The doctor may restitch the wound or allow the wound to close by itself naturally to lessen the chances of infection. Explanation helps prevent anxiety and increases compliance with the procedure. Sutures are divided into two general categories, namely, absorbable and nonabsorbable. Close the handle, then gently move the staple side to side to remove. Consider the purpose and need for cleaning a wound that has been exposed to air for an extended period. Ear examination & Cerumen extraction and washing. 9. What is the purpose of applying Steri-Strips to the incision after removing sutures? The wound appears improved to the patient. The 3-0 sutures work well for the thicker skin on the back, scalp, palms, and soles.50,51, A meta-analysis of 19 studies of skin closure for surgical wounds and traumatic lacerations found no significant difference in cosmetic outcome, wound infection, or wound dehiscence between absorbable and nonabsorbable sutures.52,53 A systematic review did not show any advantage of monofilament sutures over braided sutures with regard to cosmetic outcome, wound infection, or wound dehiscence.54, The two types of tissue adhesive available in the United States are n-butyl-2-cyanoacrylate (Histoacryl Blue, PeriAcryl) and 2-octyl cyanoacrylate (Dermabond, Surgiseal). Early suture removal risks wound dehiscence; however, to decrease scarring and cross-hatching of facial sutures, half of the suture line (ie, every other suture) may be removed on day 3 and the remainder are removed on day 5. Stapled surgical wound of the left leg of a 46-year-old woman who underwent femoral artery bypass surgery. The redness and drainage from the wound is decreasing. Parenteral Medication Administration. They deny fevers or malaise. 5. Am Fam Physician 2014;89(12):956-962. Want to create or adapt OER like this? Use tab to navigate through the menu items. Inspection of incision line reduces the risk of separation of incision during procedure. It needs to be covered with skin to heal. Excessive scarring: All wounds will form a scar, and it will take months for a scar to completely contract and remodel to its permanent form. Autotexts How-To Videos All Posts Encounter Notes Addiction Medicine Clinic Procedure Notes Hospital Women's Health Pediatrics Plans Used under theCC BY-NC-SA 3.0 IGO license. Clean techniques suffice if wounds have been exposed to the air and the wound is approximated and healing. Explain process to patient and offer analgesia, bathroom, etc. Instruct patient to take showers rather than bathe. Keloids, on the other hand, rarely go away. Injuries that require subspecialist consultation include open fractures, tendon or muscle lacerations of the hand, nerve injuries that impair function, lacerations of the salivary duct or canaliculus, lacerations of the eyes or eyelids that are deeper than the subcutaneous layer, injuries requiring sedation for repair, or other injuries requiring treatment beyond the knowledge or skill of the physician. See Figure 20.32 [1] for an example of suture removal. Ear trauma often causes a hematoma, and applying a pressure dressing can be difficult. What situations warrant staple / suture removal to be a clean procedure. Disclaimer:Always review and follow your agency policy regarding this specific skill. Excision of Benign Skin Lesion Procedure Note. Explaining the procedure will help prevent anxiety and increase compliance with the procedure. developed by Rene Anderson and Wendy McKenzie (2018) Thompson Rivers University School of Nursing. Steri-Strips support wound tension across wound and help to eliminate scarring. 18. Place Steri-Strips on remaining areas of each removed suture along incision line. After ruling out intracranial injury, bleeding should be controlled with direct pressure for adequate exploration of the wound. Wound reopening: If sutures are removed too early, or if excessive force is applied to the wound area, the wound can reopen. Tylenol or ibuprofen as needed for discomfort or fever > 102.5 Return if no improvement in 1,342 0 A meta-analysis did not show benefit with the use of prophylactic systemic antibiotics for reducing wound infections in simple, nonbite wounds.60, Wounds heal most quickly in a moist environment.61 Occlusive and semiocclusive dressings lead to faster wound healing, decreased wound contamination, decreased infection rates, and increased comfort compared with dry gauze dressings.62 Choice of moisture retentive dressing should be based on the amount of exudate expected. GNhome RN. You will need suture scissors or suture blade, forceps, receptacle for suture material (gauze, tissue, garbage bag), antiseptic swabs can be used for clean procedure, sterile dressing