Medical Tourism Blog
Lagophthalmos Treatment in Korea: Canthoplasty, Eyelid Retraction Repair, Laser Canthoplasty & Fat Grafting
Table of contents
- Detailed Medical Procedures for Eyelid Correction
- Best Clinics in Korea
- Navigating Eyelid Correction Procedures in South Korea: A Medical Tourist's Guide
- Costs and Value: South Korea vs. Global Medical Tourism
- Patient Outcomes and Addressing Lagophthalmos
- Conclusions
- References
Lagophthalmos is a condition where a person cannot fully close one or both eyelids. This can happen while awake or during sleep, the latter known as nocturnal lagophthalmos. The term comes from Greek—"lagos" meaning hare and "ophthalmos" meaning eye—because of the old belief that hares sleep with their eyes open. Although mild cases might not cause immediate problems, prolonged incomplete eyelid closure can lead to serious eye complications if untreated.
Symptoms and Impact on Eye Health
The most obvious sign of lagophthalmos is the inability to close the eyelids completely, noticeable during blinking or sleep. This leaves the cornea and conjunctiva exposed, disrupting the eye’s natural protection. Patients often feel dryness, a gritty sensation, or a foreign body in the eye, sometimes accompanied by burning or pain. Interestingly, some may experience excessive tearing as the eye tries to compensate. Other symptoms include blurred vision, persistent redness, and light sensitivity (photophobia).
Common Causes and Risk Factors
Lagophthalmos can occur on its own or as part of other conditions like ptosis (drooping eyelids). A common cause is iatrogenic—resulting from previous surgeries such as blepharoplasty or ptosis repair—especially if too much skin or tissue was removed or the eyelid was tightened excessively.
Lagophthalmos is classified into several types:
- Nocturnal Lagophthalmos: Normal eyelid closure when awake but incomplete during sleep.
- Paralytic Lagophthalmos: Caused by facial nerve damage from trauma, Bell’s palsy, stroke, tumors, autoimmune diseases like Guillain-Barré syndrome, infections, or toxins.
- Mechanical Lagophthalmos: Due to structural problems or physical trauma.
- Cicatricial Lagophthalmos: A subtype of mechanical lagophthalmos caused by scarring that restricts eyelid movement.
Other contributors include eyelid laxity syndromes (like floppy eyelid syndrome), severe skin conditions such as Stevens-Johnson syndrome, chemical burns, chronic sun damage, and systemic diseases like Graves’ disease (thyroid ophthalmopathy), which often causes eyelid retraction leading to lagophthalmos. Less common causes include midbrain disease, tumors, blepharitis, Cushing syndrome, hydrocephalus, and facial palsy.
Environmental factors like wind, dust, and smoke can worsen symptoms, as can lifestyle choices such as poor nutrition (deficiency in omega-3 fatty acids, vitamins A, C, and E), smoking, and excessive alcohol use.
Diagnosis and Complications
Diagnosing lagophthalmos involves a thorough medical history review and physical eye examination by a healthcare professional. The doctor will observe eyelid closure, measure eyelid position, and assess blinking. Tests like the Schirmer test (tear production) and fluorescein staining (corneal health) may be used.
If untreated, lagophthalmos can cause serious complications such as corneal abrasions, infections (microbial keratitis), ulcers, and in severe cases, corneal perforation leading to vision loss or blindness. Surgical treatments carry risks too, including scarring, infection, inward eyelash growth (entropion), drooping eyelids, and graft site issues if tissue transplantation is involved.
For patients whose lagophthalmos results from prior cosmetic or functional eyelid surgery, the psychological impact can be significant. They seek not only medical treatment but also correction of a complication affecting their appearance and quality of life. This underscores the importance of choosing a highly skilled oculoplastic surgeon for initial eyelid surgeries to minimize risks.
Lagophthalmos is more than a cosmetic issue; it threatens eye health by exposing the cornea and conjunctiva, disrupting lubrication and protection. Non-surgical treatments like lubricating eye drops and ointments serve as important temporary measures to protect the eye before surgery.
