Facelifts and Finishing Touches: Common Additions to a Facelift to Minimize Recovery and Maximize Rejuvenation w/ Dr. Jason Bloom

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Welcome to another episode of
Park Avenue Plastic Surgery Class,

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the podcast where we explore controversies
and breaking issues in plastic

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surgery.

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I'm your co-host Doreen Wu I'm excited
to be here with Dr. Lawrence Bass Park

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Avenue plastic surgeon, educator,
and technology innovator,

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as well as our special guest
facial plastic surgeon,

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Dr. Jason Bloom from
Bryn Mawr, Pennsylvania.

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The title of today's episode is
"Facelifts and Finishing Touches:

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Common Additions to a Facelift to Minimize
Recovery and Maximize Rejuvenation."

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I finally made the decision to
have a facelift slash neck lift,

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but now you're telling me that's not
enough Dr. Bass, what else is needed,

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and why after the stress of making the
decision to go ahead with surgery and

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picking the right surgeon for me?

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I don't want to think
about a lot of other stuff.

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There are a few
considerations here, Doreen,

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the big decision is that
it's time to go ahead.

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You see enough aging change that
you'd like to go ahead with the

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facelift. And the other
big decision is picking

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the surgeon. Who's a good fit for you.

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So once you've done that,

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each surgeon will have a standard
approach and some adjunctive

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techniques that help her or
him to get the best results and

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the least recovery.

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So you can get involved in these
issues and ask the surgeon to lay

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out how they approach things.

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Or you can just leave it to their
judgment and experience if you've

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seen some of their results and
you like what they're doing,

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that's really the bottom line,

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depending on your stage of aging.

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When you proceed with the lift,

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there are other aspects of
facial aging that may also need a

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fix. And I've said this
before on the podcast,

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we we'd like life to be simple,

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where one thing goes wrong and
one treatment fixes everything.

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But the reality is multiple
things change as we age.

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And each one of those has
its own focused treatment or

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procedure. So there are a number
of things that the facelift either

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doesn't address or has
very little impact on.

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Should I be chasing these additional
things at the same time as a facelift?

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It's typical and standard to
address other aging changes on the

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face at the same time as the facelift,

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a good facelift surgeon will point
these things out and you decide

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if they bother you enough to
treat them at the same time.

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What are some examples of this?

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So there are a few things that
are very common or typical that

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I see that are surgically
addressed at the same time as the

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facelift. One is wrinkles.

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If you have wrinkles like lipstick
bleed lines on your upper lip,

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or even some wrinkling in the cheeks,

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these are not going to be
eliminated by the facelift.

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We're not pulling you tight
as a drum. That's distorting.

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That's exactly what we're trying to avoid.

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So those are treated with
chemical peels or laser peels

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very frequently at the same time
as a face lift and eyelid changes

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are another thing. You know,
aging changes in the eyelids,

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that's the thinnest skin
on our entire bodies.

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And that's one of the earliest
parts of our face that shows aging

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changes. So most folks,

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once they've aged enough
to need a facelift,

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if they haven't already addressed
their eyelids, this might be the time.

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So I'll turn now to Dr. Bloom,

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who's graciously agreed to join
us today and is a very experienced

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facelift surgeon and always
has a very sensible approach

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to these things. So Dr. Bloom,

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what kinds of things do you see that
people need to chase at the same time as a

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facelift?

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Well, you know, there's a couple things
when I talk to a patient about facial,

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you know, and I say facial
rejuvenation surgery.

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So whether that's addressing
the jowls, the face,

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the neck but also as you said,

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the eyelids are also a
huge portion of what we do.

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And I will say easily 85% of

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my facial rejuvenation surgeries,

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which include a face neck lift also
includes something in the periocular

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area,

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whether it's upper or
lower and or lower eyelids.

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Additionally, when I'm
talking to patients,

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certainly some of our older patients,

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I say the face ages in
three different ways.

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Number one,

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we get laxity in the muscle
of the face. So, you know,

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you're starting to get some
drooping, or in the neck,

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you start to see banding or
laxity in the muscles. Number two,

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we see a volume loss.

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So whereas we lose volume in
the mid face and some there's

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two kinds of volume loss or atrophy,

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or basically a repositioning of the fat.

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So the deeper fat in the
face tends to atrophy or

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involute. And then the more
superficial fat pads tend to droop.

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So we address the more superficial fat
pads by repositioning them with surgery.