tray if this is a sterile procedure. Search dates: April 2015 and January 5, 2017. Gauze dressings with petroleum gel with or without an antibiotic are commonly used for wounds with some drainage. Also, surgeons use stitches during operations to tie ends of bleeding blood vessels and to close surgical incisions. Gently pull on the knot to remove the suture. Stitches are used to close a variety of wound types. Keloids are common in wounds over the ears, waist, arms, elbows, shoulders, and especially the chest. Emergency & Essential Surgical Care Programme. Performing Physician: _ PROCEDURE 130 Suture and Staple Removal Brian D. Schaad PURPOSE: Sutures and staples are placed to approximate tissues that have been separated. They deny fevers or malaise. Also, large keloids can be removed, and a graft can be used to close the wound. The body determines the shape of the needle and is curved for cutaneous suturing. If suture isnt removed, gently pull on suture material to determine the next entry / exit point. Discard supplies according to agency policies for sharp disposal and biohazard waste. Do not pull the contaminated suture (suture on top of the skin) below the surface of the skin. Take good care of the wound so it will heal and not scar. 14. Assess wound healing after removal of each suture to determine if each remaining suture will be removed. 2. Learn how BCcampus supports open education and how you can access Pressbooks. 1.2 Infection Prevention and Control Practices, 1.4 Additional Precautions and Personal Protective Equipment (PPE), 1.5 Surgical Asepsis and the Principles of Sterile Technique, 1.7 Sterile Procedures and Sterile Attire, 3.6 Assisting a Patient to a Sitting Position and Ambulation, 4.6 Moist to Dry Dressing, and Wound Irrigation and Packing, 6.3 Administering Medications by Mouth and Gastric Tube, 6.4 Administering Medications Rectally and Vaginally, 6.5 Instilling Eye, Ear, and Nose Medications, 7.2 Parenteral Medications and Preparing Medications from Ampules and Vials, 7.3 Intradermal and Subcutaneous Injections, 7.5 Intravenous Medications by Direct IV Route, 7.6 Administering Intermittent Intravenous Medication (Secondary Medication) and Continuous IV Infusions, 7.7 Complications Related to Parenteral Medications and Management of Complications, 8.3 IV Fluids, IV Tubing, and Assessment of an IV System, 8.4 Priming IV Tubing and Changing IV Fluids and Tubing, 8.5 Flushing a Saline Lock and Converting a Saline Lock to a Continuous IV Infusion, 8.6 Converting an IV Infusion to a Saline Lock and Removal of a Peripheral IV, 8.7 Transfusion of Blood and Blood Products, 10.2 Caring for Patients with Tubes and Attachments. Common periods of time for removal are as follows, but times vary according to the health care professionals that perform the procedure: Sutures may be taken out all at one visit, or sometimes, they may be taken out over a period of days if the wound requires it. Medical Author: 7. Visually assess the wound for uniform closure of the wound edges, absence of drainage, redness, and swelling. However, there is no strong evidence that cleansing a wound increases healing or reduces infection.10 A Cochrane review and several RCTs support the use of potable tap water, as opposed to sterile saline, for wound irrigation.2,1013 To dilute the wounds bacterial load below the recommended 105 organisms per mL,14 50 to 100 mL of irrigation solution per 1 cm of wound length is needed.15 Optimal pressure for irrigation is around 5 to 8 psi.16 This can be achieved by using a 19-gauge needle with a 35-mL syringe or by placing the wound under a running faucet.16,17 Physicians should wear protective gear, such as a mask with shield, during irrigation. They have been able to manage dressing changes without difficulty at home. This picture was taken 1 week after his fall. Adhesive agents can be used to close a wound. Lidocaine (Xylocaine) buffered with sodium bicarbonate decreases the pain associated with injection; this effect is enhanced when the solution is warmed to room temperature. AFP 2014, Other strategies to minimize pain during injection include: 1) Rapidly inserting the needle through the skin, 2) injecting the solution slowly and steadily while withdrawing the needle, and 3) Injecting into the subcutaneous tissue also minimize the pain of injection. Checklist 34 provides the steps for intermittent suture removal. Removing stitches or other skin-closure devices is a procedure that many people dread. Wound care after suture removal is just as important as it was prior to removal of the stitches. However, removal of the chest tube may also be a painful procedure for the patient. Staples are used on scalp lacerations and