injury: a surgical approach.

A young adult male developed a left-sided pinna haematoma after a rugby injury. The haematoma reaccumulated after multiple attempts at drainage under local anaesthetic in emergency rooms and required incision and drainage in the theatre under general anaesthetic. Intraoperatively, multiple venous bleeding points were identified and these were controlled with bipolar diathermy. The wound was closed and dressed with bolster and crepe bandage. On day 7 postoperatively, the sutures and dressings were removed and the haematoma had not recurred. He returned to playing rugby on day 21 postoperatively and sustained another blunt impact to his left ear. He noticed new swelling over the posterior aspect of the same ear. This was drained via needle aspiration and there was no further reaccumulation of the pinna haematoma.

Complete Salvage of Third-degree Burn of Ear by Repairing Gel-PRP-Fibrin Glue, A Case Report.

The ear is a very important facial feature and enhances the overall look of the face. Usually, patients with entire ear burns also have large areas of burn in their bodies. To save the patient, skin grafting to reduce the injured body surface area is prioritized and the treatment of the ears may be inevitably delayed, which results in minor to very severe cosmetic deformity. This has a deep effect on the life quality of a patient who survives a burn injury. Therefore, any step that decreases ear deformity or loss is very crucial for the patient. There are different challenging procedures for ear reconstruction which are very tedious works. In this study, for one patient, repairing gel-platelet-rich plasma-fibrin glue was applied for the treatment of a deep dermal burned ear as a novel, non-invasive, and simple approach to give a normal shape to the ear to prevent extensive morbidity during the acute phase and deformities later as a consequence of burns. No keloid is observed after treatment.

Keloids in Darkly Pigmented Skin: Clinical Pattern and Presentation at a Tertiary Health Facility, Southwest Nigeria.

BACKGROUND: Keloids are chronic dermal fibro-proliferative disorders resulting from excessive collagen deposition. Although it is commonly seen in the dark skin, it occurs in other races. It is a disfiguring dermatosis whose epidemiology and clinical pattern should be put into proper perspective in an area where it has not been extensively documented. SUBJECTS AND METHOD: A cross-sectional design that included 120 consenting keloids patients was made at the dermatology and plastic surgery clinics of a tertiary hospital over one year. Keloid was diagnosed clinically, risk factors, locations and patterns of affectation were documented. RESULTS: 120 patients with 192 keloids were seen. The mean age of the patients was 36.3±16.0 years with a slight female preponderance (M: F, 1:1.9). The chest was the commonest site 37 (19.3%), then earlobe 27 (14.1%) and face 21(11.0%). The buttock/feet were the least affected areas. Trauma including ear piercing, shaving, lacerations/cuts were the commonest risk factors 108 (56.2%) for keloid. The commonest observed morphological patterns in descending order of occurrence include flat 61 (31.8%), nodular 54 (28.1%) and superficial spreading 51 (26.6%) type. Flat pattern was commonest in breast and chest areas 35 (71.4%), nodular pattern on earlobes 17 (63.0%), face 11 (52.3%), scalp 3 (50.0%), neck 5 (38.5%), and guttate pattern on the face 3 (14.0%) and back 2 (22.0%). The shoulder 5 (50.0%), arms 7 (58.3%) and back 4 (44.4%) had more of the superficial spreading pattern when the morphology/patterns of keloid in these areas were compared. CONCLUSION: Keloids affects predominantly young adults with single anatomical site being the commonest presentation, with the chest mostly affected and the flat pattern commonly observed. The morphological distinction of keloids and location may influence the choice of treatment modality.