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But sometimes we need to add volume
to the face with fat grafting,

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which is a common additional
procedure that I do,

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to some of the deeper fat pads. And
the last part of aging is the skin.

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As you mentioned, rhytids,

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this is when I say facial rejuvenation
surgery, like a facelift surgery,

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face and neck. This is a surgery
of the muscle and not of the skin.

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We are repositioning

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the muscular tissues and the deeper
tissues to a more rejuvenated setting

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are in more rejuvenated area,

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but we're not pulling the skin tight.

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So rhytids or the skin texture needs
to be addressed with, as you said,

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chemical peels or some kind of
energy based laser or device

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to resurface those skin wrinkles.

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You know, another thing that
we used to do an awful lot of,

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I don't think we do quite
as much now is brow lifting.

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And a lot of patients are surprised
that their brow and tempolaris

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is not going to be picked
up by the facelift.

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And that's partly because
incisions have changed compared to

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facelifting in let's say the 1980s,

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when the incision typically
went almost up to the coronal

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brow lift point.

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Yeah. I would say that I tend to do

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less brow lifting just
because just in my experience,

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that procedure has not lasted
super long in my hands.

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What I tend to do is if
I'm looking at a brow

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lift,

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and the majority of the
hood of the brow is lateral.

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And over the tempolaris muscle, like the
muscle, when you bite your teeth down,

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you can feel, I will tend
to do a temporal brow lift,

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which is easily accessible through
an incision in the hairline.

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And I think that does a nice
job in order to pick up the

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lateral or temporal aspect of the brow.

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Now another type of lift that we're
actually doing more of nowadays

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is lip lifting because as we age,

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the lip changes in a number of significant
ways, including getting longer,

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and lip lift helps with that
and with some other features.

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So is this what you
found in your experience?

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Yeah, I have been doing more
lip lifts than I ever have.

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Certainly I think it's kind of in Vogue

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right now. But yes,

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we do a modified kind of

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like Bullhorn upper lip lift and,

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and depending on the amount
of tooth show that the patient

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wants and volume in the
lip or red lip show,

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you can basically modify that

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based on the patient's wishes.

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I would say maybe every sixth

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facelift I'm doing, I'm adding
some kind of lip lifting procedure.

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And so that's important that there are
a few aesthetic features that the lip

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lift addresses depending on
the individual needs of the

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patient. It could be too long, a lip.
It could be not enough tooth show,

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not enough for a million or the
pink part of the lip showing.

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And all of those things can be
adjusted to an extent with a lip

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lift.

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And this uses an incision
as Dr. Bloom described.

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That's just underneath the
nostrils at the top edge of the lip

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extending around the corner of the
nostril sometimes to an extent,

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and through that incision,
these adjustments can be made.

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So tell me what your thought
process is in deciding whether

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a patient needs fat grafting
along with the facelift.

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I mean,

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obviously we're going to get a degree
of facial shaping with the facelift by

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repositioning those fat pads
and muscles as you described.

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But sometimes that's just not enough.

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Yeah. I mean,

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I think the patients that are really
volume deplete they tend to be

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good candidates for fat
grafting, certainly another,

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when I'm talking to patients,

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another area that I tend to fat
graft because it's not addressed

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during like even a facelift where
you get some mid-face improvement

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is the temples. If they have
a lot of temple hollowing,

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I'll tend to fat graft that.

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I did that today in the operating room
with a patient who is getting a face/neck

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lift. Additionally, my preferred technique
for lower eyelid surgery involves

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an incision through the eyelid
to remove some of the fat.

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And then I do conservative
fat removal there,

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and then I will fat graft around the eyes.

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And so when I do that, and I'm fat
grafting already for lower eyelid surgery,

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I tend to add a little bit of fat in
the cheeks to help position their cheek

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higher, little bit higher,

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to add some in the deep medial
aspect of the face and or the temple,

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if they need to.

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And so if I'm already doing fat
graft for the eyelid eyelid surgery,

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I will add some volume for the face.

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Now we mentioned this earlier,

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when we were going over
our notes for this session,

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that even though you get a number
of other procedures or treatments

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done at the same time as the facelift,

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there may still be some need for
maintenance treatments going forward.

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And that's an important thing for
people to remember and plan for,

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to tell me why, why that is,

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why doesn't the face lift
along with a chemical peel,

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an eyelid plasty, why
doesn't that just cover it?

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Yeah, I mean, I can't tell
you how many patients come in.

