Author Affiliations: Division of Facial Plastic and Reconstructive Surgery, Yeh Facial Plastic Surgery, Laguna Woods, California (Dr Yeh); and Division of Facial Plastic and Reconstructive Surgery, Williams Center Plastic Surgery Specialists, Latham (Dr Williams), and Facial Plastic and Reconstructive Surgery, Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany (Dr Williams), New York.
Objective To evaluate the long-term aesthetic results in patients treated with autologous periorbital lipotransfer.
Methods A retrospective review of 114 consecutive patients during 4 years who underwent autologous periorbital lipotransfer. Of these patients, 99 were identified who had complete photographic and medical records and were therefore included in the study. Patients were placed into 5 groups based on their total length of postoperative follow-up. Periorbital volume augmentation was assessed by 3 independent masked evaluators using a standard aesthetic scale from 0 to 2 (with 0 indicating no improvement; 1, mild improvement; and 2, marked improvement). Interobserver correlation was determined by κ correlation, and Mann-Whitney tests were used to assess for statistical significance comparing the same patients in each group.
Results Scores from the 3 independent evaluators correlated well (κ = 0.316); aesthetic improvement was seen in almost all patients (86.4%), who had demonstrated improvement for the first 3 years of follow-up. The degree of improvement decreased each year, and only mild improvement was retained in most patients (68.2%) by the 3-year follow-up point (P = .049).
Conclusions Results from most patients who underwent autologous periorbital lipotransfer demonstrated improvement that lasted as long as 3 years. Autologous periorbital lipotransfer remains a valid and effective technique for periorbital rejuvenation and demonstrates long-term potential effectiveness.
Rejuvenation of the periorbital area continues to be a topic of great interest to surgeons and patients. Aging around the eyes involves a complex series of anatomical and physiologic changes that can be seen in patients as young as their mid-30s and is accentuated in subsequent decades. Multiple techniques have been developed that aim to restore a youthful appearance to the eyes and have included novel surgical approaches and several nonsurgical modalities. One of the most popular techniques for periorbital rejuvenation is autologous lipotransfer.
The periorbital area is defined as the skin, soft tissue, and bony structures that surround the eye and include the upper and lower eyelids, the eye-cheek junction extending to the midface, and the infraorbital and supraorbital rims. Although previous reports have described rejuvenation techniques for the upper zone of the periorbital area, this article focuses on the lower eyelid and midface complex. Two of the most defining features of a youthful lower eyelid are shortness and fullness. This starkly contrasts with a senile eyelid, which clinically appears longer and deflated and demonstrates anatomical features such as laxity, pseudoherniation of orbital fat through a weakened orbital septum, and loss of volume.1 A progressive weakening of the orbital-retaining ligaments and a downward displacement of the zygomatico-cutaneous ligament result in laxity of the lower eyelid over time.2 This physiologic change combined with the effect of gravity on soft-tissue components accounts for the appearance of a longer eyelid in the vertical plane (Figure 1). Another prominent anatomical change seen in the senile eyelid is the pseudoherniation of orbital fat as a result of a compromised orbital septum. This frequently results in a significant change in contour over the infraorbital rim, which manifests as an unnatural soft-tissue bulge or convexity. The most recent advancement in our understanding of the aging lower eyelid is the concept of soft- tissue volume loss.
Figure 1. Aging changes of the lower eyelid include weakening of the zygomatico-cutaneous ligament, descent of the suborbicularis oculi and malar fat pads, and loss of periocular volume.
Similar to other areas of the face and body, a loss of volume in the periorbital area results from a reduction in subcutaneous fat, muscle atrophy, and changes in the skeletal framework. In the periorbital area, this process is thought to be secondary to gravitational descent of the suborbicularis oculi and malar fat pads, as well as atrophy of the subcutaneous tissue of the lower eyelid. In approaching the periorbital complex, many facial plastic surgeons have modified traditional blepharoplasty techniques in an effort to restore this lost volume. These techniques have included the subperiosteal midface lift, the suborbicularis oculi fat pad lift, and transposition of orbital fat.3,4 Others have sought to replace this lost volume with various injectable agents that have become increasingly available in the past few years. In the search for the ideal soft-tissue filler, our group turned to periorbital lipotransfer as a primary means of addressing lower eyelid volume loss.
