Endoscopic lipofilling for velopharyngeal insufficiency after transoral surgery: a technical note.

BACKGROUND: Velopharyngeal insufficiency (VPI) is a known complication of transoral surgery, with a reported incidence of 8.1%. The main factor related to VPI is the split of the soft palate. However, dead space resulting from transoral decompression may play a pivotal role in the pathogenesis of the dysfunction. In our experience, functionally significant dead space is almost constantly present after transoral decompression. This is probably due to malformation in children and postoperative scarring, thus configuring a nosological entity that we could define as "syndrome of the nasopharyngeal dead space." Palatal prosthesis and pharyngoplasty have been proposed, though these surgical procedures are technically tricky and with possible complications, such as OSA symptoms, snoring, and nasopharyngeal stenosis. METHODS: We proposed an effortless and minimally invasive procedure to treat this condition based on lipofilling the nasopharynx posterior wall endoscopically. To test the procedure's functional result, the submucosa of the nasopharynx posterior wall was initially filled with resorbable material, namely fibrin glue and autologous blood. The result was optimal but regressed after one month. Then, we repeated the procedure by lipofilling with autologous abdominal fat, resulting in a more stable anatomical and functional outcome at six months follow-up. RESULTS: The patient had a prompt significant improvement of his complaints (rhinolalia and oronasal regurgitation) and a correct projection of the nasopharynx posterior wall, with correct closure during phonation and absence of oronasal reflux. CONCLUSIONS: The "syndrome of the nasopharyngeal dead space" should be correctly identified after transoral surgery. It can be effectively treated with lipofilling of the posterior nasopharyngeal wall, a simple and minimally invasive procedure.

Arteriovenous fistula of the mandible: a case report.

Intraosseous arteriovenous malformations (AVM) are uncommon high-flow vascular malformation that can affect the maxilla or mandible. AVM may present with aspecific and misleading signs and symptoms. The diagnosis is often accidental and bleeding may represent the first symptom. Radiographically, there are few characteristic features and misdiagnosis is easy. Here we report the case of a young male affected by arteriovenous fistula on the right side of the mandible initially misdiagnosed as a cystic lesion. The patient underwent transarterial embolization of the vascular malformation and subsequently the lesion was surgically removed. 1-year follow-up showed complete healing of the mandibular bone and absence of recurrence. Intraosseous arteriovenous malformations are rare entities. However, due to their harmfulness, both clinicians and radiologists must be aware of this type of lesion and should always consider them in the differential diagnosis of osteolytic lesions.

Validation of the Quality Analysis of Medical Artificial Intelligence (QAMAI) tool: a new tool to assess the quality of health information provided by AI platforms.

BACKGROUND: The widespread diffusion of Artificial Intelligence (AI) platforms is revolutionizing how health-related information is disseminated, thereby highlighting the need for tools to evaluate the quality of such information. This study aimed to propose and validate the Quality Assessment of Medical Artificial Intelligence (QAMAI), a tool specifically designed to assess the quality of health information provided by AI platforms. METHODS: The QAMAI tool has been developed by a panel of experts following guidelines for the development of new questionnaires. A total of 30 responses from ChatGPT4, addressing patient queries, theoretical questions, and clinical head and neck surgery scenarios were assessed by 27 reviewers from 25 academic centers worldwide. Construct validity, internal consistency, inter-rater and test-retest reliability were assessed to validate the tool. RESULTS: The validation was conducted on the basis of 792 assessments for the 30 responses given by ChatGPT4. The results of the exploratory factor analysis revealed a unidimensional structure of the QAMAI with a single factor comprising all the items that explained 51.1% of the variance with factor loadings ranging from 0.449 to 0.856. Overall internal consistency was high (Cronbach's alpha = 0.837). The Interclass Correlation Coefficient was 0.983 (95% CI 0.973-0.991; F (29,542) = 68.3; p < 0.001), indicating excellent reliability. Test-retest reliability analysis revealed a moderate-to-strong correlation with a Pearson's coefficient of 0.876 (95% CI 0.859-0.891; p < 0.001). CONCLUSIONS: The QAMAI tool demonstrated significant reliability and validity in assessing the quality of health information provided by AI platforms. Such a tool might become particularly important/useful for physicians as patients increasingly seek medical information on AI platforms.