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And they think that once
they have a facelift,

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that every one of their
issues is taken care of

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and they won't need any
treatments further, but, you know,

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I tell patients certainly a lot of
what we do with neuromodulators and

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the upper face and the
crow's feet it's to, I mean,

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that's due to the muscle action.

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So a facelift doesn't doesn't stop that.

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So we like keeping the face
rejuvenated and keeping up

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with our neuromodulators and
or fillers for fine lines

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or chemical peels or
laser resurfacing and not

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just ongoing,

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but it'll also help maintain
the results of their surgery

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for years later, you know,

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they just had a big outlay of
money and time and downtime and

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all of this to have this
procedure and they want to keep

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the results looking good.

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So just like you can't buy an
expensive car and expect not

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to like update it every, you know, to
take it in for servicing every so often.

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So what I say is you need to come
in for your regular servicing

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of your face to keep it looking good,

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to keep it in tiptop
condition and allow the

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procedure results to kind of maintain
for the longest amount of time.

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Yeah. I think that, I agree with
all of that. That's absolutely true.

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There are just parts of the
face, like the forehead that

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we're typically treating with Botox and
other neuromodulators that the facelift

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is just not addressing we're expressly,

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trying not to pull really
hard and distort the mouth.

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And so we still need some fillers
in fold areas around the mouth and

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that fabric of the skin that's 50, 60,

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70 years old with all the sun
exposure needs some ongoing

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maintenance and that maintenance is
exactly what's let the facelift age

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trickle up over the last
20 years. And that will,

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by the same token,

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allow the facelift procedure that
you end up having to have more

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longevity and to allow
you to have an overall

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much more completely
rejuvenated appearance.

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Continuing the conversation of
the doing the combined procedures.

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I'm curious,

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what are the advantages and disadvantages
of doing these procedures in

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conjunction with the facelift?

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Well, the big advantage of course,

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is you have one recovery and
you don't have to go back to

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the operating room, have more
anesthesia, have more time off work.

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So everyone would like to
squeeze everything in at once.

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Yeah. I mean, I definitely
agree. I mean, patients want to,

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if they have this big downtime and
I tell them for a face neck lift,

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you're looking at around two weeks
and that's, you know, at a minimum

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they want to have multiple
things done. On the flip side.

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I mean,

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when we talk about disadvantages of
including a lot of different procedures,

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it's time under anesthesia,
it's longer cases.

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They do have potentially more
downtime when all of these

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procedures start to build
and add up on each other.

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Just a little bit more recovery is added.
All of these things kind of add up.

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00:15:57,060 --> 00:16:01,830
They're not without any
disadvantages, but like I said,

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over 85% of my patients seeking
facial rejuvenation surgery have some

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kind of combined adjunctive procedure.

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And I think that's an important point.

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It's okay to group a bunch
of these things together,

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but at some point it becomes
too much for one day.

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There are also some procedures
that we can't do quite as well

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if we do them in
conjunction with a facelift.

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So the most common
example that I run into is

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laser resurfacing.

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If we want to do laser
resurfacing or a laser peel on the

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00:16:41,190 --> 00:16:42,950
lipstick bleed lines,
or the forehead lines,

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we can do that just as aggressively
as we would if we were not doing a

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facelift, but if we're treating
the full face with laser,

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we have to really modify
how much laser exposure the

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skin gets over the areas of
facial skin that are going

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to be undermined or elevated with the
facelift surgery so that the healing

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can still proceed in a safe fashion.

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I totally agree with that. I tend to,

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even when I am doing lasers
laser procedures in conjunction

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00:17:18,660 --> 00:17:22,670
with with a facelift
surgery, around the mouth,

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I tend to go still pretty, very
aggressive doing fully ablative,

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but on the areas where we lift
the skin laterally by the ears and

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jawline,

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I tend to doing fractional
things and a much lighter one

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other thing I'll add
about combined procedures.

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And you said there comes a time where
it's just like too much during the day and

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you see this more than I do, because
I'm just a facial plastic surgeon.

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But I mean,

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I've had people that come in and they want

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tummy tuck and lipo and the breast aug
at the same time as a facial rejuvenation

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surgery. And I, you know,

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now we're talking massive amount
of times in the operating room.

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I've never done like a super long,

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I've done cases like tummy tuck
and a nose job or tummy tuck

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and with some, you know,
plastic surgeons in my area,

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we've done some combined cases
doing a body case and a face case,

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but anything we're talking a
long case on the face neck and

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some kind of combined body
surgery, we always split it up.

