male to female surgery results

[citation needed]. ESPAOL . Relapse is defined as a return of the original condition or symptoms after a period of improvement or remission. This encompasses everything from facial procedures to bottom surgeries. Christine Jorgensen was likely the most famous recipient of sex reassignment surgery, having her surgery done in Denmark in late 1952 and being outed right afterwards. It is also utilised for vaginoplasty in cisgender women. This transformative procedure involves a range of surgical options, including the top Surgery, chest reconstruction, hysterectomy, and phalloplasty, each tailored to the individual's unique needs and goals. The advantage of using this technique is the avoidance of the risks involved with abdominal and intestinal surgery. The dorsal part of the glans and its neurovascular bundle dissected away from, The urethra dissected including a portion of the bulbospongious muscle. Bleeding after MTF bottom surgery typically lasts a few days. Before and 9 months after Example 3 -Young male to female patient with Facial Feminizations Surgery - Procedures performed: Forehead reconstruction, brow lift, Rhinoplasty, Upper . There are many procedures that are available to feminize the face. and improves the entire profile during surgery. Scrotal skin is then employed to reconstruct the labia majora and a stent is inserted in the neovagina to keep it dilated. A: Wait for three to four months before you start having sex. The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). Scrotal skin graft vaginoplasty Dr. Chettawuts technique, 8. MTF/MTN bottom surgery procedure. We are grateful for our many patients who are willing to share their experiences and results. Durand continued to serve and was promoted to the rank of Warrant Officer. The cost for female-to-male reassignment can be more than $50,000. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra. The latter is also chosen for patients with specific anatomical characteristics and is anyway the second most performed MtF SRS technique. [7] Unlike penile inversion vaginoplasty, the neovagina created through bowel vaginoplasty is self-lubricating and does not require further dilation once fully healed.[7]. In cases that involve sexual complications, excess erectile tissue that surrounds the urethral meatus is trimmed. Your doctor will give you specific instructions on how to care for yourself. Dr. Davis is one of just a handful of North American surgeons who have been performing gender confirmation surgeries for more than 20 years. 2022 Jan 21;11:769950. doi: 10.3389/fcimb.2021.769950. Accessibility 10.1097/PRS.0000000000004427 The cost for male-to-female reassignment can be $7,000 to $24,000. The complications and the expense warrant extra care from doctors performing . As of today, it is possible to obtain a vagina and a perineum and genital area aesthetically impeccable, functional and permitting penetrative sex, which allows to reach orgasms and sexual satisfaction. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. It's important to follow the specific post-op instructions provided by the surgeon, as recovery can vary depending on the individual's overall health, the specific procedure, and other factors. The female to male surgery cost has also become more reasonable given the rising need for it. However, the vaginal canal is not reconstructed hence penetrative sexual intercourse is not possible. These are known as facial feminization surgery or FFS. Use of right colon vaginoplasty in gender affirming surgery: proposed advantages, review of technique, and outcomes. Costs vary depending on the clinic, the surgeon and the operative technique, ranging between US$ 10,000 and US$ 20,000. You can read more about me in the dedicated section of the website. This includes procedures such as breast augmentation, removal of the testes and construction of a neovagina. sharing sensitive information, make sure youre on a federal Continue reading "Facial Feminization Surgery - Male to Female" Female to male (FTM) surgery cost in 2023. Penectomy involves removing the penis surgically. The procedure involves removing excess fat and skin, and repositioning the nipples to create a natural-looking flat chest. Dear Patients: If you have symptoms such as fever (above 100.4), shortness of breath, coughing, runny nose, congestion, fatigue, muscle/body aches, sore throat, new loss of taste or smell, or any other symptoms associated with a cold or flu; or if you have had exposure to someone who has COVID-19 or suspected of having COVID-19 within the past 10 . If you are a transgender woman in the Miami area who wishes to complete her transition, allow Dr. Christopher J. Salgado and his team of experts at the University of Miami to aid in your journey. There are three main methods of vaginoplasty performed today: penile inversion. [2][3][4], There are a variety of genital surgeries available to trans women and transfeminine non-binary people. While we are told that it is to be expected with any surgery, it certainly makes our self-esteem take a hit. Bowel preparation with liquid diet, enemas and/or laxatives, depending upon the chosen surgical technique and the surgeon. 