CONTEXTE: Les chéloïdes sont des troubles dermiques chroniques fibro-prolifératifs résultant d'un dépôt excessif de collagène résultant d'un dépôt excessif de collagène. Bien qu'elle soit couramment dans les peaux foncées, elle se produit dans d'autres races. Il s'agit d'une dermatose défigurante dermatose dont l'épidémiologie et le profil clinique doivent être mis en perspective dans une région où elle n'a pas été largement documentée. SUJETS ET MÉTHODE: Une étude transversale incluant 120 patients consentants atteints de chéloïdes a été réalisée dans les cliniques de dermatologie et de chirurgie plastique d'un hôpital tertiaire sur une période d'un an. La chéloïde a été diagnostiquée cliniquement, les facteurs de risque, les localisations et les schémas d'affectation ont été documentés. RÉSULTATS: 120 patients présentant 192 chéloïdes ont été examinés. L'âge moyen des patients était de 36,3±16,0 ans avec une légère prépondérance féminine (M : F,1:1.9). La poitrine était le site le plus fréquent 37 (19,3%), puis le lobe de l'oreille 27 (14,1 %) et le visage 21 (11,0 %). Les fesses et les pieds étaient les zones les moins touchées zones les moins touchées. Les traumatismes, y compris le perçage des oreilles, le rasage, les lacérations/coupures, étaient les facteurs de risque les plus courants.les facteurs de risque les plus courants 108 (56,2 %) pour la chéloïde. Les formes morphologiques les plus courantes morphologiques les plus fréquemment observés, par ordre décroissant de fréquence sont le type plat 61 (31,8 %), le type nodulaire 54 (28,1 %) et le type d'extension superficielle 51 (26,6 %). La forme plate était la plus fréquente dans les zones du sein et de la poitrine.35 (71,4 %), le type nodulaire sur le lobe des oreilles 17 (63,0 %), le visage 11 (52,3 %), cuir chevelu 3 (50,0 %), le cou 5 (38,5 %), et le motif en gouttes sur le visage 3 (14,0 %) et le dos 2 (22,0 %). L'épaule 5 (50,0 %), les bras 7 (58,3 %) (58,3 %) et le dos 4 (44,4 %) présentaient davantage de motifs d'étalement superficiel morphologie/profil de la chéloïde dans ces zones. CONCLUSION: Les chéloïdes touchent principalement les jeunes adultes. site anatomique unique est la présentation la plus courante, le thorax étant le plus souvent touché. La poitrine est la plus touchée et le modèle plat est couramment observé. Le site distinction morphologique des chéloïdes et de leur localisation peut influencer le choix de la modalité de traitement. MOTS CLÉS: Chéloïde, Peau foncée, Épidémiologie, Profil Clinique.

The use of a caudal auricular axial pattern flap for repair of a degloving pinna wound in a dog.

A 3-year-old male neutered French bulldog was presented for an anatomical degloving injury of the left pinna following a conflict with a larger dog at a park. Approximately 2/3 of the dorsal skin was removed from the convex surface of the left pinna along with an irregular, full thickness injury on the lateral aspect of the pinna distal to the cutaneous marginal pouch. A caudal auricular axial pattern flap (CAAPF) was used to reconstruct the pinna. The flap healed with no noted necrosis over the long-term. Postoperative cellulitis was noted for approximately 3 mo. The dog was medically managed for bilateral otitis externa multiple times over the course of recovery. Long-term function and cosmesis at 1.5 y after surgery revealed adequate functional movement of the pinna and acceptable cosmesis. It is concluded that, rather than a pinnectomy, a CAAPF can be offered as a surgical option in dogs that have injuries localized to the pinna. Key clinical message: A CAAPF is an alternative to pinnectomy for reconstruction of the pinna after degloving injury and yields a functional and cosmetically acceptable outcome.

Utilisation d'un lambeau auriculaire caudal axial pour la réparation d'une plaie de dégantage du pavillon de l'oreille chez un chien. Un bouledogue français mâle castré âgé de 3 ans a été présenté pour une blessure anatomique par dégantage du pavillon gauche suite à un conflit avec un chien plus gros dans un parc. Environ les 2/3 de la peau dorsale ont été retirés de la surface convexe du pavillon gauche avec une lésion irrégulière de pleine épaisseur sur la face latérale du pavillon distal par rapport à la poche cutanée marginale. Un lambeau auriculaire caudal axial (CAAPF) a été utilisé pour reconstruire le pavillon. Le lambeau a cicatrisé sans nécrose notée à long terme. Une cellulite postopératoire a été notée pendant environ 3 mois. Le chien a été pris en charge médicalement pour une otite externe bilatérale à plusieurs reprises au cours de sa convalescence. La fonction à long terme et l'esthétique à 1,5 ans après la chirurgie ont révélé un mouvement fonctionnel adéquat du pavillon de l'oreille et une esthétique acceptable. Il est conclu que, plutôt qu'une pinnectomie, un CAAPF peut être proposé comme option chirurgicale chez les chiens qui ont des blessures localisées au pavillon.Message clinique clé :Un CAAPF est une alternative à la pinnectomie pour la reconstruction du pavillon après une blessure par dégantage et donne un résultat fonctionnel et esthétiquement acceptable.(Traduit par Dr Serge Messier).