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Yeah. That's important safety. We
want everybody to look amazing,

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but safety has to come first.

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And when you get to some
of these body procedures,

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there's much more metabolic
impact to the body

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surgeries. The face surgery,

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00:18:54,840 --> 00:18:59,490
even combined with a number
of additional procedures or

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treatments on the face does not
have a lot of metabolic impact or

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00:19:04,510 --> 00:19:08,410
stress on the body, but
the body procedures do.

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00:19:09,270 --> 00:19:13,970
And so there are really
important limitations

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00:19:14,580 --> 00:19:19,090
based on safety when you're trying
to do those combined procedures.

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00:19:20,000 --> 00:19:23,810
Both of you briefly touched upon recovery
times in your discussion earlier.

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I wanted to ask,

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what are some of the techniques that are
reducing the recovery time associated

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00:19:28,851 --> 00:19:29,890
with the facelift?

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00:19:30,700 --> 00:19:33,710
Well, in my practice, I typically put,

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00:19:34,060 --> 00:19:38,870
instead of just a small amount of
local anesthesia with epinephrine

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00:19:38,890 --> 00:19:43,670
for vasoconstriction, I use a
more dilute local anesthesia,

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00:19:44,060 --> 00:19:48,670
more like the tumescent anesthesia
we use for liposuction and this

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00:19:49,420 --> 00:19:54,390
facilitates dissection, and
also helps minimize blood loss.

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00:19:55,370 --> 00:19:58,190
And one of the other things
we've been doing recently,

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that's had a lot of attention for
plastic surgeons is the use of

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00:20:03,220 --> 00:20:08,110
tranexamic acid which helps
the body's ability to clot

300
00:20:08,250 --> 00:20:13,150
and has reduced swelling and
bruising in almost every plastic

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00:20:13,151 --> 00:20:15,590
surgery procedure that we do.

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00:20:16,650 --> 00:20:21,070
So that's had a big impact on
recovery time for my patients.

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00:20:23,050 --> 00:20:26,250
I will a hundred percent agree
with both of those things.

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00:20:26,770 --> 00:20:30,330
I tend to tumesce the face and neck
when I'm doing these procedures.

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00:20:30,331 --> 00:20:32,650
So putting a little bit
more of a dilute anesthesia,

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00:20:33,190 --> 00:20:37,610
and then I put tranexamic acid. Now
there's multiple different ways to do it.

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00:20:38,270 --> 00:20:39,103
And actually

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00:20:43,670 --> 00:20:45,930
in aesthetic surgery journal open forum,

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00:20:46,430 --> 00:20:49,320
my fellow two years ago wrote a

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00:20:50,820 --> 00:20:53,680
an interesting analysis of all

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00:20:55,270 --> 00:20:57,680
tranexamic acid cases in cosmetic surgery.

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00:20:58,220 --> 00:21:03,080
And I'm presenting some of this data
next week at the facial plastics

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00:21:03,081 --> 00:21:03,914
meeting.

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00:21:04,160 --> 00:21:08,880
But interestingly you can
actually hang it up and give it

315
00:21:09,060 --> 00:21:09,670
IV.

316
00:21:09,670 --> 00:21:14,240
What I tend to do is I mix the
tranexamic acid into my tumescent fluid,

317
00:21:14,820 --> 00:21:19,360
as well as my local anesthetic.
And it works exceedingly well.

318
00:21:19,500 --> 00:21:24,320
It is really been a game
changer in my practice.

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00:21:25,020 --> 00:21:29,960
The one other thing that I will
say is that I don't use drains in

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00:21:29,961 --> 00:21:31,200
my face neck lift surgery.

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00:21:32,900 --> 00:21:36,760
So I use a fibrin sealant
it's called Artiss,

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00:21:37,050 --> 00:21:40,480
which is FDA approved for
rhytidectomy or facelift surgery.

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00:21:41,520 --> 00:21:46,240
And I tend to spray this fibrin
sealant into the neck and lateral

324
00:21:46,400 --> 00:21:47,280
face. And well

325
00:21:48,800 --> 00:21:53,720
certainly nothing's gonna prevent an
expanding hematoma or bleeding that you

326
00:21:53,721 --> 00:21:58,110
would need to evacuate,

327
00:21:58,650 --> 00:22:03,390
but it does help with you know,

328
00:22:03,580 --> 00:22:07,710
helping bleeding and helping the
tissues kind of stick down in the neck

329
00:22:09,010 --> 00:22:09,843
and the recovery.