Autologous lipotransfer is a technique by which autogenous fat is harvested from a donor site, typically the abdomen or thighs, with a low-pressure cannula and specially prepared for reinjection into areas of facial volume loss. In the periorbital area, the fat is carefully delivered to the lower eyelid and midface complex by a specialized technique that allows the deposition of small amounts of fat into tissue planes. Our group has performed hundreds of periorbital lipotransfer procedures during the past few years and has obtained long-term data from this experience. We have performed a comprehensive review of our experience and summarized our long-term data in this article.
One of us (E.F.W.) performed a retrospective review of all patients who underwent autologous periorbital lipotransfer from January 1, 2004, to December 31, 2008. A total of 114 patients were identified as having given informed consent after exclusion of patients who had undergone simultaneous upper facial rejuvenation procedures, including upper blepharoplasty, lower blepharoplasty, browlift, subperiosteal midface lift, chemical peel, or laser resurfacing. Patients also were excluded from the study if they had undergone any subsequent periorbital injections with synthetic products or autologous fat after the initial periorbital lipotransfer procedure. Of the 114 patients, 99 patients were identified who had complete photographic and medical records and therefore were included in the study. All preprocedure and postprocedure photographs were standardized for orientation and color (Adobe Photoshop, version CS4; Adobe Systems Inc, San Jose, California), and postprocedure photographs were included at a minimum of 6-month intervals extending as long as 4 years of follow-up at the time of analysis. Patients were divided into groups based on their length of total postoperative follow-up: group 1, from 0 months to 1 year; group 2, from 1 to 2 years; group 3, from 2 to 3 years; group 4, from 3 to 4 years; and group 5, from 4 to 5 years.
The degree of aesthetic improvement of the periorbital area, which in this study included the lower eyelid and midface complex extending to the malar eminence, was assessed by 3 independent masked evaluators. The periorbital area was given a standard aesthetic rating using previously validated methods from 0 to 2 (with 0 indicating no improvement; 1, mild improvement; and 2, marked improvement) (Figure 2).5,6
Figure 2. Patients before (left) and after (right) periocular autologous lipotransfer. Aesthetic scores of 0 (no improvement) (A and B), 1 (mild improvement) (C and D), and 2 (marked improvement) (E and F).
The procedure is performed with the patient receiving monitored anesthesia via intravenous sedation or receiving local anesthesia and oral anxiolytics. Before the procedure, preoperative photographs are reviewed, and the amount of fat needed is determined. Typically, 6 to 10 mL of processed fat is sufficient. The areas of planned injection and the donor sites are delineated with a surgical marking pen. The 2 most common donor sites are the abdomen and the lateral aspect of the thighs, although other easily accessible areas include the medial aspect of the thighs, the flanks, and the lateral aspect of the buttocks. A single-stab incision is made with a No. 11 blade, and a 15-cm liposuction aspiration cannula with a single port is placed through the incision and directed outward in a fanlike pattern. A tumescent solution containing 1 mL of 1% lidocaine with 1:100 000 epinephrine, 4 mL of 1% plain lidocaine, and 15 mL of isotonic sodium chloride is slowly delivered in a second pass. Typically, two 20-mL syringes of tumescent solution are used for each donor site. After 15 minutes is allowed for maximal vasoconstrictive effect, the same liposuction aspiration cannula is affixed to a 10-mL Luer-Lok syringe (BD, Franklin Lakes, New Jersey). Manual aspiration of fat is then performed with hand suction only, using repetitive forward and backward movements of the cannula with the nondominant hand directing and maintaining the cannula in the proper subcutaneous tissue plane. After aspiration, the stab incision is closed with a 5-0 fast absorbing gut suture, and the procedure is repeated on the contralateral side. At the conclusion of the fat retrieval, a compression dressing is wrapped around the donor site to reduce postprocedure swelling.5
The plungers of the 10-mL syringes filled with aspirated fat are removed, and a metal stopper is placed on the ends of the syringes. These syringes are then centrifuged for 13 minutes at 3500 rpm. After centrifugation, the stoppers are then removed to allow drainage of the serous fluid (which contains tumescent solution and blood), and the superficial oil layer is removed by wicking this solution with a semimoist 10.16 × 10.16–cm gauze sponge.