Primary Reattachment of Near-Complete Ear Amputation: A Successful Outcome.

OBJECTIVES: Traumatic amputation of the ear constitutes a great aesthetic deformity that can have a tremendous negative impact. Reports describing the survival of near-complete ear amputation using non-microsurgical replantation are scarce. We aimed to study the surgical outcome of patients with near-complete ear amputations supplied by small pedicle bridges that were treated with primary reattachment. METHODS: We retrospectively studied patients with near-complete ear amputation who were admitted at Al Ain Hospital from January 2016 to December 2019. RESULTS: Five patients were studied. The most common mechanism of injury was motor vehicle injury, followed by cutting injury. The skin pedicle was inferior in 3 (60%) patients of patients. The median width of the skin pedicles was 8.5 mm. The median interval between the injury and the surgical management was 4 hours. All patients underwent primary reattachment of the ear without microsurgery. One patient developed a small area of necrosis of the ear lobe. All patients recovered with a completely healed pinna and satisfactory overall appearance. CONCLUSIONS: Primary reattachment without microsurgery of the near-complete ear amputation can be safely performed in the presence of an intact skin pedicle. It can achieve an aesthetically satisfactory outcome without severe complications.

Auricular haematoma an avoidable cosmetic deformity: A chance or negligence.

PURPOSE: This study highlights the importance of immediate intervention needed in cases of auricular trauma cases so as to prevents complications leading to cauliflower ear, loss of cartilage, necrosis. MATERIALS & METHODS: Total 10 cases of primary haematoma & recurrent cases were included in the study. A detailed history was entered in proforma. Procedure was done under local anaesthesia with all aseptic precautions. A cruciate incision was given over the most dependent part of the swelling and flaps were raised. The collection was drained and the under surface of the flap was scraped using Rosen''s knife followed by insertion of small drain tube and pressure dressing was done. Patients were followed up for three months. RESULTS: Out of the 10 cases 6 were primary cases and 4 were recurrent cases out of which males were 80% and females 20%. None of them showed recurrence. Overall cosmetic deformity was negligible with most of the patients. 1 patient developed perichondrial reaction with pain and inflammation which required long course of analgesics and antibiotics. In 3 cases a thickening of the auricle at the site of incision was noticed. CONCLUSION: Auricular haematoma most commonly is seen in male players of contact sports. These patients may land up in emergency department. Thus, by developing collaborative relationships with ENT specialists, emergency department can help ensure that patients experience possible treatment. This will help reduce the cosmetic deformities of pinna which are seen as complication of auricular haematoma.

Medical Device-Related Pressure Injury to the Ear from a Mask.

ABSTRACT: Mask wearing is now ubiquitous because of the COVID-19 pandemic and has given rise to medical device-related pressure injuries in persons at risk of skin breakdown. The ear has unique anatomy that is particularly susceptible to injury from pressure. In this time of mandatory personal protective equipment requirements in healthcare facilities, protection and assessment of skin in the vulnerable postauricular area are needed. This article presents a case report of a pressure injury on the ear, reviews the anatomy of the ear, and provides strategies for assessment and treatment of pressure injuries in this often overlooked anatomic region.

Arterial only anastomosis associated with modified Baudet technique in ear replantation: Case reports and literature review.

BACKGROUND: Total ear amputation is a relatively rare trauma with an absolute indication for surgical treatment. Numerous techniques for auricular reconstruction have been described. When local and general conditions allow microsurgical replantation, this must be the first choice. We propose the association of microsurgical techniques with some modification (modified Baudet technique) to obtain higher survival rate of the reimplanted stump. METHODS: This study included cases of 3 male patients with total ear amputation, the injuries and their mechanism (workplace accident) being identical. Chief complaints were pain, bleeding, important emotional impact due by an unaesthetic appearance. The established diagnosis was traumatic complete ear amputation (grade IV auricular injury according to Weerda classification). Microsurgical replantation was performed only with arteriorraphy, and no vein anastomosis. Cartilage incisions and skin excisions were made to enlarge the cartilage-recipient site contact area. Medicinal leeches were used to treat venous congestion, to which systemic anticoagulant therapy was added. RESULTS: The results showed the survival of the entire replanted segment in all cases, with good function and esthetical appearance. Patients were fully satisfied with the final outcome. CONCLUSION: Microsurgical replantation is the gold standard, for the surgical treatment of total ear amputation. We believe that cartilage incisions and the increased surface of contact between cartilage and recipient site has an adjuvant role in revascularization of the amputated stump (with only arterial anastomosis) and the use of hirudotherapy helps to relieve early venous congestion.