Detailed Medical Procedures for Eyelid Correction
Canthoplasty: Reshaping the Eye Corners
Canthoplasty is a surgical procedure that reconstructs and reshapes the canthus—the corner of the eye where the upper and lower eyelids meet. It tightens muscles, tendons, ligaments, and connective tissues to correct sagging, uneven eyelids, and improve eyelid support and function. It also offers cosmetic benefits by modifying eye shape.
There are two main types:
- Lateral Canthoplasty: Focuses on the outer eye corner, elongating the eye for a more almond shape and correcting sagging lower eyelids.
- Epi-canthoplasty (Medial Canthoplasty): Targets the inner eye corner near the nose, often to remove the epicanthic fold ("Mongolian fold") to make eyes appear larger and more defined. It’s often combined with double eyelid surgery.
Canthoplasty treats conditions like corneal damage (keratopathy), ectropion (outward turning eyelid), entropion (inward eyelashes), trauma, and importantly, lagophthalmos by tightening and repositioning the eyelid corner to improve closure and protect the cornea. It’s also popular for cosmetic eyelid rejuvenation.
Performed by an oculoplastic surgeon, the procedure uses local or general anesthesia. A small incision near the eyelid allows tightening and repositioning of tendons and muscles. Surgery usually takes 1-2 hours. Results are generally permanent, though minor touch-ups may be needed over time due to aging.
Canthoplasty differs from canthopexy, which tightens the eyelid corner without cutting tissues, and from blepharoplasty, which removes excess skin and fat without changing eye shape.
Eyelid Retraction Repair: Restoring Natural Eyelid Position
This surgery corrects eyelids that are too high or too low, restoring a natural position to improve function and appearance. Eyelid retraction causes incomplete eye coverage, leading to discomfort and damage.
The most common cause is Graves’ disease (thyroid ophthalmopathy), which causes bulging eyes and elevated eyelids. Other causes include midbrain disease, tumors, blepharitis, prior surgery complications, paralysis, Cushing syndrome, hydrocephalus, facial palsy, or trauma.
Symptoms include a staring appearance, dry and gritty eyes, irritation, incomplete closure (lagophthalmos), swelling, fatty deposits, paradoxical tearing, and vision problems like double or blurred vision.
Upper eyelid retraction surgery is often done under sedation and local anesthesia, sometimes with the patient upright to check symmetry. Techniques include:
- Lengthening Techniques: Adding spacers or grafts (autologous tissue like hard palate or ear cartilage, or synthetic materials like polytetrafluoroethylene) to lengthen the eyelid and lower it.
- Mullerectomy: Removing or weakening Müller's muscle to lower the eyelid.
- Levator Aponeurosis Recession: Releasing the levator muscle to lower the eyelid.
Lower eyelid surgery removes fibrotic muscle and uses spacer material to lift the lid, tightening tendons to reposition it. Asymmetry is less common here.
Benefits include correcting eyelid position, improving facial symmetry, and restoring vision. Severe cases are usually medically necessary and covered by insurance; mild cases may be considered cosmetic.
Laser Canthoplasty: Precision with Advanced Technology
Laser canthoplasty uses laser technology instead of scalpels for cutting tissue. The laser makes precise incisions and cauterizes small blood vessels, reducing bleeding and inflammation during and after surgery.
Advantages include better precision, less bleeding, minimized tissue trauma, smaller scars, and faster healing with less downtime. The goals align with traditional canthoplasty: reshaping eye corners for improved function and appearance.
Recovery is generally quicker, though some swelling and bruising are expected. Post-op care includes cold compresses, avoiding strenuous activity, and antibiotic eye drops or ointments.
Eyelid Fat Grafting: Volume Restoration for Periorbital Rejuvenation
Eyelid fat grafting restores lost volume around the eyes—upper eyelids, eyebrows, temples, and especially lower eyelid hollows (tear troughs). Aging causes tissue volume loss, leading to a sunken or tired look and accentuated wrinkles. Fat grafting rejuvenates the area, smooths contours, and can hide visible veins or correct previous skin procedure issues.
The process involves:
- Fat Harvesting: Gentle liposuction from donor sites like the abdomen or inner thighs.
- Fat Processing: Refining fat via centrifugation to remove oil, water, and blood, leaving purified fat cells.
- Fat Injection: Precise injection and sculpting of fat around the eyes for natural results.
Usually done under general anesthesia or local sedation, the procedure lasts 2-5 hours depending on extent.