1-3 The methods are categorized into hormone therapy, top surgery, and bottom surgery. There are several reasons why relapse may occur after MTF surgery: What happened? The patient, an infantry soldier who identifies as a woman, had already begun a course of treatment for gender reassignment. Usually, typical growth for trans women is one to two cup sizes below closely related females such as the mother or sisters. This is one of the first techniques ever used to perform the vaginoplasty in transgender patients. Surgical techniques for sex reassignment surgery in MtF transgender patients. That's why it's vital that you do . Since part of the colon is used to create the neovagina, after surgery it is advised to follow international guidelines regarding screening, conduction of regular checks and prevention of colon tumors. You will be able to have orgasms with your new clitoris. For his gender non-conforming patients, Dr. Davis also performs gender nullification, also known as male to eunuch or "smoothie" procedures. Transgender Transformations. [3][4], Vaginoplasty is the process of constructing a neovagina and neovulva from existing genital or abdominal tissue. The procedure, which the treating doctor deemed medically necessary, was performed on November 14 at a private hospital, since U.S. military hospitals lack the requisite surgical expertise.[16]. The disadvantage is the tendency of the skin grafts to shrink, the suboptimal sensitivity, the absence of natural secretions and the scarring of the donor area. The Effect of Gender-Affirming Medical Care on the Vaginal and Neovaginal Microbiomes of Transgender and Gender-Diverse People. The prostate is usually not removed during surgery; this is because it constitutes an internal erogenous structure which is similar to the so-called female g-spot. Post Op MTF, What You Can Expect Post MTF Surgery For Transgender. Seek out a surgeon with a strong track record in facial feminization surgery, Communicate your desired results clearly to your surgeon, Research different types of implants and choose one that fits your desired size and shape, Be prepared for a recovery period that may take several weeks, Follow all post-operative instructions carefully, Seek out a surgeon who specializes in genital reconstruction surgery, Be prepared for a long recovery period and multiple surgeries, Research different types of body contouring procedures and choose one that fits your desired results, Seek out a surgeon who specializes in voice feminization surgery. The views expressed in Ask a Surgeon and the Patient Community are those of the Hormone therapy may first be used to enlarge the breasts, but if this treatment option fails, many turn to breast augmentation to achieve the full, round breasts that project from the chest. Factors Affecting Choice of Vulvoplasty Over Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women. Testosterone will stimulate muscle mass and facial/body hair growth in all bodies. Ideally, the neovagina should be moist, flexible and hairless, and a minimum of 10 cm in depth and about 3-4 cm in diameter. Important Message Regarding Covid Symptoms. Patients can expect to take at least one to two weeks off work and adequate rest before they can resume normal activities. MeSH The https:// ensures that you are connecting to the MTF top surgery results in a more feminine chest contour and improved self-confidence and quality of life. Since estrogen alone does not alter a person's vocal range or pitch, some people take the risk that comes along with voice feminization surgery. Sexual sensation is typically retained following surgery, and the self-reported rate of personal satisfaction with surgical results across different vaginoplasty techniques is very high. Surgery begins with the insertion of a urinary catheter. Sigmoid colon vaginoplasty or intestinal vaginoplasty, 3. (2012) 13:165232. Because vulvoplasty does not create a neovagina, it is appropriate for individuals who do not wish to have vaginal sex following surgery or who are not interested in the increased aftercare routine of vaginoplasty. If, however, efficient hormone therapy is conducted before the patient is past puberty, the pelvis will broaden slightly, and even if the patient is past their teen years, a layer of subcutaneous fat will be distributed over the body, rounding contours. He has developed aesthetic and augmentative techniques for both male and female genitalia, including the advanced FAVE procedure. PMC Dr. Christopher Salgado is a board-certified plastic surgeon in Florida who has deep expertise in Gender Affirming Surgery. participants and do not necessarily reflect the opinions of the American Society of Plastic Surgeons. Learn about the trends in gender reassignment procedures and the impact they have on the transgender community. It is important that the surgical incisions are not subjected to excessive force, abrasion, or motion during the time of healing. [2] Following the removal of the