Burned Ear Reconstruction Using a Superficial Temporal Fascia Flap.

OBJECTIVES: Ear deformity caused by burns is one of the most difficult types of deformity to treat with plastic surgery, and the reconstruction of burned ears undoubtedly remains a substantial challenge. This study aims to report the therapeutic regime of using a superficial temporal fascial flap to cover the framework in burned ear reconstruction. METHODS: Autologous costal cartilage was used to form the ear framework in all of the reconstruction cases. A superficial temporal fascial flap was used as soft tissue to cover the ear scaffold. RESULTS: Five patients with 6 ears were included in our study. The external ear healed well and the location, size, and shape of both ears were generally symmetrical. No complication was observed in any of the patients. CONCLUSIONS: The superficial temporal fascial flap is a good choice for covering the autogenous cartilage framework when treating ear deformities after burns.

Lobe of sound: prosthetic rehabilitation of partial auriculectomy defect.

Loss of facial organs in an individual may be due to congenital anomalies or acquired causes. The missing parts of the face like ear, eyes and nose are considered as maxillofacial defects that can be rehabilitated by a prosthesis and/or cosmetic surgeries. This frontier of science has developed into a more reliable and predictable process due to the ever-increasing development of materials and equipments used in this procedure. The fabrication of an ear prosthesis is considered by many prosthetists to be one of the most difficult replacements in maxillofacial reconstruction. The severe undercuts and pronounced convolutions of the ear present a challenge in simulating a naturally proportioned prosthesis. Proper assessment of the disfigured facial organs and a feasible approach to rehabilitating them has for long been the target of clinical maxillofacial prosthodontics. This report describes a simple and engrossing technique to rehabilitate a patient with a partial auricular defect in the most aesthetic and economical manner using medical-grade room temperature vulcanising silicone.

Outcomes of Dog Bite Avulsion Injury Reconstruction With Urinary Bladder Matrix.

Dog bite avulsion injuries of the head and neck are difficult to manage in pediatric patients. This study assesses the outcomes of using porcine urinary bladder extracellular matrix (UBM) for reconstruction of these complete avulsion injuries. Five male pediatric patients underwent reconstruction using UBM. Two (40%) patients underwent reconstruction of the nose; the other 3 patients underwent reconstruction of the forehead, forehead/glabella, and auricle. The average size of the avulsion defect was 7.0 ± 2.4 cm2. No patient developed wound dehiscence, graft loss, or wound infection. Four (80%) patients received pulsed dye laser treatment to improve wound cosmesis. Use of UBM is a safe and effective reconstructive option after dog bite avulsion injuries of the head and neck. Given the advantages of convenient availability and avoidance of donor site morbidity, UBM can be considered for reconstruction of posttraumatic avulsion injuries or Mohs defects.

Pigment epithelium-derived factor attenuates angiogenesis and collagen deposition in hypertrophic scars.