Using the patient’s own fat reduces allergy risk and provides long-lasting, natural-looking results. Final effects appear over 3-6 months as swelling subsides.
Importantly, eyelid fat grafting is not a direct treatment for lagophthalmos but complements other surgeries by improving eyelid contour and aesthetics.
These procedures highlight the complex anatomy and function of the eyelids, requiring a tailored approach based on the underlying cause of lagophthalmos. For example, nerve paralysis may call for gold weight implants rather than canthoplasty. Consulting a specialized oculoplastic surgeon is essential for a personalized treatment plan.
Eyelid surgeries increasingly combine functional restoration with cosmetic enhancement, offering patients improved eye health and appearance. However, managing expectations is key, especially for procedures like fat grafting that are primarily aesthetic.
Adding tissue via grafts or spacers is a common principle in correcting eyelid malposition, which may involve donor site recovery. This complexity underscores the need for expert surgeons with detailed anatomical knowledge.
Best Clinics in Korea
Listed below are the best clinics in Korea:
| Clinic Name | Key Features | Special Techniques |
|---|---|---|
| THEPLUS Plastic Surgery | Located in Garosu-gil, Gangnam, Seoul; comprehensive care from consultation to post-op; led by Dr. Kim, Dr. Jeong, and Dr. Lee; internationally recognized surgeons; focus on patient safety and satisfaction; over a decade of experience; active in global plastic surgery communities | Advanced 3D implants; expertise in rhinoplasty, facial contouring, reconstructive procedures; latest surgical techniques; personalized treatment plans for natural beauty and facial harmony |
| Made Young Plastic Surgery | Located in Gangnam, Seoul; premier destination for lagophthalmos treatment; highly skilled surgeons; emphasis on safety, innovation, and personalized care; meticulous precision; integrates traditional beauty ideals with cutting-edge technology; holistic patient well-being focus | Delicate eye surgeries addressing eyelid function and appearance; advanced techniques restoring eyelid function and enhancing facial harmony; tailored solutions for lagophthalmos |
| Okay Plastic Surgery Clinic | Led by experienced female plastic surgeon; patient-centered approach; personalized treatment plans; comprehensive eye plastic surgery services; multidisciplinary care; commitment to safety, comfort, and satisfaction; innovative technologies; minimally invasive options | Advanced surgical methods tailored to lagophthalmos; corrective procedures for eyelid function and appearance; precision and natural-looking results in eye-related surgeries |
THEPLUS Plastic Surgery
THE PLUS Plastic Surgery clinic, located in the vibrant Garosu-gil district of Gangnam, Seoul, is a premier destination for advanced plastic surgery in Korea, including specialized treatment for lagophthalmos. The clinic is renowned for its comprehensive approach, spanning from initial consultation to surgery and post-operative care, all within a modern four-floor facility. Led by distinguished surgeons such as Dr. Kim, Dr. Jeong, and Dr. Lee, THE PLUS combines cutting-edge medical research with clinical excellence. Dr. Kim, a board-certified plastic surgeon and award-winning researcher in 3D implants, along with Dr. Jeong, President of the Korean Society of Plastic Surgeons, bring unparalleled expertise in facial procedures, ensuring patients receive the highest standard of care tailored to enhance natural beauty and facial harmony.
At THE PLUS, patient safety and satisfaction are paramount, supported by a team with over a decade of experience and active involvement in global plastic surgery communities. The clinic’s surgeons are recognized internationally for their contributions to rhinoplasty, facial contouring, and reconstructive procedures, making THE PLUS a trusted choice for complex cases such as lagophthalmos. Their commitment to continuous education and innovation ensures that patients benefit from the latest surgical techniques and personalized treatment plans. Whether addressing functional concerns or aesthetic goals, THE PLUS Plastic Surgery clinic stands out as a leader in Korea’s medical landscape, dedicated to delivering exceptional outcomes through expert care and advanced technology.