330
00:22:10,820 --> 00:22:15,710
Yeah. And it's interesting
because I've been using the TXA or

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00:22:15,900 --> 00:22:19,590
tranexamic acid in the two
medicine fluid in the same fashion.

332
00:22:19,591 --> 00:22:22,270
And I just think the potential

333
00:22:24,450 --> 00:22:28,790
it puts the medicine where it
needs to be without with a minimum

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00:22:29,240 --> 00:22:33,110
issue of any systemic effect. But

335
00:22:35,390 --> 00:22:38,630
I think all of these
approaches, as you said,

336
00:22:38,631 --> 00:22:41,910
are not going to prevent a surgical bleed,

337
00:22:41,911 --> 00:22:45,750
that bleeding that's big enough to
require a trip back to the operating room.

338
00:22:45,930 --> 00:22:50,350
But what it's done for us is to critically

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00:22:50,820 --> 00:22:55,390
telescope down the period of
bruising, swelling recovery,

340
00:22:56,180 --> 00:22:59,070
that takes people away from their job,

341
00:22:59,460 --> 00:23:03,070
away from their social activities.
It doesn't make it zero,

342
00:23:03,290 --> 00:23:07,630
but it makes it considerably
shorter than it was historically.

343
00:23:08,330 --> 00:23:11,550
And in our busy, modern
life in the 21st century,

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00:23:11,970 --> 00:23:16,950
that's critical when people are deciding
whether they can go ahead with a

345
00:23:16,951 --> 00:23:18,150
procedure or not.

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00:23:19,230 --> 00:23:20,250
Before we conclude,

347
00:23:20,450 --> 00:23:23,850
I would like to ask both of you to share
some key takeaways for our listeners,

348
00:23:23,851 --> 00:23:26,130
Dr. Bass, would you like to start us off?

349
00:23:27,000 --> 00:23:31,770
Sure. I think the key thing
is to pick a surgeon you're

350
00:23:31,771 --> 00:23:33,130
comfortable working with.

351
00:23:33,131 --> 00:23:37,490
You like their artistry and
the style of their lift,

352
00:23:37,491 --> 00:23:38,570
aesthetically,

353
00:23:38,571 --> 00:23:43,490
the way it looks to you more than whether
they use one technique or another,

354
00:23:43,491 --> 00:23:48,360
that's really important
that there's a good match

355
00:23:48,361 --> 00:23:49,400
in that regard.

356
00:23:49,401 --> 00:23:54,320
And my second piece of advice is don't

357
00:23:54,321 --> 00:23:59,280
leave an obvious aging feature untreated
that you'll be back in a few months

358
00:23:59,281 --> 00:24:03,920
having another operation. You know, if
you look at an aging feature and say,

359
00:24:04,480 --> 00:24:08,160
"I can live with that as it
progresses for the next five years,"

360
00:24:09,560 --> 00:24:13,120
okay, there's no rush to
treat it today, but you know,

361
00:24:13,520 --> 00:24:18,040
if when you're lifted, you're going to
be looking at the saggy eyelid skin,

362
00:24:18,280 --> 00:24:21,080
or you're going to be looking
at the lipstick or bleed lines.

363
00:24:21,760 --> 00:24:24,520
And you're going to be back in three
months doing another procedure.

364
00:24:25,200 --> 00:24:29,680
You may as well just get it done and not
have to make another trip back to the

365
00:24:30,240 --> 00:24:31,073
operating room.

366
00:24:31,500 --> 00:24:36,220
I cannot stress how important
that is. You know I will say,

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00:24:36,860 --> 00:24:41,740
I always like to have the patients
lead the consult in the sense that

368
00:24:42,040 --> 00:24:45,580
my first question always to
them is what's bothering you.

369
00:24:46,480 --> 00:24:49,260
And so when I hear what's bothering them,

370
00:24:49,261 --> 00:24:51,140
they're talking about
their jowls and their neck.

371
00:24:52,180 --> 00:24:57,060
I will then make a suggestion as to,
okay, well, I think the facelift is,

372
00:24:57,060 --> 00:24:59,580
and a neck lift is the right option here.

373
00:25:01,320 --> 00:25:06,140
But I will also interject
if I think something could

374
00:25:07,850 --> 00:25:12,140
also be addressed at the same time
and maybe they don't overtly say it,

375
00:25:12,141 --> 00:25:15,180
but I say to them, "if
we're doing this surgery,

376
00:25:15,860 --> 00:25:19,660
I think it would be beneficial to
address your eyelids at the same time.