Scar forming wounds are often characterized by higher levels of vascularity than non-scarring wounds and normal skin, and inhibition of angiogenesis has been shown to inhibit scar formation in some model systems. The rabbit ear hypertrophic scar (HS) model has been widely used to study the mechanisms that underlie the development of HS as well as the effectiveness of various treatments. Although the rabbit ear HS model is well characterized in terms of scar formation, the rate and level of angiogenesis has not been investigated in this model, and the cause-effect relationship between angiogenesis and rabbit HSs has not been examined. In the current study, full-thickness excisional wounds were created on the ventral side of New Zealand White rabbit ears to induce HS formation, and the dynamic pattern of angiogenesis and the expression of angiogenic regulatory factors were examined over time. Blood vessel density was found to peak at 2.7% on day 14 post-wounding, decreasing to 1.7% by day 28. mRNA levels of the proangiogenic factor VEGF-A peaked at day 14, while the expression of the antiangiogenic factors pigment epithelium-derived factor (PEDF) and thrombospondin 1 (TSP1) peaked at day 28 post-wounding. To examine whether inhibition of angiogenesis influences HS formation in this model, wounds were treated with exogenous soluble antiangiogenic agents including recombinant PEDF (rPEDF) and a functional PEDF peptide (PEDF-335). rPEDF and PEDF-335 were administered intradermally from day 4 post-wounding every 3 days until day 19. Intradermal injection of rPEDF or PEDF-335 both led to decreased angiogenesis and decreased collagen deposition at the wound site. The results support the utility of antiangiogenic therapies, including rPEDF/PEDF-335, as a potential new strategy for the prevention or treatment of HSs.

Liposome-encapsulated statins reduce hypertrophic scarring through topical application.

Hypertrophic scar is an important clinical problem with limited therapeutic options. Aside from their roles as 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, statins have also been demonstrated to decrease scarring by reducing connective tissue growth factor (CTGF) expression. However, poor penetrative ability limits their utility as topical treatments for hypertrophic scar. Here, we aim to develop novel statin formulations using liposomes to enhance dermal penetrative ability and to evaluate their efficacy against formation of hypertrophic scar utilizing our validated rabbit ear hypertrophic scar model. Liposomal simvastatin or pravastatin were compounded using a novel, flexible liposomal formulation and applied topically to rabbit ear hypertrophic scars daily from postoperation day (POD) 14 until POD 25. Scar color, including erythema and melanin, was measured using reflectance spectrophotometry on POD 28, and scar tissue was harvested for evaluation of scar elevation index as well as gene and protein expression. Human foreskin fibroblasts were also treated with statin formulations and CCN2 expression was determined by quantitative PCR. Both simvastatin and pravastatin were efficiently encapsulated in liposomes, forming nanometer-scale particles possessing highly negative charges. Topical treatment with liposomal simvastatin and pravastatin at 6.5% concentration significantly reduced scar elevation index and decreased type I/III collagen content and myofibroblast persistence in the wound. The erythema/vascularity of scars was reduced by liposomal statin treatment, with concomitant decrease of CD31 expression as measured histologically. Expression levels of transcripts encoding CTGF, collagen I, and collagen III collagen in scar tissue were also decreased by liposomal pravastatin treatment, as were myofibroblast persistence and the type I/III collagen ratio as assessed by immunofluorescence and picrosirus red staining, respectively. Treatment of human foreskin fibroblasts with simvastatin or with liposome-encapsulated pravastatin resulted in decreased expression of transcript encoding CTGF. Overall, our novel statin formulations encapsulated in liposomes were successfully delivered through topical application, significantly reducing hypertrophic scarring in a rabbit ear model.

Atypical replantation and reconstruction of frozen ear: A case report.

RATIONALE: The first successful ear replantation was performed by Pennigton in 1980 in Sydney. At least 84 ear replantations have been described in the literature over a period of 37 years since the first case. The authors have not found any previous case of frozen ear replantation in the literature. PATIENT CONCERNS: We report the case of a 38-year-old man, who had an injury to the head while working with a machine. DIAGNOSIS: The patient suffered total traumatic avulsion of the left ear. The ear was wrapped in moistened, sterile gauze and was transported on dry ice. At the time of admission to our department, the amputated ear was frozen to stiff, solid nonelastic matter. INTERVENTIONS: We attempted replantation. Despite repeated arterial thrombosis during surgery, the ear was successfully replanted with arterial and venous anastomosis. OUTCOMES: Venous congestion occurred within 9 h of surgery and was treated using leeches. Freezing cold injury developed during reattachment. The radix and proximal parts of the helix exhibited necrosis and so were reconstructed by contralateral conchal cartilage graft, which was wrapped with a local subauricular skin flap. On completion of treatment, a satisfactory shape was achieved, although the replanted and reconstructed left auricle slightly was smaller than the contralateral auricle. LESSONS LEARNED: Our report confirms that the replantation of a frozen, amputated ear is possible, and we suggest that ear replantation should be the method of choice for the treatment of ear loss even under these conditions.

Genetic correlations between cartilage regeneration and degeneration reveal an inverse relationship.