Orbital Exenteration in Recurrence Cancer: 5 Years Experience.

INTRODUCTION: The purpose of this study was to assess the overall survival (OS) and disease-free survival (DFS) of patients who underwent orbital exenteration for periorbital, conjunctival, and primary intraorbital carcinomas. Additionally, we assessed the outcomes of anterior retrograde temporalis muscle flap restoration. METHODS: For all patients who had orbital exenteration in the previous five years, a non-comparative retrospective assessment of their medical records, histology, and radiographic imaging was carried out. We investigated the relationships between the various qualitative factors using Cramer's V Kaplan-Meier (KM) analysis. For each of the patient's categorical factors that were of relevance, estimates of the survival distribution were displayed, and log-rank tests were used to determine whether the survival distributions were equal. RESULTS: This study looks at 19 participants. The sample is made up of 13 men (68%) and 6 women (32%). The degree of relationship (Cramer's V index) between lymph node metastases (N) and the existence of distant metastases (M) is high, at 64%, and is statistically significant because the p-value is 0.0034 < 0.005. Lymph node metastases had a statistically significant impact on overall survival (p = 0.04 < 0.05). Thirteen of the nineteen patients tested had no palsy (68%). There was no one presenting a CSF leak. CONCLUSION: Our findings show how crucial it is to identify any lymph node involvement that orbital neoplasms may have. In patients who have received many treatments, sentinel lymph node biopsy (SLNB) may be used to determine the stage and spread of the cancer. To determine whether additional tumor characteristics may be explored, more expertise in the SLNB field for patients with orbital cancer who have received many treatments may be helpful. To prevent additional scarring and to be comparable to previous techniques for facial nerve lesions, the anterior retrograde approach and the transorbital procedure for temporal muscle flap in-setting are both effective methods.

The Use of a CAD/CAM Thermoformed Splints System in Closed Reduction of Condylar Fractures.

(1) Background: Mandibular fractures are very common. Common indications of closed treatment for mandibular fractures are non-displaced or minimally displaced simple fractures in adult compliant patients with good dentition, the absence of occlusal disruption, and fractures in growing children. In closed treatment, the mandible is maintained in centric occlusion with a maxillomandibular fixation (MMF) with orthodontic elastics. Many methods of MMF have been described, often using orthodontic appliances. In recent years, CAD-CAM technology has improved many procedures used in maxillofacial surgery and orthodontics. The device we present is manufactured following a digital workflow, and was designed specifically for MMF. (2) Materials: Two patients with mandibular fractures were treated with an MMF method whose procedure comprised scanning of the dental arches, followed by construction of thermoformed splints on which buttons for the elastics and retention holes are made. The splints were fixed on the dental arches with composite resin at the level of the holes, and were kept in place for the period of healing of the fracture, with the intermaxillary elastics hooked to the buttons. (3) Results: The application time of the splints was very quick. The splints remained stable for the necessary time, without causing particular discomfort to the patients. (4) Conclusions: From our experience, this technique has proved to be reliable and reproducible and could represent a valid tool in the closed treatment of mandibular fractures.

Accuracy of ChatGPT-Generated Information on Head and Neck and Oromaxillofacial Surgery: A Multicenter Collaborative Analysis.

OBJECTIVE: To investigate the accuracy of Chat-Based Generative Pre-trained Transformer (ChatGPT) in answering questions and solving clinical scenarios of head and neck surgery. STUDY DESIGN: Observational and valuative study. SETTING: Eighteen surgeons from 14 Italian head and neck surgery units. METHODS: A total of 144 clinical questions encompassing different subspecialities of head and neck surgery and 15 comprehensive clinical scenarios were developed. Questions and scenarios were inputted into ChatGPT4, and the resulting answers were evaluated by the researchers using accuracy (range 1-6), completeness (range 1-3), and references' quality Likert scales. RESULTS: The overall median score of open-ended questions was 6 (interquartile range[IQR]: 5-6) for accuracy and 3 (IQR: 2-3) for completeness. Overall, the reviewers rated the answer as entirely or nearly entirely correct in 87.2% of cases and as comprehensive and covering all aspects of the question in 73% of cases. The artificial intelligence (AI) model achieved a correct response in 84.7% of the closed-ended questions (11 wrong answers). As for the clinical scenarios, ChatGPT provided a fully or nearly fully correct diagnosis in 81.7% of cases. The proposed diagnostic or therapeutic procedure was judged to be complete in 56.7% of cases. The overall quality of the bibliographic references was poor, and sources were nonexistent in 46.4% of the cases. CONCLUSION: The results generally demonstrate a good level of accuracy in the AI's answers. The AI's ability to resolve complex clinical scenarios is promising, but it still falls short of being considered a reliable support for the decision-making process of specialists in head-neck surgery.