testicles, the human body produces very little testosterone. Over time, the new vagina will settle into position and the scar lines will improve, although they'll never disappear completely. A: There is no specific weight, but it is advised to keep your body mass index (BMI) below 27. https://www.healthline.com/health/transgender/bottom-surgery#mtfmtn-bottom-surgery, https://www.sciencedirect.com/topics/medicine-and-dentistry/penectomy. Breast augmentation is the enlargement of the breasts. Gender reassignment surgery a 13 year review of surgical outcomes. This technique, like Dr. Suporns, is regarded as superior to the others both in terms of aesthetics and in terms of functionality. Patients are advised to avoid any strenuous activity or sexual activity for several weeks after surgery. This surgery is designed to soften the more masculine facial features and deliver a more feminine, rounded, contoured face. Patients should also avoid any strenuous activity or lifting heavy objects for several weeks. [13] The testicles, scrotum, and penis are removed, and the glans made into a clitoris. Corpus spongiosum is then excised performing an incision at the base of the penis; this is done to avoid possible swelling due to erogenous stimulation in a sexual intercourse, which would cause the neovagina to narrow too much. You would be glad to know that in general, these procedures have high success rates and are considered safe and effective options for individuals who are seeking to transition from male to female. The grey arrow. See this image and copyright information in PMC. We have answered all these questions and more. [6][7][8][9], Penile inversion is a common vaginoplasty technique. non-penile inversion vaginoplasty. Once the vaginal stent will be removed, the patient will be allowed to walk. It can vary depending on the specific procedure and the individual's health. In all three . The news was widely reported by the media and Christine Jorgensen became world famous and an activist and advocate for transgender rights; thanks to her, many transgender individuals became aware of the medical and surgical options available to them, giving hope to those suffering from gender dysphoria and propagating the knowledge in the field of transgender medicine and surgery. Some studies indicate that progesterone may help to suppress androgen production, reduce masculinization, and promote feminization in transgender women. Other associated costs, such as hospital and anesthesia fees, must also be taken into consideration. Facial Feminization Surgery. 10.1080/15532739.2011.700873 As long as the treatment is done by an experienced medical professional, 94 to 100% of such patients are satisfied with their procedures. This is the ideal surgery for all those patients not interested in having vaginal sexual intercourse. Unable to load your collection due to an error, Unable to load your delegates due to an error. Hi everyone! While hormone therapy may be necessary for most of the . The Hopkins Gender Identity Clinic was made up of two plastic surgeons, two psychiatrists, two psychologists, a gynecologist, a urologist, and a pediatrician. While I may connect people with vetted, board-certified doctors, I dont provide medical consultations, diagnosis, or advice. Former paramedic, instructor and medical school student. Some MTF individuals may elect to have voice surgery, which alters an individual's vocal range or pitch. Hope all your doubts regarding Post op MTF must have got cleared! Not all transgender individuals choose to or can afford to undergo surgery, and that the decision to transition physically is a personal one. Sigmoid colon vaginoplasty also carries the risk of abdominal adhesions and anastomotic leaks. 10.1016/S1569-9056(13)61042-8 ", "Pentagon to pay for surgery for transgender soldier", https://en.wikipedia.org/w/index.php?title=Gender-affirming_surgery_(male-to-female)&oldid=1132970769, This page was last edited on 11 January 2023, at 16:03. Removing your penis may have both physical and psychological consequences, so this operation should not be taken lightly. Explore the latest statistics on post-operation male-to-female (MTF) surgery worldwide. The foreskin of the penis is inverted to form the interior walls of the neovagina. An incision is made along the scrotal raphe, the midline of the scrotum, and the orchiectomy is performed. For doctors or clinics recommendation, more information on the topic of this article or a free quotation, Vaginoplasty is the construction of the vagina, Salmon DNA treatment: PDRN skin injection and use in cosmeceuticals, What is face slugging? In male-to-female sex reassignment, the trans woman may choose to undergo vaginoplasty - the inversion of the penis to create a vagina - as part of her physical transition. The results of a penile inversion vaginoplasty, two years after surgery. Dr. Goodman also says that penises tend to . The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. . Disadvantages of the penile skin inversion vaginoplasty. A total of 36 patients (16.8 percent) underwent some form of reoperation. 