The usable fat is transferred from the 10-mL syringe into individual 1-mL Luer-Lok syringes using a Luer-Lok transfer device. Nerve blocks of the infraorbital and zygomaticofacial nerves are performed in addition to anesthetizing the stab incision site using 1% lidocaine with 1:100 000 epinephrine. An 18-gauge NoKor needle (BD) is used to create small stab incisions at the sites of entry, typically at the malar eminence and inferolaterally to the lateral canthus. A combination of a 0.9-mm and 1.2-mm fat injection blunt tip cannula (Tulip Medical Products, San Diego, California) is then attached to the syringe in preparation for fat transfer. The fat is injected at many different angles in a fan technique with multiple small back-and-forth passes. This allows for the initial deposition of a minimal amount of fat (ie, 0.03-0.05 mL per pass) in the deep plane just superior to the periosteum of the infraorbital rim. Additional fat is injected into a more superficial plane within the subcutaneous tissue of the lower eyelid with careful attention to avoid bolus deposition and a too superficial injection directly under the lower eyelid skin. Next, attention is turned to the malar eminence, and fat is injected into and along the superior borders of the zygomaticus major, zygomaticus minor, and levator labii superioris muscles and the malar fat pad from an entry site at the inferior region of the muscles. A total of 3 to 5 mL of fat is typically injected into each side. At the conclusion of fat injection, the face is cleansed with isotonic sodium chloride solution, and a small amount of bacitracin ointment is placed on each of the stab incisions. The injected areas are aggressively iced for the first 48 hours to decrease edema and ecchymoses.
Median scores of the independent evaluators' aesthetic ratings were calculated for each group, and interobserver agreement was assessed by κ analysis. Periorbital aesthetic rating scores were then subjected to Mann-Whitney tests by comparing the same patients in each group over time.
The most common complication from periorbital autologous lipotransfer was prolonged postoperative edema that lasted longer than 2 weeks. Other complications included ecchymosis from the stab incisions and skin overlying the subcutaneous injection tunnels, undercorrection, and minor tissue irregularities and asymmetries.
The study group consisted of 94 women and 5 men, with postoperative follow-up of 6 months to 4 years (mean, 19 months). Patient age varied from 35 to 71 years (mean, 51 years). The amount of fat injected into the periorbital area for each side ranged from 3 to 5 mL (mean, 4.1 mL). On the basis of total length of postoperative follow-up, 99 patients were in group 1 (ie, 0-1 years of follow-up), 46 patients in group 2 (ie, 1-2 years of follow-up), 22 patients in group 3 (ie, 2-3 years of follow-up), 7 patients in group 4 (ie, 3-4 years of follow-up), and 2 patients in group 5 (ie, 4-5 years of follow-up). Data from the 3 independent evaluators correlated well, with a κ value of 0.316.
Surgical results from almost all patients (94 [94.9%]) in group 1 demonstrated positive aesthetic ratings (median score, 1) that were closely divided between mild and marked improvement: 5 (5.1%) received a no-improvement rating, 50 (50.5%) received a mild-improvement rating, and 44 (44.4%) received a marked-improvement rating. In group 2, results from 38 of 46 patients (82.6%) demonstrated a positive aesthetic rating (median score, 1): those from 8 patients (17.3%) received a no-improvement rating, those from 24 patients (52.2%) received a mild-improvement rating, and those from 14 patients (30.4%) received a marked-improvement rating (Figure 3). A Mann-Whitney test comparing the aesthetic scores of the same 46 patients in groups 1 and 2 showed no significant decrease in improvement over time (P = .20).
Figure 3. Aesthetic scores for results from patients in each group. A, Group 1, up to 1-year follow-up; B, group 2, 1-year to 2-year follow-up; C, group 3, 2-year to 3-year follow-up; D, group 4, 3-year to 4-year follow-up; and E, group 5, 4-year to 5-year follow-up.
Similar to group 2, a total of 19 of 22 patients (86.4%) in group 3 demonstrated a positive aesthetic rating (median score, 1). A trend away from marked improvement was observed in this group because results from 3 patients (13.6%) received a no-improvement rating, those from 15 (68.2%) received a mild-improvement rating, and those from 4 (18.2%) received a marked-improvement rating. The results of Mann-Whitney tests comparing the aesthetic scores of the same 22 patients in groups 1 and 2, as well as groups 2 and 3, showed no significant change (P = .20). However, a comparison between groups 1 and 3 reached statistical significance (P = .049), indicating that the degree of improvement from periorbital lipotransfer in the first year decreased significantly over time by the 2-year to 3-year follow-up point.