Patient-Specific Facial Implants in Polyetheretherketone and Their Stability: A Preliminary Study.

BACKGROUND: Polyetheretherketone (PEEK) is a synthetic material with many favorable characteristics; PEEK implants are increasingly used for a variety of applications ranging from cranioplasty to orthopedic surgery and facial implants. METHODS: This study is a retrospective review of patients who underwent PEEK implant placement in our department over the last 5 years. Polyetheretherketone computer-aided design and manufacture facial implants were designed from high-resolution computed tomography (CT) scans of each patient. The implants placed were onlay implants used for facial rehabilitation purposes to correct malformative and posttraumatic malformations. RESULTS: Twenty-eight consecutive patients (11 males and 17 females) underwent PEEK implant positioning between January 2015 and December 2020. Common indications were anterior plagiocephaly, hemifacial microsomia, and residual facial imbalance after orthognathic surgery. No complications of implant breakdown, exposure, infection, or displacement were noticed during the follow-up period. During routine controls on 3 patients, we requested a craniomaxillofacial CT scan for reasons unrelated to the implanted prostheses. The CT scans were all high resolution (<1-mm slices). The CT images indicated that bone was starting to form around the implant in all 3 patients as well as in the penetrating holes that were planned in the implants. CONCLUSIONS: In our experience, computer-designed, patient-specific PEEK onlay implants are a valid option for the treatment of malformative and posttraumatic malformations. This is, to the best of our knowledge, the first clinical report on bone reaction to PEEK implantation in the maxillofacial field. Moreover, based on the signs of bone regrowth that we observed in CT controls we can presume that the design of this type of prosthesis can probably take advantage of some technical stratagems not yet codified and fully exploited. Despite our preliminary favorable results, further multicentric and comparative studies are necessary to evaluate outcomes and better understand the behavior of this promising material and thus optimize its use in craniomaxillofacial surgery.

Our problems and observations in 3D facial implant planning.

BACKGROUND: Three-dimensional renderings of two-dimensional computed tomography data have allowed for more precise analysis in the craniofacial field. Design, engineering, architecture, and other industries have paved the way for the manipulation and printing of three-dimensional objects. The usual planning is only carried out based on the bony structures, often without taking into consideration the presence of soft tissues and soft structures. During our practice, we have found ourselves facing the challenge posed by these structures; the aim of this article is to discuss our experience in designing implants presenting our tips and tricks for a better planning leading to an easy and reliable positioning. CASE PRESENTATION: We have retrieved all patients in 5 years among those who underwent computer-aided design/computer-aided manufacturing implant placement in the last 5 years in order to review the eventual problems and the solutions found. A total number of 25 patients were retrieved and, among them, 10 patients were selected, in which planning inaccuracy caused difficulties during implant placement and which then led to induced changes during the planning of similar cases or in which the problems were noted before or during the planning which led to changes in the plan to address those problems. Six of the selected cases were polyetheretherketone facial implants for the correction of residual deformities in malformed or deformed patients. One case was a delayed orbital reconstruction with a titanium implant. Two cases were titanium functional and anatomical reconstruction of the mandible in patients with failed post-oncological reconstructions. There was 1 case with a mandibular ramus complex and hard-to-treat fracture. CONCLUSIONS: The planning of the implant mostly relies on hard tissue three-dimensional reconstruction, but it should not be limited at what is immediately evident. A surgeon's clinical experience should always guide the process, with knowledge of the patient's anatomy and evaluation of the quality and of the soft tissue response being taken into consideration. The implant should always be tailored not only based on the bone defect and evaluations but also using the patient's previewed and actual anatomy, evaluating eventual interferences and pitfalls.

Influence of SARS-CoV-2 lockdown on the incidence of facial trauma in a tertiary care hospital in Rome, Italy.