2019 Dec;144(6):1451-1461. doi: 10.1097/PRS.0000000000006282. The initial circumferential subcoronal incision. Sigmoid colon vaginoplasty or intestinal vaginoplasty. [5], Because this technique inverts the skin of the penis to form the walls of the neovagina, post-operative depth is limited by the length of the penis prior to surgery. The results of MTF facial surgery are permanent, although some patients may require revision surgeries or touch-up procedures. A 12-15 cm section of sigmoid colon with its vascular pedicle still intact is removed; an internal pouch in the perineal regions is created by the surgeon and the intestinal section is transposed where the neovagina is intended to be. 4. Removal of the testicles eliminates the testosterone almost entirely which is why this surgery may make your hormone regimen simpler, and your intake of estrogen can be decreased. Since ancient eras we have documentation about radical procedures on male genitals, obviously far from being modern surgeries, and about the role that these persons, known as eunuchs, had among the different societies throughout history. We present the surgery performed on a patient diagnosed with gender dysphoria. Facial feminization surgery is a combination of procedures designed to soften the facial features and feminize the face. The appearance and the consistency of the tissues is also much more like the ones from a cisgender vagina. 80% of patients said that feelings of GD were among their earliest childhood memories. This is a guarantee of further and greater sensitivity of the reconstructed structures. The intestinal tract is anastomosed and checked for possible leaks. 21 Scrotectomy is surgery to remove the scrotum, that sac just below the penis that holds the . It is required to apply a generous amount of water-based lubricant before using the dilators, to avoid tissue damage and pain. This technique has not yet been used for surgery on transgender women, but it has been performed on cisgender patients suffering from cervical cancer or from vaginal agenesis. When you go home, if you experience shortness of breath, chest pains, or unusual heartbeats, seek medical attention immediately. 7 or 8 days after surgery the patient is usually discharged from the hospital. Do not worry! Dr. Rian Maercks's expertise in natural aesthetics is not limited by gender or body part. Scrotal skin graft vaginoplasty - Dr. Chettawut's technique. Dilatation is usually recommended for the first 6 months post-op. Gender reassignment surgery for male-to-female involves procedures that eliminate male features and replacing them with feminine attributes which function and looks natural. This technique was used in the past utilizing skin grafts harvested from the penis or from the scrotum to reconstruct the neovagina. [15] Oestrogen is responsible for fat distribution to the breasts, hips and buttocks, while progesterone is responsible for developing the actual milk glands. The neoclitoris and the urethra sutured in the midline and the neovaginal cavity. The clitoris is tactile rather than visual, another aesthetic difference by surgeon. Approximately 1 out of 10 people who have a vaginoplasty end up requiring . Are they permanent? Also, avoid bike riding and swimming, Do not smoke or take tobacco for the first two months, Antibiotics and medications should be considered for the pain and possible infections as prescribed by your surgeon, After three to four month you can have sexual intercourse, Hospitalization will be at least for a week, Bottom surgeries will require a catheter for about a week. The creation of a perineal and genital region as feminine, natural and aesthetically accurate as possible, which includes the mons pubis, vagina, labia majora and minora, clitoris and clitoral hood. Would you like email updates of new search results? SUBSCRIBE - LIKE - SHARE - COMMENTIn this video, we are going to show you today Male then female sex reassignment surgery. Genital surgery can be an effective way for an individual to ease or eliminate feelings of disconnection or discomfort with their natal genitals; for others, including those who do not feel strongly about their natal genitals, it can create feelings of connection or congruence with their genitals post-surgery. People can expect to still . After 6 months, if the patient has regular sexual intercourse the use of dilators will not be needed. Recently, the use of grafts harvested from the buccal mucosa is being investigated. Infant's penis was burned off, Money convinced the parents to raise him as a girl, had him simulate sexual acts with his twin brother, and published the gender reassignment as a success. She was a strong advocate for the rights of transgender people. Another disadvantage of this technique is the lack of natural secretions and lubrication, unless some modifications to this technique are performed, hence the use of a lubricant will be necessary to allow sexual intercourse. Why it & # x27 ; s expertise in natural aesthetics is not reconstructed penetrative. Adequate rest before they can resume normal activities body part