The aesthetic ratings from groups 4 and 5 are shown in Figure 3, but comparisons with other groups could not be made because of the small number of study participants (n = 7 and n = 2, respectively).
The periorbital area is one of the first facial regions to show signs of aging. Traditional techniques, such as lower eyelid blepharoplasty, result in aesthetic improvement but frequently do not sufficiently address the component of periorbital volume loss. Furthermore, a blepharoplasty can result in a hollowed or skeletonized appearance of the infraorbital rim, which may become more pronounced over time if aggressive resection of the orbital fat pads and orbicularis muscle is performed. Complementary procedures, such as the suborbicularis oculi fat pad lift, lower eyelid fat transposition, and subperiosteal midface lift, can produce some improvement in lower eyelid contour, but we have found that direct volume replacement with autologous lipotransfer produces the most aesthetically pleasing results.2 Although surgeons have used autologous lipotransfer for many reconstructive efforts and have used this technique in different areas of the face, our study was specifically designed to examine the aesthetic improvement from autologous lipotransfer solely in the periocular area.
Neuber7 pioneered the lipotransfer procedure in 1893 when he used fat to fill facial defects formed by tuberculosis. Miller8 described the infiltration of fat using cannulas in 1926, but the further development of lipotransfer did not occur until the 1970s to 1980s with the subsequent use of liposuction procedures. Since then, several authors9,10 have reported on the use of autologous fat as a soft-tissue filler for reconstructive purposes, including treatment of hemifacial atrophy, congenital anomalies, and acquired defects. In the 1990s, our understanding of lipotransfer was significantly advanced by Coleman11,12 with the development of modern techniques, including gentle removal and handling of aspirated fat and injection techniques using small volumes of fat and multiple passes. Fournier,13 Donofrio,14 and others have contributed to our collective understanding of periorbital aging and have appropriately emphasized the importance of volume preservation in our surgical techniques and illustrated the success of volume restoration using fat.
Although autologous lipotransfer has been widely accepted as a successful technique to address facial volume loss, a frequent criticism of this procedure is the uncertainty regarding the longevity of its results. This viewpoint is reasonable given the many reports that only show impressive short-term results (ie, during <6 months) or claim long-lasting improvement without corroborating data. Furthermore, disparity exists in the literature regarding long-term outcomes, with rates of survivability of transplanted fat varying from 10% to 90%.15,16 In fact, the report by Ersek15 of 10% survival of fat grafts at 3 years after surgery has been disputed by Coleman16 and others in the literature. A study by Pinski and Roenigk17 reported that fat surviving at 6 months will continue to endure, although a pivotal study by Guerrerosantos18 demonstrated 3-year to 5-year survival of fat. Anderson et al19 studied periocular fat graft survival in patients undergoing reconstructive surgery in which soft- tissue volume augmentation was needed in postenucleation socket syndrome. Their findings included evidence of healthy adipose cells with some chronic inflammation and fibrous septa in patients longer than 3 years after surgery. Also, survival of fat grafts for as long as 5 years has been documented in an animal study20 with histologic analysis for transplanted adipocytes.
Although fat harvesting and processing techniques vary widely in the literature, no studies exist, to our knowledge, that directly compare a purported technique and its direct effect on fat longevity in the periocular region. However, most recent studies, such as those by Anderson et al19 and Meier et al,21 as well as our own, use an autologous periorbital lipotransfer technique based on 3 consistent technical considerations. First, the use of a small blunt-tipped harvesting cannula, such as the Coleman cannula, has allowed for more reliable harvesting of viable fat particles using gentle negative manual pressure with the cannula attached to a Luer-Lock syringe. Second, the processing of the harvested fat with the centrifugation technique has allowed for separation of the fat aspirate into its various components: enriched fat, blood particles with tumescent solution, and the supernatant oil layer. With this separation into distinct layers, injection of the enriched fat only into the periorbital area allows for the elimination of the other components and a theoretical reduction of inflammatory mediators. The third technical consideration is the use of fine-tipped reinjection cannulas, such as the 0.9-mm cannula (Tulip Medical Products). In our experience, this has allowed for precise placement of small amounts of autologous fat via multiple passes, which has directly resulted in fewer complications, such as the formation of nodules, granulomas, and larger fat boluses.