commonly used to close surgical wounds. Non-absorbent sutures are usuallyremoved within 7 to 14 days. They may require removal depending on where they are used, such as once a skin wound has healed. Steri-Strips applied. All Rights Reserved. Inform patient that the procedure is not painful, but the patent may feel some pulling of the skin during suture removal. Sutures must be left in place long enough to establish wound closure with enough strength to support internal tissues and organs. Do not peel them off. When scheduled to have the stitches removed, be sure to make an appointment with a person qualified to remove the stitches. If there are concerns, question the order and seek advice from the appropriate health care provider. Chapter 3. Tissue adhesive should not be applied to misaligned wound edges. 15. The adhesive simply falls off or wears away after about 5-7 days. An order to remove sutures must be obtained prior to the procedure, and a comprehensive assessment of the wound site must be performed prior to the removal of the sutures by the healthcare provider. This provides patient with a safe, comfortable place, and attends to pain needs as required. If the galea is lacerated more than 0.5 cm it should be repaired with 2-0 or 3-0 absorbable sutures.39 Skin can be repaired using staples; interrupted, mattress, or running sutures, such as 3-0 or 4-0 nylon sutures; or the hair apposition technique (Figure 535 ). Grasp knotted end with forceps, and in one continuous action pull suture out of the tissue and place cut knot on sterile 2 x 2 gauze. Explain process to patient and offer analgesia, bathroom etc. Contact physician for further instructions. Other methods include surgical staples, skin closure tapes, and adhesives. Gather sterile staple extractors, sterile dressing tray, non-sterile gloves, normal saline, Steri-Strips, and sterile outer dressing. Cartilage has poor circulation and is prone to infection and necrosis. It also prevents scratching the skin with the sharp staple. Staple removal is a simple procedure and is similar to suture removal. Pat dry, do not scrub or rub the incision. This 26-year-old man received many cuts and bruises after falling from a 7-story window. 1.2 Infection Prevention and Control Practices, 1.4 Additional Precautions and Personal Protective Equipment (PPE), 1.7 Surgical Hand Scrub, Applying Sterile Gloves and Preparing a Sterile Field, 2.5 Head-to-Toe / Systems Approach to Assessment, 2.6 Head-to-Toe Assessment: head and neck / Neurological Assessment, 2.7 Head-to-Toe Assessment: Chest / Respiratory Assessment, 2.8 Head-to-Toe Assessment: Cardiovascular Assessment, 2.9 Head-to-Toe Assessment: Abdominal / Gastrointestinal Assessment, 2.10 Head-to-Toe Assessment: Genitourinary Assessment, 2.11 Head-to-Toe Assessment: Musculoskeletal Assessment, 2.12 Head-to-Toe Assessment: Integument Assessment, 3.3 Risk Assessment for Safer Patient Handling, 3.7 Types of Patient Transfers: Transfers without Mechanical Assistive Devices, 3.8 Types of Patient Transfers: Transfers Using Mechanical Aids, 3.10 Assisting a Patient to Ambulate Using Assistive Devices, 4.3 Wound Infection and Risk of Wound Infection, 4.6 Advanced Wound Care: Wet to Moist Dressing, and Wound Irrigation and Packing, 6.3 Administering Medications by Mouth and Gastric Tube, 6.4 Administering Medications Rectally and Vaginally, 6.5 Instilling Eye, Ear, and Nose Medications, 7.2 Preparing Medications from Ampules and Vials, 7.6 Intravenous Medications by Direct IV (Formerly IV Push), 7.7 Administering IV Medication via Mini-Bag (Secondary Line) or Continuous Infusion, 7.8 IV Medications Adverse Events and Management of Adverse Reactions, 8.2 Intravenous Therapy: Guidelines and Potential Complications, 8.6 Infusing IV Fluids by Gravity or an Electronic Infusion Device (Pump), 8.7 Priming IV Tubing / Changing IV Bags / Changing IV Tubing, 8.8 Flushing and Locking PVAD-Short, Midlines, CVADs (PICCs, Percutaneous Non Hemodialysis Lines), 8.9 Removal of a PVAD-Short, Midline Catheter, Percutaneous Non Hemodialysis CVC, and PICC, 8.11 Transfusion of Blood and Blood Products, 10.2 Caring for Patients with Tubes and Devices, Appendix 2: Checklists - Summary and Links. These changes may indicate the wound is infected. Not all areas of the body can be taped. Snip first suture close to the skin surface, distal to the knot. 4.5 Staple Removal. Suture removal is determined by how well the wound has healed and the extent of the surgery. 