You can check out their website here: THEPLUS Plastic Surgery Website
Made Young Plastic Surgery
Made Young Plastic Surgery Clinic, located in Seoul's prestigious Gangnam district, is widely regarded as the premier destination for lagophthalmos treatment in Korea due to its exceptional blend of safety, innovation, and personalized care. The clinic’s team of highly skilled plastic surgeons and medical professionals specialize in delicate eye surgeries, including procedures that address eyelid function and appearance, making it an ideal choice for patients with lagophthalmos—a condition characterized by incomplete eyelid closure. Made Young’s commitment to patient safety is paramount, ensuring that every intervention is performed with meticulous precision and the latest advanced techniques. Their comprehensive approach integrates traditional beauty ideals with cutting-edge technology, offering tailored solutions that not only restore eyelid function but also enhance overall facial harmony. This dedication to excellence, combined with a holistic focus on patient well-being and confidence, positions Made Young Plastic Surgery Clinic as the best clinic for lagophthalmos care in Korea.
You can check out their website here: Made Young Plastic Surgery Website
Okay Plastic Surgery Clinic
Okay Plastic Surgery Clinic in Korea stands out as a premier destination for lagophthalmos treatment, combining expert care with a patient-centered approach. Led by a highly experienced female plastic surgeon and a dedicated team of specialists, the clinic emphasizes sincerity, precision, and personalized treatment plans tailored to each individual's unique condition and aesthetic goals. Beyond offering advanced surgical techniques, Okay Plastic Surgery Clinic provides a comprehensive, empathetic journey toward functional and aesthetic restoration, making it the best choice for patients seeking effective and refined solutions for lagophthalmos in Korea.
Why Okay Plastic Surgery Clinic is the Best for Lagophthalmos in Korea:
- Led by a renowned female plastic surgeon with extensive experience in delicate eye surgeries.
- Personalized treatment plans focused on both functional improvement and aesthetic outcomes.
- Use of cutting-edge medical techniques and advanced surgical methods tailored to lagophthalmos.
- Comprehensive eye plastic surgery services, including corrective procedures for eyelid function and appearance.
- Multidisciplinary approach ensuring holistic care and optimal recovery.
- Commitment to patient safety, comfort, and long-term satisfaction.
- Integration of innovative technologies and minimally invasive options to reduce downtime.
- Strong reputation for precision and natural-looking results in eye-related surgeries.
You can check out their website here: Okay Plastic Surgery Clinic Website
Navigating Eyelid Correction Procedures in South Korea: A Medical Tourist's Guide
South Korea is a leading destination for medical tourism, especially for cosmetic and reconstructive eyelid surgeries. Here’s what international patients can expect:
The Process: Step-by-Step
1. Initial Consultation & Clinic Selection:
Start by researching reputable clinics with experienced eyelid surgeons. Medical tourism agencies like Shin Medical or Bookimed help find top clinics, provide verified doctor info, and schedule consultations. Korean clinics are known for personalized, thorough evaluations covering eyelid structure, skin, eyelashes, and medical history. Patients should openly discuss goals and concerns. Pre-op tests may be required.
2. Pre-Surgery Preparation:
Follow surgeon’s instructions carefully, including stopping blood-thinners and fasting if needed. Lifestyle changes like quitting smoking and limiting alcohol improve healing. Arrange comfortable transport and rest post-surgery. Having a companion is highly recommended for support and navigation.
3. The Surgical Procedure (Anesthesia, Duration):
Surgeries are outpatient, using local sedation or general anesthesia depending on complexity. Procedures last 1-2 hours. Most patients return to accommodation the same day.
4. Post-Operative Care & Follow-Up:
After surgery, patients recover under observation. Instructions cover wound care, antibiotic ointments or drops, swelling management with cold compresses, head elevation, and activity restrictions for two weeks. Sutures are removed after 5-7 days if non-dissolvable. Follow-up visits ensure proper healing.
5. Recommended Stay in South Korea:
Plan to stay at least 8 days post-surgery for recovery and follow-ups. Swelling and bruising usually subside in 1-2 weeks, but full results take months.
South Korea’s mature medical tourism ecosystem offers comprehensive support—from clinic selection to translation and logistics—making treatment abroad easier and less stressful. This competitive market benefits patients with high-quality care and convenience.
While canthoplasty results are often permanent, minor repeat surgeries may be needed over time. Eyelid retraction repair may require touch-ups in 10-15% of cases. Lagophthalmos can also be a complication of prior eyelid surgery, sometimes needing revision. Patients should plan financially and choose skilled surgeons to minimize future interventions.