The major objectives of our study were to measure the degree of aesthetic improvement from periocular lipotransfer in patients and to see whether the results changed over time. We found that results from almost all patients (94.9%) improved with periocular fat transfer compared with their results at 1 year as assessed via preoperative photographs. Within this first year of follow-up, results from as many as 44.4% of patients showed marked improvement and those from 50.5% showed mild improvement. When we examined how these results changed over time by comparing them with those from the same 46 patients who had as long as 2 years of follow-up, we found that results from 82.6% of patients continued to show improvement (ie, those from 30.4% showed marked improvement and those from 52.1% showed mild improvement). Statistical comparisons confirmed that the aesthetic improvement persisted into the second year of follow-up by demonstrating no significance in aesthetic scores between the same patients in groups 1 and 2. By the time patients had reached as many as 3 years of follow-up, our data begin to reflect some degree of fat loss in the periocular area. Although results from 86.3% of patients showed improvement, a trend away from marked improvement was observed (ie, from 18.2% of patients), and results from most patients demonstrated only mild improvement (ie, from 68.2% of patients; P = .049). The results from our study, therefore, confirm that autologous lipotransfer can create improvement in the periocular area that can persist for years, but we found that the degree of improvement tends to decrease by a significant amount at the third postoperative year.
Limitations of the present study include those inherent to retrospective reviews in which patient follow-up is limited over time. Selection bias may be present, particularly in the longer-year follow-up, because our data exist only for those patients who came back year after year for postoperative follow-up and photography. It is possible that we were able to follow up a percentage of those patients because of the positive experience they had with their periorbital lipotransfer results, although our data may not reflect the true amount of suboptimal results from patients who could not be followed up. These limitations could be minimized in the future by a prospectively designed study with a predetermined follow-up protocol.
Another potential limitation is that the data are derived from a subjective aesthetic analysis using 2-dimensional photography. Although we have attempted to minimize this limitation through analysis by 3 independent masked evaluators and use of consistent photography, recently developed technology may prove useful. In a recent study, Meier et al21 attempted to quantitate the longevity of autologous fat grafting in the midface by using 3-dimensional imaging software. In that study, the authors followed up 33 patients for a mean time of 16 months, with an average amount of 10.1 mL of autologous fat injected into each midface region. The authors found an average of 31.8% residual volume augmentation at their patients' last postoperative visit. The results of the Meier et al21 study cannot be directly compared with those of our study because patients undergoing complementary procedures, such as rhytidectomy or blepharoplasty, were not excluded, and the authors specifically studied fat grafting in the midface. However, their approach, quantitating the amount of fat survival through image analysis, is unique. We believe that the data from our study are important and beneficial to patients and surgeons because our data regarding our analysis of degree of improvement over time can be used in consultations with prospective patients who are considering periocular lipotransfer. The challenge regarding the data from the study by Meier et al21 and others22 who used alternate imaging techniques, such as magnetic resonance imaging volume retention, is to apply these data pertaining to the percentage of fat survival to the aesthetic outcome of an individual patient. In other words, it may be difficult for a surgeon or a patient to translate a percentage of fat survival into an informed opinion regarding whether the procedure should be considered successful and whether the aesthetic results have maintained an acceptable level of improvement over time.
Anecdotally, we and other surgeons believe that risk factors to premature absorption of the transplanted fat include smoking, excessive exercise, and the extremes of age (ie, <30 and >70 years). Although sufficient data are not available to substantiate this claim, a scientific basis is possible given the severe vasoconstrictive effect of smoking and the altered metabolism seen in youth and elderly patients. One could postulate that the effect is then magnified by the fragility of transplanted fat, with its limited and tenuous vascular supply. Another point of debate is whether interval treatment with an additional transfer of fat is necessary to maintain an acceptable degree of volume replacement. Lam et al23 recently reported that in most cases, fat grafting endures after a single treatment, but an additional touch-up session is often necessary to achieve the optimal result. However, the authors caution that a touch-up procedure performed sooner than 6 months after surgery may be premature because results “continue to mature and improve over 6 months to 2 years.” Although the scientific basis for this claim is unclear, proposed mechanisms include stem cell rejuvenation in neighboring tissues and positive metabolic effects on the overlying skin from estrogen-laden fat donor cells. In the study by Meier et al,21 8 of 33 patients (24.2%) required an additional touch-up procedure. In our study, our data reflect only patients who had undergone 1 periorbital lipotransfer procedure.