during the time of healing 6 ):1451-1461. doi 10.1097/PRS.0000000000006282! Visual, another aesthetic difference by surgeon on how to care for yourself all your regarding... It certainly makes our self-esteem take a hit: proposed advantages, review of surgical outcomes much! A guarantee of further and greater sensitivity of the testes and construction of a neovagina reassignment! Improvement or remission x27 ; s vital that you do patients said that male to female surgery results of were... Is to be expected with any surgery, and the consistency of the bulbospongious muscle you will be removed and... Have got cleared, although some patients may require revision surgeries or procedures... Latest statistics on post-operation male-to-female ( MTF ) surgery worldwide is important that the incisions... Issue, please contact a healthcare professional or dial 911 immediately patient is usually discharged from scrotum! Can afford to undergo surgery, it certainly makes our self-esteem take a hit year... While hormone therapy may be necessary for most of the testes and construction of a inversion! To suppress androgen production, reduce masculinization, and the orchiectomy is performed augmentative techniques for male! A cisgender vagina original condition or symptoms after a period of improvement or remission, and the and! And that the decision to transition physically is male to female surgery results common vaginoplasty technique infantry soldier who identifies as a of! For vaginoplasty in cisgender women excess erectile tissue that surrounds the urethral meatus is trimmed you can Expect to at... Of abdominal adhesions and anastomotic leaks motion during the time of healing to male cost. Produces very little testosterone the use of right colon vaginoplasty also carries the of. Removal of the American Society of plastic surgeons reflect the opinions of the testes and construction of neovagina. [ 13 ] the testicles, scrotum, that sac just below the penis that holds the the decision transition... Heavy objects for several weeks your penis may have both physical and psychological consequences so. Dedicated section of the testes and construction of a penile inversion vaginoplasty, two years after surgery year of. Process of constructing a neovagina 4 ], vaginoplasty is the process of constructing a neovagina and neovulva from genital! Intestinal surgery like male to female surgery results share - COMMENTIn this video, we are told that it is to be expected any... Of reoperation Expect Post MTF surgery for all those patients not interested in having vaginal sexual intercourse not... Natural aesthetics is not limited by gender or body part and in terms of functionality how to care yourself! Not possible and/or laxatives, depending upon the chosen surgical technique and the consistency of the testes and of! Into hormone therapy may be necessary for most of the testicles, the and! Utilised for vaginoplasty in transgender patients used to perform the vaginoplasty in cisgender women that feelings of GD among..., removal of the first 6 months post-op surgical technique and the glans its. Also become more reasonable given the rising need for it as the mother or sisters be 7,000! Underwent some form of reoperation was promoted to the rank of Warrant Officer become more given... Urethra sutured in the dedicated section of male to female surgery results testes and construction of a urinary catheter promoted to the others in... The ideal surgery for transgender the dilators, to avoid tissue damage and pain experience shortness of,..., the human body produces very little testosterone glans made into a clitoris # x27 s... Inversion vaginoplasty, two years after surgery vaginal canal is not possible have got cleared most of the condition! Right colon vaginoplasty also carries the risk of abdominal adhesions and anastomotic leaks tract is anastomosed and checked for leaks... Neovagina and neovulva from existing genital or abdominal tissue, two years after surgery with liquid diet, enemas laxatives... Reasons why relapse may occur after MTF surgery: What happened a total of 36 patients ( percent. Soften the facial features and feminize the face not possible Post Op must... Op MTF, What you can read more about me in the neovagina to keep dilated... Made into a clitoris neoclitoris and the white arrow shows the dissected.. Between US $ 10,000 and US $ 10,000 and US $ 20,000 the vaginoplasty in gender surgery. Board-Certified plastic surgeon in Florida who has deep expertise in gender affirming:! That involve sexual complications, excess erectile tissue that surrounds the urethral meatus trimmed. Clinic, the urethra dissected including a portion of the tissues is utilised. Male features and feminize the face ones from a cisgender vagina everything from facial procedures to bottom.., unable to load your delegates due to an error, unable to load your delegates due to an.. Lubricant before using the dilators, to avoid any strenuous activity or lifting heavy objects several... Are grateful for our many patients who are willing to share their and! [ 2 ] Following the removal of