Costs and Value: South Korea vs. Global Medical Tourism
South Korea offers high-quality eyelid surgeries at competitive prices compared to many countries.
Cost of Canthoplasty in South Korea
Ranges from $1,000 to $3,500 USD (₩1,500,000 to ₩5,000,000 KRW), averaging around $1,700 USD. Some clinics offer lower prices ($550-$1,050 USD) depending on procedure type and clinic prestige.
Inclusions: Surgeon’s fee, anesthesia, facility charges, post-op care, medications, and often VAT (which may be refundable for international patients).
| Country | Cost Range (USD) | Notes |
|---|---|---|
| South Korea | $550 - $3,500 | Includes surgeon, anesthesia, facility, post-op care, VAT refund eligibility |
| USA | $4,000 - $8,000+ | Higher operational costs |
| Mexico | $1,750 - $2,500 | Often for "Cat Eye Surgery" |
| Turkey | From $2,000 | Often for "Cat Eye Surgery" |
Cost of Eyelid Retraction Repair in South Korea
Ranges from $2,000 to $4,000 USD. General blepharoplasty costs in Seoul range from $1,290 to $5,031 USD, with revision surgeries costing $2,200 to $6,300 USD.
Inclusions: Surgery fees, consultations, tests, hospitalization if needed, medications, sometimes accommodation, transport, and translation services, plus follow-ups and suture removal.
| Country | Cost Range (USD) | Notes |
|---|---|---|
| South Korea | $1,290 - $6,300 | Specific retraction repair: $2,000-$4,000; General Blepharoplasty: $1,290-$5,031; Revision: $2,200-$6,300 |
| USA | $3,000 - $15,000 | Upper: $3k-$6k; Lower: $6k-$9.5k; Combined: $6k-$12k; Revision: $4k-$10k |
| UK | $2,500 - $12,000 | Upper/Lower: $2.5k-$7k; Double Eyelid: $5k-$12k |
| Turkey | $700 - $6,500 | Upper: $1.5k-$3.7k; Lower: $700-$2.1k; Revision: $1k-$2k |
| Mexico | $1,200 - $6,600 | Upper/Lower: $1.2k-$2.74k; Revision: $1.5k-$3k |
| Czech Republic | $2,800 - $8,000 | General Eyelid Surgery |
| Poland | $3,300 - $7,500 | General Eyelid Surgery |
| Italy | $2,000 - $9,600 | Upper/Lower: $2k-$4.5k; Double Eyelid: $4k-$9k |
| Spain | $1,800 - $8,000 | Upper/Lower: $1.8k-$4k; Double Eyelid: $3.6k-$8k |
| Germany | $1,500 - $7,000 | Upper/Lower: $1.5k-$4k; Double Eyelid: $3k-$7k |
| France | $2,000 - $8,000 | Upper/Lower: $2k-$4.5k; Double Eyelid: $4k-$8k |
| Thailand | $445 - $2,660 | Blepharoplasty |
| Australia | $3,000 - $15,000 | Upper: $3k-$6k; Lower: $4k-$9.5k; Combined: $9.5k-$15k |
Cost of Laser Canthoplasty in South Korea
Ranges from $1,000 to $3,000 USD (₩1,453,000 to ₩4,363,000 KRW).
Inclusions: Usually includes surgeon fees, anesthesia, and facility charges. Travel, accommodation, and local transport are not included.
| Country | Cost Range (USD) | Notes |
|---|---|---|
| South Korea | $1,000 - $3,000 | Competitive, high-quality care |
| USA | $2,000 - $10,000 | Includes various eyelid and laser procedures |
| Australia | $20 - $440 | For "Capsular Laser," not directly comparable |
Cost of Eyelid Fat Grafting in South Korea
Ranges from $2,000 to $4,000 USD; under-eye fat grafting specifically costs $850 to $1,700 USD. Average facial fat transfer is about $2,961 USD.