Complications of periorbital autologous lipotransfer are infrequent but may be technique dependent. A moderate learning curve is associated with periorbital fat transfer to avoid complications, such as the formation of visible lumps or gross asymmetries as a result of bolus deposition of fat or injection into a too superficial tissue. These problems are best avoided by placing small amounts of fat (ie, 0.03-0.05 mL) via multiple passes and a slow delivery technique within a fat pad or just superficial to the periosteum. Novice injectors may struggle with undercorrection or overcorrection until becoming comfortable performing this procedure. Although ecchymosis and prolonged edema may be evident in some patients (typically, 15%), other potential complications of this technique, such as infection, hyperpigmentation of the overlying skin, lower eyelid deformity, or vascular embolization with visual loss, are rare.
Currently, periorbital volume restoration can be achieved with the injection of a variety of available dermal filling agents, including hyaluronic acid derivatives (Restylane; Medicis Aesthetics Inc, Scottsdale, Arizona; Juvederm; Allergan Inc, Irvine, California). A calcium hydroxylapatite derivative (Radiesse; Bioform Medical Inc, San Mateo, California) can be effective when placed along the upper midface and malar eminence, but care must be taken when approaching the infraorbital rim given the thicker consistency of the product. Similarly, a poly-L-lactic acid dermal filler (Sculptra; sanofi-aventis, Bridgewater, New Jersey), which was recently approved by the Food and Drug Administration, also must be used with caution given the potential for granuloma formation in the periocular region, but interest has surfaced given its reported potential for longer-term efficacy. Previous authors24 and our group have learned the importance of thorough dilution of poly-L-lactic acid dermal filler with water, as well as avoiding the technique of a depot injection close to the orbital rim to avoid complications. Although the potential for limited recovery using these nonsurgical injections is a distinct advantage, all these dermal fillers are limited by their effective longevity, which ranges from 6 months to 1 year (possibly longer with poly-L-lactic acid dermal filler). Despite the wide availability of these alternative facial volume fillers, the advantages of autologous fat in the rejuvenation of the periorbital region are numerous, such as a sufficient supply of adipose tissue in most patients; lower expense compared with specially prepared synthetic dermal fillers; the biocompatibility, safety, ease of harvesting, and ready availability of fat; minimal tissue reaction caused by fat transfer; and potential longer-lasting effects of volume restoration provided by fat transfer.
In summary, our experience has led us to believe that the role of volume replacement in periorbital rejuvenation is critical in patients who clearly demonstrate lower eyelid aging due to periocular volume loss. In our experience, periocular volume replacement is achieved most reliably with autologous lipotransfer. Periorbital lipotransfer appears to provide a sufficiently longer-lasting result than other available dermal fillers. Not only does this benefit the patient aesthetically over time but it also allows for a potentially lower financial cost to the patient in the long term by avoiding annual repeated injections. Furthermore, the easy availability of additional autologous fat permits the surgeon to completely contour the periorbital complex appropriately without concern for a compromised undercorrection as a result of using a limited supply of an alternative dermal filler.
Correspondence: Cory C. Yeh, MD, Division of Facial Plastic and Reconstructive Surgery, Yeh Facial Plastic Surgery, 24331 El Toro Rd, Ste 350, Laguna Woods, CA 92637 (info@YehFacialPlasticSurgery.com).
Accepted for Publication: March 15, 2011.
Author Contributions:Study concept and design: Yeh and Williams. Acquisition of data: Yeh and Williams. Analysis and interpretation of data: Yeh and Williams. Drafting of the manuscript: Yeh and Williams. Critical revision of the manuscript for important intellectual content: Yeh and Williams. Statistical analysis: Yeh. Administrative, technical, and material support: Yeh and Williams. Study supervision: Williams.
Financial Disclosure: None reported.
Previous Presentation: This study was presented at the 2010 American Academy of Facial Plastic and Reconstructive Surgery Fall Meeting; September 24, 2010; Boston, Massachusetts.
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