377
00:25:20,100 --> 00:25:25,060
I think you have enough aging there,"
and they usually say in most cases,

378
00:25:25,240 --> 00:25:27,220
"oh, you know, those are bothering me too.

379
00:25:29,480 --> 00:25:34,180
It makes enough sense that while we're
going there for this procedure to

380
00:25:34,181 --> 00:25:37,260
bundle that together." And actually, not

381
00:25:38,890 --> 00:25:40,010
that I have to,

382
00:25:40,110 --> 00:25:44,850
but I will say that if patients do
book multiple procedures at the same

383
00:25:44,880 --> 00:25:47,890
time, like if they're booking
their face, neck, and eyelids,

384
00:25:48,170 --> 00:25:52,650
I tend to work with the
price and make it more

385
00:25:52,651 --> 00:25:55,850
reasonable for them to do all the
cases together at the same time.

386
00:25:56,800 --> 00:26:01,010
Well, Dr. Bloom, thank you for
joining us on this podcast.

387
00:26:01,770 --> 00:26:06,730
I think you've given our listeners
a lot of very useful advice from an

388
00:26:07,010 --> 00:26:11,730
experienced and wise surgeon
on how to think about

389
00:26:12,070 --> 00:26:15,330
the entire face rather than
just a single procedure.

390
00:26:17,190 --> 00:26:20,450
And we appreciate your joining
us and sharing your wisdom.

391
00:26:21,040 --> 00:26:22,890
Well, thank you so much
for having me again.

392
00:26:22,891 --> 00:26:25,330
It's always wonderful
talking to both of you.

393
00:26:25,700 --> 00:26:29,730
Thank you, Dr. Bloom for taking the time
to share insight and expertise with us,

394
00:26:29,830 --> 00:26:32,050
and thank you to our listeners
for joining us today,

395
00:26:32,310 --> 00:26:35,930
to hear about the common procedures and
techniques that are helping to maximize

396
00:26:36,070 --> 00:26:39,050
facial rejuvenation in
conjunction with a facelift.

397
00:26:39,330 --> 00:26:42,610
I hope you found this episode as
informative and fascinating as I did.

398
00:26:43,140 --> 00:26:46,800
If you think of other exciting
developments or trends
in plastic surgery that

399
00:26:46,801 --> 00:26:49,160
you would like us to discuss
in upcoming episodes,

400
00:26:49,180 --> 00:26:52,520
please reach out via email or
Instagram. We'll see you next time.

401
00:26:53,820 --> 00:26:57,310
This is Doreen Wu, thanking you
for joining Dr. Bass, Dr. Bloom,

402
00:26:57,310 --> 00:26:59,630
and me for this discussion
of additional procedures,

403
00:26:59,631 --> 00:27:03,430
commonly performed simultaneously
with a facelift or neck lift.

404
00:27:03,850 --> 00:27:06,990
Be sure to tune in next time. And don't
forget to subscribe to our podcast,

405
00:27:07,290 --> 00:27:10,950
to stay up to date with all of the
exciting content that is coming your way.

406
00:27:12,240 --> 00:27:16,190
Thank you for joining us in this episode
of the Park Avenue Plastic Surgery

407
00:27:16,320 --> 00:27:20,830
Class podcast with Dr. Lawrence
Bass Park Avenue plastic surgeon,

408
00:27:21,630 --> 00:27:23,630
educator, and technology innovator.

409
00:27:23,930 --> 00:27:26,390
The commentary in this
podcast represents opinion.

410
00:27:26,620 --> 00:27:29,070
This podcast does not
present medical advice,

411
00:27:29,370 --> 00:27:33,390
but rather general information about
plastic surgery that does not necessarily

412
00:27:33,450 --> 00:27:36,510
relate to the specific conditions
of any individual patient.

413
00:27:36,890 --> 00:27:41,590
No doctor patient relationship
is established by listening
to or participating

414
00:27:41,690 --> 00:27:42,523
in this podcast,

415
00:27:42,860 --> 00:27:46,950
consult your physician to advise you
about your individual healthcare.

416
00:27:47,210 --> 00:27:48,630
If you enjoyed this episode,

417
00:27:48,810 --> 00:27:52,950
please share it with your friends and
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418
00:27:52,951 --> 00:27:56,790
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419
00:27:57,090 --> 00:27:59,310
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