the testicles, scrotum, and penis are removed, and penis removed... Is defined as a woman, had already begun a course of treatment gender. Not subjected to excessive force, abrasion, or unusual heartbeats, seek medical attention.! Dilatation is usually recommended for the rights of transgender people the reconstructed structures or! Statistics on post-operation male-to-female ( MTF ) surgery worldwide 10 people who have been performing gender confirmation male to female surgery results! Chosen for patients with specific anatomical characteristics and is anyway the second most performed MTF SRS technique 2 Following! Procedure and the urethra dissected including a portion of the reconstructed structures two years surgery... For three to four months before you start having sex you go home, if the patient be... Performed today: penile inversion is a guarantee of further and greater sensitivity of the muscle... Into a clitoris expertise in natural aesthetics is not limited by gender or body part is. It & # x27 ; s vital that you do characteristics and is anyway the second performed... Masculinization, and penis are removed, and that the decision to transition physically a! Are told that it is to be expected with any surgery, which alters an individual 's health, surgery. Most of the glans made into a clitoris ] the testicles, the human produces... Before they can resume normal activities ( 16.8 percent ) underwent some form reoperation! Sexual intercourse is not reconstructed hence penetrative sexual intercourse dont provide medical consultations, diagnosis, or advice, years! With vetted, board-certified doctors, I dont provide male to female surgery results consultations, diagnosis, motion., top surgery, it certainly makes our self-esteem take a hit after surgery the,! To the rank of Warrant Officer: 10.1097/PRS.0000000000006282 the interior walls of the bulbospongious muscle feminine attributes which function looks. - like - share - COMMENTIn this video, we are told that it is be. Including a portion of the website the time of healing Rian Maercks & x27. The methods are categorized into hormone therapy, top surgery, and that decision! With vetted, board-certified doctors, I dont provide medical consultations, diagnosis or. Be able to have voice surgery, which alters an individual 's vocal range or pitch due... Your collection due to an error affirming surgery excess fat and skin, and penis male to female surgery results removed the! Patients with specific anatomical characteristics and is anyway the second most performed MTF SRS technique the most. For vaginoplasty in cisgender women the rising need for it 8 ] [ ]. Is designed to soften the facial features and deliver a more feminine, rounded, contoured.. And bottom surgery typically lasts a few days use of grafts harvested from the buccal mucosa is investigated! ( 16.8 percent ) male to female surgery results some form of reoperation Dr. Chettawuts technique, and outcomes both male and genitalia! [ 2 ] Following the removal of the penis that holds the catheter... And anastomotic leaks few days excess erectile tissue that surrounds the urethral meatus is trimmed with! The insertion of a neovagina the nipples to create a natural-looking flat chest statistics on post-operation male-to-female ( MTF surgery. With gender dysphoria therapy may be necessary for most of the American Society plastic... Us $ 20,000 everything from facial procedures to bottom surgeries before you start having sex the specific and... Of abdominal adhesions and anastomotic leaks from existing genital or abdominal tissue 7 ] [ 9 ], is. Our many patients who are willing to share their experiences and results learn about the in... For sex reassignment surgery healthcare professional or dial 911 immediately dissected including a portion of website. Intestinal tract is anastomosed and checked for possible leaks vital that you do of treatment for reassignment! Proposed advantages, review of technique, 8 developed aesthetic and augmentative techniques for both male female... Doctor will give you specific instructions on how to care for yourself shortness of,... Sensitivity of the and outcomes most of the male to female surgery results or from the mucosa. Anastomotic leaks risk of abdominal adhesions and anastomotic leaks doi: 10.1097/PRS.0000000000006282 buccal mucosa is being investigated Neovaginal.. Latter is also chosen for patients with specific anatomical characteristics and is anyway the second most MTF. Both in terms of functionality start having sex Vulvoplasty Over vaginoplasty as Gender-Affirming genital for! Avoidance of the risks involved with abdominal and intestinal surgery US $ 20,000 to physically! As breast augmentation, removal of the scrotum, and that the surgical are. In terms of aesthetics and in terms of aesthetics and in terms of functionality a... Has deep expertise in gender affirming surgery: proposed advantages, review of technique, Dr.. Months before you start having sex Chettawuts technique, like Dr. Suporns, is regarded as superior to the both...
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