OBJECTIVE: The etiology of osteoarthritis (OA) is unknown, however, there appears to be a significant contribution from genetics. We have identified recombinant inbred strains of mice derived from LG/J (large) and SM/J (small) strains that vary significantly in their ability to repair articular cartilage and susceptibility to post-traumatic OA due to their genetic composition. Here, we report cartilage repair phenotypes in the same strains of mice in which OA susceptibility was analyzed previously, and determine the genetic correlations between phenotypes. DESIGN: We used 12 recombinant inbred strains, including the parental strains, to test three phenotypes: ear-wound healing (n = 263), knee articular cartilage repair (n = 131), and post-traumatic OA (n = 53) induced by the surgical destabilization of the medial meniscus (DMM). Genetic correlations between various traits were calculated as Pearson's correlation coefficients of strain means. RESULTS: We found a significant positive correlation between ear-wound healing and articular cartilage regeneration (r = 0.71; P = 0.005). We observed a strong inverse correlation between articular cartilage regeneration and susceptibility to OA based on maximum (r = -0.54; P = 0.036) and summed Osteoarthritis Research Society International (OARSI) scores (r = -0.56; P = 0.028). Synovitis was not significantly correlated with articular cartilage regeneration but was significantly positively correlated with maximum (r = 0.63; P = 0.014) and summed (r = 0.70; P = 0.005) OARSI scores. Ectopic calcification was significantly positively correlated with articular cartilage regeneration (r = 0.59; P = 0.021). CONCLUSIONS: Using recombinant inbred strains, our study allows, for the first time, the measurement of genetic correlations of regeneration phenotypes with degeneration phenotypes, characteristic of OA (cartilage degeneration, synovitis). We demonstrate that OA is positively correlated with synovitis and inversely correlated with the ability to repair cartilage. These results suggest an addition to the risk paradigm for OA from a focus on degeneration to regeneration.

Traumatic complete outer ear amputation by human bite, a forensic case report and review of the literature.

We present a case of a complete external ear amputation, caused by a human bite, that took place during a quarrel in a local farmers' market. The male victim was transferred to the Hospital. After surgical reattachment of the auricle, a forensic clinical examination was performed, as per legal obligation. During examination, the victim was found to have sustained: contusions of the orbital regions (lower eyelids), bilaterally, soft tissue oedema of the forehead (to the left of the middle line), and contusion of the right neck area. He also sustained multiple soft tissue injuries (contusions, abrasions) on the torso and on both upper and lower extremities. Clinical forensic examination of human bite injuries requires thorough description of the wound, proper photography and possibly collection of swabs for DNA identification (in case of unknown perpetrator). Nevertheless, the Forensic Pathologist is often required to perform clinical examination, only after medical care has been provided. Therefore, clinicians should be aware of the need of proper documentation and act accordingly.

An unusual pattern of post-mortem injury caused by Australian fresh water yabbies (Cherax destructor).

A 67-year-old woman with a history of previous cerebrovascular accidents who was confined to a wheel chair drowned in a pond in a public park. Features compatible with drowning included congestion and edema of the lungs with prominent hemolytic staining of the intima of the aortic root. Minor bruises and abrasions were identified. Toxicology was negative. An additional unusual finding was that of patterned symmetrical injuries to the earlobe and pinna of both ears. The injuries consisted of small irregular areas of skin loss that were sometimes linear and parallel and had the appearance of animal nibble marks. Given the presence in the pond of numerous Australian fresh water yabbies (Cherax destructor), and no other predators, it appeared that the injuries had been caused by post mortem feeding by these crustaceans. This case therefore extends the range of animals that may be involved in post mortem predation that may be encountered in cases of freshwater drowning/immersion in an Australian context, with a specific pattern of injury focused on the ear lobes.

Binky Bites and Other Oronasal Pressure Injuries.

Initial examination and exploration of childhood injuries may not lead to an obvious explanation of abuse. Although abusive oronasal injuries have been described, ones including nasal destruction are rare. We describe 4 children abused using implements that ultimately were thought to have caused significant nasal tissue destruction. In 2 of the cases, a forced pacifier placement was implicated in causing pressure injuries. In the other 2 cases, gags were part of the children's injuries. All 4 children had other findings of abuse and neglect.