BACKGROUND: Italy has been the first affected country in the western hemisphere by SARS-CoV-2 with over 200,000 cases during the first months of the pandemics. To control the spread of the virus, the whole country was placed under lockdown with limitations in the circulation of people and vehicles from March 2020 to the first half of the month of May. METHODS: We aimed to analyze the incidence and type of facial traumas referred to our tertiary care hospital during the months of Italy lockdown due to SARS-CoV-2 spread compared with those during the same months of 2019 to determine eventual variations in the incidence, type and causes of trauma. RESULTS: During the 2 months of COVID-19-related lockdown, a dramatic decrease in facial trauma patients was observed at our tertiary care hospital with a shift toward older age ranges. Regarding the causes of trauma, the largest percentage reduction was found in road, sports and work accidents; this percentage reduction was not found in aggressions. CONCLUSIONS: A small increase in the percentage was also found regarding surgical indications, likely because more severe cases were more prone to be referred to the hospital despite the fear of being infected.

An Orthodontic Index assessment and its relationship with total treatment time in surgery first orthognathic approach: an observational study.

BACKGROUND: The aim of this study was to highlight the connection between orthodontic difficulty before surgical treatment and in the transient malocclusion as evaluated by the mean of the of Complexity, Outcome, and Need (ICON) Score and total treatment time in surgery-first approach (SFA). METHODS: For each patient, the ICON Score was evaluated preoperatively and on the 3rd postoperative day in order to assess the orthodontic difficulty of presurgical occlusion and the transient malocclusion. RESULTS: Our group of patients at the preoperative stage showed score values between hard and very hard with only one patient scored as "easy" and nine "medium" patients. All scores lowered after surgical treatment. This confirms that the surgery first approach can change a malocclusion from not orthodontically treatable to an orthodontically treatable one. In our study, this was objectified by improvements in the ICON Score. CONCLUSIONS: In the conventional three-phase approach of orthognathic surgery the total treatment time found in literature is around 18-36 months. In our study, even the most difficult cases do not have a duration of more than 15 months This demonstrates that the surgery-first approach can reduce the total treatment time even in more severe cases.

Patient First: Surgery First and More.

INTRODUCTION: The success of surgery first approach has been defined by the number of advantages offered and is definitively determined by the satisfaction of the patients themselves. The strength of this protocol resides in its philosophy that puts the patient at the center of the whole diagnostic-therapeutic process. The compliance of the patient, its happiness and comfort are the best guarantee of a good final results. While pursuing this philosophy we have wondered whether there was way to increase the comfort of surgery first approach even more and to make it even more appealing for the patients. For these reasons, we have decided to work on a preliminary protocol in order to reduce or even eliminate the use of orthodontic braces and wires during perioperative stages. Materials and Methods: No orthodontic braces or wires are bonded on the teeth before surgery. Intraoperatory intermaxillary fixation (IMF) is carried out with the use of IMF screws which are positioned at the beginning of the operation on the edge between keratinized and nonkeratinized gingiva. Once the osteotomies are performed IMF with IMF screws is carried out on the planned occlusion with the use of surgical splints.Discussion and Conclusions: In selected cases the postsurgical orthodontic treatment can be carried out with the use of clear aligners, completely eliminating the need of braces and wires with an additional level of comfort.

Approach to Fronto-Orbital Sequelae in Anterior Synostotic Plagiocephaly: Our Flow Chart Based on Di Rocco Classification.

INTRODUCTION: Anterior synostotic plagiocephaly recognizes the synostosis of one of the hemicoronal sutures as a cause and can manifest itself with varying degrees of severity. Clinically it presents a reduction of the sagittal growth of the affected side and flattening of the frontoparietal complex. MATERIALS AND METHODS: The authors retrospectively examined our case sample dividing it into 3 groups based on the Di Rocco classification. For each category, we assessed the extent of facial alterations at the end of skeletal growth and retrospectively analyzed the surgical options aimed at correcting aesthetic and skeletal deficits. RESULTS: The authors found that predictable results could be obtained by standardizing the surgical procedure based on Di Rocco's classification groups; in particular, the authors achieved satisfactory results by assigning a specific surgical procedure to each class.

Functional Upper Airway Space Endoscopy: A Prognostic Indicator in Obstructive Sleep Apnea Treatment with Mandibular Advancement Devices.