5. The search included relevant POEMs, Cochrane reviews, diagnostic test data, and a custom PubMed search. After assessing the wound, decide if the wound is sufficiently healed to have the sutures removed. If a person has received stitches, they should be given instructions for taking care of the stitches and wound, and be given an approximate date to have the stitches removed. Devitalized and necrotic tissue in a traumatic wound should be identified and removed to reduce risk of infection.4,5, If a foreign body (e.g., dirt particles, wood, glass) is suspected but cannot be identified visually, then radiography, ultrasonography, or computed tomography may be needed. If using a blade to cut the suture, point the blade away from you and your patient. Bite wounds with a high risk of infection, such as cat bites, deep puncture wounds, or wounds longer than 3 cm,43 should be treated with prophylactic amoxicillin/clavulanate (Augmentin).47,48 Clindamycin may be used in patients with a penicillin allergy.49, Physicians should use the smallest suture that will give sufficient strength to reapproximate and support the healing wound.50,51 Commonly used sutures are included in Table 250,51; however, good evidence is lacking regarding the appropriate suture size for laceration repair. Anesthesia may be necessary to achieve hemostasis and to explore the wound. Hypertrophic scars are scars that are bulky but remain within the boundaries of the wound. Approximately 6 million patients present to emergency departments for laceration treatment every year.1 Although many patients seek care at emergency departments or urgent care centers, primary care physicians are an important resource for urgent laceration treatment. Many aspects of laceration repair have not changed over the years, but there is evidence to support some updates to standard management. Apply clean non-sterile gloves if indicated. Remove sterile backing to apply Steri-Strips. This is intended to be a repository for efficiency tools for use at VCMC. Instruct patient to pat dry, and to not scrub or rub the incision. Some of your equipment will come in its own sterile package. Wound Check Visit Note Subjective: The patient presents today for a wound check. Followup: The patient tolerated the procedure well without complications. These are used to close the skin and for other internal uses where a permanent stitch is not needed. This reduces the risk of infection from microorganisms on the wound site or surrounding skin. Right hip sutures removed. Want to create or adapt OER like this? Cleanse drain site: 10. See Additional Information. Explaining the procedure will help prevent anxiety and increase compliance with the procedure. 16. D48.5 Neoplasm of uncertain behavior of skin. 16. Obese patients (greater than 30 kg/m2) have a higher risk of dehiscence than patients with a normal BMI. PROCEDURE: The appropriate timeout was taken. However, scarring may be excessive when sutures are not removed promptly or left in place for a prolonged period of time. They may be placed deep in the tissue and/or superficially to close a wound. Removal of sutures must be ordered by the primary health care provider (physician or nurse practitioner). 19. All wounds form a scar and will take months to one year to completely heal. Instruct patient to take showers rather than bathe. How to Prepare for Removing Stitches (Sutures), Suture Removal and Healing Time for Wounds. endstream endobj 3 0 obj << /N 1 /Domain [ 0 1 ] /FunctionType 2 /C0 [ 0.12 ] /C1 [ 0.28 ] >> endobj 4 0 obj << /FontFile3 136 0 R /CapHeight 680 /Ascent 708 /Flags 262242 /ItalicAngle -13 /Descent -206 /XHeight 482 /FontName /Times-SemiboldItalic /FontBBox [ -167 -218 1025 919 ] /StemH 110 /Type /FontDescriptor /StemV 110 >> endobj 5 0 obj << /Name /ZaDb /Subtype /Type1 /BaseFont /ZapfDingbats /Type /Font >> endobj 6 0 obj << /Filter /FlateDecode /Length 700 >> stream Tetanus immune globulin is not indicated for clean, minor wounds (Table 4).63. After cleansing the wound, the doctor will gently back out each staple with the remover. Staples are made of stainless steel wire and provide strength for wound closure. Scarring may be more prominent if sutures are left in too long. People may feel a pinch or slight pull. Parenteral Medication Administration. Scissors and forceps may be disposed of or sent for sterilization. Wound infection: If signs of infection begin, such as redness, increasing pain, swelling, and fever, contact a doctor immediately. 