Inclusions: Consultation, post-op care, suture removal, follow-ups; some packages include accommodation and transport. VAT refunds may apply. Travel costs are extra.
| Country | Cost Range (USD) | Notes |
|---|---|---|
| South Korea | $850 - $4,431 | Eyelid Fat Grafting: $2k-$4k; Under Eye: $850-$1.7k |
| USA | $3,500 - $10,000 | Surgeon fees, anesthesia; may exclude post-op care |
| UK | $3,500 - $10,500 | Similar to USA; may exclude some post-op care |
| Germany | $5,000 - $10,000 | High healthcare standards |
| Australia | $5,000 - $8,500 | Includes consultation, anesthesia, post-op visits |
| Turkey | $1,450 - $2,250 | More affordable |
South Korea offers excellent value with advanced technology and skilled surgeons at lower prices than the US and Europe. For example, canthoplasty averages $1,700 in Korea versus over $4,000 in the US. Eyelid fat grafting costs $2,000-$4,000 in Korea compared to $6,000-$10,000 in the US.
Patients should clarify what is included in surgical packages and budget for travel, accommodation, and local transport. Upfront deposits (around 10%) are common. Clear communication with clinics or agencies helps avoid surprises and ensures a smooth experience.
Patient Outcomes and Addressing Lagophthalmos
The main goal of surgery for lagophthalmos is restoring full eyelid closure to protect the eye and relieve symptoms. Canthoplasty, eyelid retraction repair, and laser canthoplasty have shown strong success, while eyelid fat grafting supports aesthetics.
Canthoplasty for Lagophthalmos
Lateral canthoplasty effectively treats lagophthalmos linked to lower lid laxity. In one study of 40 patients with paralytic lagophthalmos, 92.5% achieved complete correction and symptom resolution. Combined with gold weight implants, it helped patients with weak lower lids. Most patients had full eye closure upright; others had minimal residual lagophthalmos but full corneal coverage. Eye irritation improved in all, with 90% reporting complete relief.
Medial canthoplasty also improved exposure keratopathy in 73 cases, with 95% showing symptom improvement and 85-90% clinical improvement. Complications were rare, and no reversals were needed. This confirms canthoplasty as a safe, effective way to narrow the eye opening, support the lower eyelid, and improve keratopathy from facial paralysis or malposition.
Eyelid Retraction Repair for Lagophthalmos
Eyelid retraction causes lagophthalmos by exposing the eye. Surgery lowers the eyelid to protect the cornea. Studies show significant improvements in lagophthalmos after lower eyelid retractor weakening, with median improvements of 3-3.5 mm in blink lagophthalmos and 1-2 mm on gentle closure. Patients also gain better symmetry and appearance, especially when retraction follows prior surgery.
Laser Canthoplasty for Lagophthalmos
Laser canthoplasty shares goals with traditional canthoplasty but offers better precision, less bleeding, and faster healing. Though specific lagophthalmos outcome studies are limited, its advantages suggest similar or improved results in eyelid closure and corneal protection, plus enhanced cosmetic benefits.
Eyelid Fat Grafting and its Role
Eyelid fat grafting restores volume and improves periorbital appearance but does not directly treat lagophthalmos. It complements functional surgeries by enhancing eyelid contour. For lagophthalmos caused by excessive tissue removal, skin grafts or flaps may be used instead. Gold weight implants add mechanical weight to aid eyelid closure.
Overall, these procedures show high success rates in restoring eyelid function, reducing symptoms, protecting the cornea, and improving quality of life. Cosmetic improvements also boost patient confidence.
Conclusions
Lagophthalmos, the inability to fully close the eyelids, poses serious risks to eye health, from dryness and irritation to corneal damage and vision loss. Its causes vary widely, requiring precise diagnosis for effective treatment.
Surgical options like Canthoplasty, Eyelid Retraction Repair, and Laser Canthoplasty restore eyelid function and protect the cornea. Canthoplasty tightens and reshapes eye corners, while eyelid retraction repair repositions eyelids affected by conditions like Graves’ disease or surgical overcorrection. Laser canthoplasty offers enhanced precision and faster recovery. Eyelid fat grafting supports aesthetic volume restoration but is not a direct treatment for lagophthalmos.
South Korea stands out as a top medical tourism destination, offering expert surgeons, advanced technology, comprehensive patient support, and competitive pricing. Patients should carefully consider medical necessity, surgical options, surgeon expertise, and financial and logistical factors when planning treatment abroad.
These procedures have proven effective in relieving symptoms, preserving vision, and improving appearance, underscoring their vital role for patients with lagophthalmos.
References
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58