PURPOSE: The use of a mandibular advancement device (MAD) in the treatment of obstructive sleep apnea (OSA) is a consolidated therapy. This study aimed to evaluate the predictive value of awake upper airways (UA) functional endoscopy in identifying the outcome of MAD therapy. METHODS: This observational prospective study included 30 adult OSA patients, all patients underwent pre-treatment awake UA functional endoscopy, during the exam subjects were instructed to advance their mandible maximally, and they were divided into three different groups according to the response of the soft tissue, group A (expansion), group B (stretch), group C (unchanged). The results of this test were used in combination with other noninvasive indexes to predict the treatment outcome in terms of apnea-hypopnea index (AHI) reduction. RESULTS: We found that a substantial AHI reduction occurred in group A and group B while e slight AHI reduction was measured in group C. CONCLUSION: Based on our experience the awake UA endoscopy is a valid prognostic exam for discriminating responder and non-responder patients; in addition our results indicate the possibility of predicting a range of post-treatment AHI index values.

Virtual Surgical Planning for Reconstruction of Giant Ameloblastoma of the Mandible.

Ameloblastoma is a histologically benign tumor that behaves aggressively because of its tendency to invade local structures, and it has a high probability of local recurrence. If neglected, ameloblastomas can grow substantially over the course of years, reaching the size of giant ameloblastomas. This large size can lead to deformities in facial appearance and impairments in speaking, swallowing, eating, and breathing.Surgical planning can be challenging because of the extension of the tumor and the consequent reconstructive issues.In this article, we present our experience with the reconstruction of 2 cases of giant ameloblastomas planned on the basis of occlusal casts and acrylic splints. In these patients, computerized planning was rendered complex and potentially inaccurate because of the dimensions of the tumor, the loss of anatomical landmarks, and the loss of occlusal landmarks. The cases were successfully reconstructed, but the technique can be flawed. A 3-dimensional virtual model of the mandible can be used as a template to develop cutting guides for reconstruction with free fibular flaps. This will allow us to overcome limitations, standardize the procedure, and achieve optimal functional and aesthetic results.

Use of an Oral Device in the Stabilization of Facial Advancement after Early Removal of the Osteodistraction Device for Postoperative Sequelae.

The aim of this study is to present an oral device that improves splanchnocranium stability after osteodistraction in children treated for correction of craniofacial malformations. When removal of the distraction device before the end of the treatment is necessary, the reposition of a new fixation system might not be possible. In these cases, regrown bone is immature, and relapse of malformation occurs frequently. We have been treating these cases by the application of an oral device named Maxillary Advancement Contention (MAC). MAC is used in every patient when any complication interrupts the protocol of osteodistraction before the end of the stabilization time. The device is placed immediately after the removal of the distraction device and left in place for at least three months. We used MAC in six children surgically treated for correction of craniosynostosis with facial or craniofacial advancement. To establish the relapse of malformation we analyzed relations Sella-Nasion-Orbitale (SNOr) and Sella-Nasion-A point (SNA) angles before application of the MAC and after one year. The analysis of stability was excellent in every patient. This device might help, with a minimally invasive procedure, to maintain the obtained advancement allowing stabilization of the regrown bone.

Use of Navigation System in Craniofacial Surgery.

The use of navigated surgery in the treatment of craniofacial malformations can help obtain optimal results. In this article, the authors will discuss a case of anterior plagiocephaly, corrected with frontorbital bandeau remodeling. Navigation was used during the osteotomy and the reposition phase to ensure the correct positioning of the osteotomy instruments. It was also used to ensure that the bandeau was correctly repositioned in accordance with the surgical plan determined during the virtual simulation phase of the surgery.

Early Surgical Treatment in Anterior Synostotic Plagiocephaly: Is This the Best Choice?