9. Several stitches may be needed to accomplish this. Sutures are tiny threads, wire, or other material used to sew body tissue and skin together. Hypertrophic scars tend to develop a peak size and then get smaller over months to years. They are not generally used in hair-bearing areas (except in the hair apposition technique). His eyebrow and neck wounds have been closed with adhesive strips. Alternate sutures (every second suture) are typically removed first, and the remaining sutures are removed once adequate approximation of the skin tissue is determined. This is based on expert opinion and experience. Topical and injectable local anesthetics reduce pain during treatment of lacerations and may be used alone or in combination.2123 Topical anesthetics (eTable A) are particularly useful when treating children. Perform a point of care risk assessment for necessary PPE. It is within the RNs independent scope of practice to apply Steri-Strips to a wound without an order (BCCNP, 2019). Learn how BCcampus supports open education and how you can access Pressbooks. Toenail removal; The body of the needle is the portion that is grasped by the needle holder during the procedure. Skin closure tapes, also known as adhesive strips, have recently gained popularity. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Absorbable sutures rapidly break down in the tissues and lose their strength within 60 days. Remove remaining staples, followed by applying Steri-Strips along the incision line. For problems with the EHR, call the HCA Helpdesk at (805) 677-5119. Complete patient teaching regarding Steri-Strips and bathing, wound inspection for separation of wound edges, and ways to enhance wound healing. PLAN OF CARE: patient/family verbalized understanding of dx & POC, agreed with dx & POC did not agree with dx & POC - encouraged to seek second opinion. In addition, if the sutures are left in for an extended period of time, the wound may heal around the sutures, making extraction of the sutures difficult and painful. If concerns are present, question the order and seek advice from the appropriate health care provider. Provide opportunity for the patient to deep breathe and relax during the procedure. This allows for dexterity with suture removal. VENTURA COUNTY MEDICAL CENTERFAMILY MEDICINE RESIDENCY PROGRAM. Parenteral Medication Administration. Betadine, an antiseptic solution, is used to cleanse the area around the wound. Medscape. Provide opportunity for the patient to deep breathe and relax during the procedure. 9. Jasbir is going home with a lower abdominal surgical incision following a c-section. . 2023 WebMD, Inc. All rights reserved. Traditionally, a large subungual hematoma involving more than 25% of the visible nail indicated nail removal for nail bed inspection and repair, but a recent review concluded that a subungual hematoma without significant fingertip injury can be treated with trephining (drainage through a hole) alone.42, Up to 19% of bite wounds become infected. Prepare the sterile field and add necessary supplies (staple extractor). Allow the Steri-Strips to fall off naturally and gradually (usually takes one to threeweeks). This is also a relatively painless procedure. Data Sources: The authors used an Essential Evidence summary based on the key words facial laceration, laceration, and tissue adhesives. This step prevents the transmission of microorganisms. Nonabsorbent sutures are usually removed within 7 to 14 days. 10. Position patient appropriately and create privacy for procedure. Grasp the knot of the suture with forceps and gently pull up. Staple removal is a simple procedure and is similar to suture removal. Steri-Strips support wound tension across wound and eliminate scarring. Skin cleansed well with chlorhexidine and NS solution cc of 2% Lidocaine injected at the laceration site. This action prevents the suture from being left under the skin. Cut under the knot as close as possible to the skin at the distal end of the knot. This prevents the transmission of microorganisms. When removing staples, consider the length of time the staples have been in situ. Skin cleansed well with NS solution x variable_22 in situ. Acki is discharged from the clinic following removal of sutures in his knee following a mountain biking accident. About one-third of foreign bodies may be missed on initial inspection.6. Wound becomes red, painful, with increasing pain, fever, drainage from wound. All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. AIM To remove sutures using aseptic technique whilst preventing any unnecessary discomfort, trauma or risk of infection to the patient. The patient was prepped and draped in a sterile fashion. Below are some good ones Ive come across. 