At the end of craniofacial growth, in anterior synostotic plagiocephaly, some aesthetical deficiencies may still be evident. This can depend on an inadequate initial correction or on altered postoperative growth or even on the combination of the 2 factors.Aesthetic alterations can result from various factors that could potentially affect the skeleton, the skin, subcutaneous, and muscular tissues.The pathological changes in the cutaneous and subcutaneous tissues are greater in patients who have undergone multiple surgical treatments of the frontoorbital area. The aim of this observational cohort study is to assess the residual aesthetic and functional impairment at the end of skeletal growth, in patients affected by anterior synostotic plagiocephaly who have undergone surgery at an early age. The purpose is to investigate whether early surgery can still be considered unavoidable in patients with this malformation.Between July 2012 and February 2015, patient's data were retrieved from our archives among the patients referred to our department from 2003 to 2012 for Anterior Synostotic Plagiocephaly at an early age.The authors studied this patient with CT scans and photographic documentation. On CT scans, the authors have assessed skeletal alterations, soft tissues alterations, and muscular tissue alterations. With photographic documentation, the authors have studied the perception of the malformation among external subjects.From this study it was possible to demonstrate that is many esthetical alterations are to still to be found in patients treated with an early surgical approach; for this reason in children without early complications, the authors suggest that surgical treatment should be delayed after the end of craniofacial growth.

The Rules of Attractiveness: A Study on the Lower Facial Third.

What is considered attractive may not fall into the "norm," and it can vary from culture to culture and depending on the historical time, for this reason the standard cephalometric and antropometric references may not be sufficient in these cases.Lately some techniques have arose to popularity that are aimed to changing the frontal and lateral aspect of the facial lower third, such as V-line or the Chin-Wing Osteotomy technique, but no reference system exists at the moment to define to which extent a modification of the lower third falls within what is considered beautiful, and everything is left to the patient's will or to the surgeon's sensitivity.The aim of this article is to study which antropometric value is considered attractive by the most for what concerns the frontal shape of the lower third of the face.Twenty-four female models were enrolled in this study and the angle taken into consideration was the one at the intersection between the 2 lines connecting the cutaneous gonial angle of each side of the face and the most external part of the chin on the same side. Measures were made on pictures in frontal view.Two hundred two random examiners were asked to see the pictures and rate them as attractive or nonattractive.Results were then paired with the angles values.Among the models the higher angle measured was 107.5° (found in 1 individual) while the lower angle was 76° (found in 1 individual), the average measure calculated was 88.3° while the median angle was 89.5°.According to the result the subjects considered more attractive were those with an angle between 84.5 and 91.5 (92 for male examiners).This could be an important starting point for studies who can evaluate attractiveness from a numerical point of view.

Phosphaturic mesenchymal tumor, an unusual localization in head and neck.

Phosphaturic mesenchymal tumor (PMT) is a rare mesenchymal neoplasm associated with tumor-induced osteomalacia involving bone and soft tissue that produces paraneoplastic hypophosphatemic osteomalacia. The common physiologic defect in this conditions involves an impairment in renal tubular phosphate reabsorption with a downregulation of renal 1α-hydroxylase activity, while calcium metabolism remains essentially unaffected. Microscopic features consist of spindle cells, multinucleated giant cells and calcifications embedded in a chondromyxoid matrix with variable cellularity and prominent vascularity. Approximately 95% of PMTs involve the extremities and appendicular skeleton, with only 5% occurring in the head and neck region. Localization in the head and neck is pretty uncommon, nose and paranasal sinuses are preferentially affected. Due to its rarity, the purpose of the study was to report a new case of PMT whose locations in temporomandibular joint was never reported in literature.

Alveolar ridge augmentation with maxillary sinus elevation and split crest: Comparison of 2 surgical procedures.

The purpose of this study was to evaluate the clinical and radiological outcomes of 2 piezosurgical split techniques performed in conjunction with the sinus lift.The present retrospective study included 20 patients with edentulism of the posterior maxilla who had undergone the sinus lift and alveolar ridge split treatment separately or the sinus lift combined with the monoblock alveolar ridge split. Differences between these 2 techniques were analyzed.All the surrounding areas successfully produced an adequate bone volume for the insertion of implants. A clinical evaluation showed a mean vertical augmentation of 3.6 ±â€Š0.4 mm in Group A and 3.2 ±â€Š0.7 mm in Group B. With regards to the lateral augmentation, the clinical evaluation gives a mean gain of 5.2 ±â€Š0.3 mm in Group A and 4.9 ±â€Š0.5 mm in Group B. The mean vertical and horizontal bone augmentation recorded for both types of surgical procedures were comparable.The proposed surgical procedures enabled the tridimensional volume of the alveolar ridge to be recreated. This resulted in the creation of a natural contour of hard and soft tissues which enabled a functional and aesthetic rehabilitation of the edentulous posterior maxilla to be obtained.