17. Laceration through the portion of the upper or lower lid medial to the punctum often damages the lacrimal duct or the medial canthal ligament and requires referral to an ophthalmologist or plastic surgeon. . POST-OP DIAGNOSIS: Same 9. Wound well approximated. The wound appears improved to the patient. "Suturing Techniques." Procedure Notes Procedure Name: Laceration Repair Indication: Reduce risk of infection Location: __________________ Pre-Procedure Diagnosis: Laceration Post-Procedure Diagnosis: Repaired Laceration Informed consent was obtained before procedure started. Non-Parenteral Medication Administration, Chapter 7. The border should be marked before anesthetic injection because the anesthetic may blur the border. Only remove remaining sutures if wound is well approximated. Continue cutting in the same manner until the entire suture is removed, inspecting the incision line during the procedure. post-procedure bleeding. 15. Staple extractor may be disposed of or sent for sterilization. Wound The drainage is serosanguinous as expected, no evidence of extension of erythema, the dressing was changed, the patient tolerated well. This step allows for easy access to required supplies for the procedure. Continue to keep the wound clean and dry. PROCEDURE: Perform a point of care risk assessment. PROCEDURE: skin cleaned with wound cleanser skin cleaned with Hibiclens skin cleaned with Betadine skin cleaned w NS drain/packing removed closure material removed small amount of purulent . Data sources: BCIT, 2010c; Perry et al., 2014. In addition, if the sutures are left in for an extended period of time, the wound may heal around the sutures, making extraction of the sutures difficult and painful. If the wound is well healed, all the sutures would be removed at the same time. Stitches then allow the skin to heal naturally when it otherwise may not come together. Do not pull up while depressing handle on staple remover or change the angle of your wrist or hand. Allow small breaks during removal of staples. Continue to remove every second staple to the end of the incision line. Never leave suture material below the surface. Confirm prescribers orders, and explain procedure to patient. The most commonly seen suture is the intermittent or interrupted suture. Sutureremoval is determined byhow well the wound has healed and the extent of the surgery. Individual patient . Disadvantages of staples are permanent scars if used inappropriately and imperfect aligning of the wound edges, which can lead to improper healing. A variety of suture techniques are used to close a wound, and deciding on a specific technique depends on the location of the wound, thickness of the skin, degree of tensions, and desired cosmetic effect (Perry et al., 2014). Position patient appropriately and create privacy for procedure. Sutures should be removed after an appropriate interval depending on location (Table 535 ). Observe the wound for signs and symptoms of infection and notify a healthcare professional if any concerns. 14. Supervising Physician (if applicable): _ 18. Removal of sutures must be ordered by the primary healthcare provider (physician or nurse practitioner). The wound line must also be observed for separations during the process of suture removal. Then soak them for removal. Cleaning also loosens and removes any dried blood or crusted exudate from the staples and wound bed. https://www.youtube.com/watch?v=-ZWUgKiBxfk, https://lacerationrepair.com/alternative-wound-closure/hair-apposition-technique/. Disclaimer:Always review and follow your hospital policy regarding this specific skill. Wound well approximated. Patients who have not had at least three doses of a tetanus vaccine or who have an unknown tetanus vaccine history should also receive a tetanus immune globulin. The sterile2 x 2 gauze is a place to collect the removed suture pieces. Use distraction techniques (wiggle toes / slow deep breaths). Sutures must be left in place long enough to establish wound closure with enough strength to support internal tissues and organs. The goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk of infection. Data source: BCIT, 2010c;Perry et al., 2014. Do not pull off Steri-Strips. 13. Place Steri-Strips on remaining areas of each removed suture along incision line. Gather appropriate supplies after deciding if this is a clean or sterile procedure. Suture removal is determined by how well the wound has healed and the extent of the surgery. Patients with a clean and minor wound should receive the tetanus vaccine only if they have not had a tetanus vaccine for more than 10 years. h|RKo0WlY/n]-'e'vXI~>'+>0`PO ZPyZg1|B_$7!-E&' 9fUXs4REUJQ_l :;'a"-jU(/mWvCm"i\p;k7jz`iW/y)Oc. c$|!isq3lQ4mnpfo.QEt-"Cnya29-usT.>W0p@DisRsrp.T=q$}/d-[F%3 p What patient teaching is important in relation to the wound? 1996-2023 WebMD, Inc. All rights reserved. Non-Parenteral Medication Administration, Chapter 7. Some of these are illustrated in Figure 4.2. For a video of suturing techniques, see https://www.youtube.com/watch?v=-ZWUgKiBxfk.
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