Plastic Surgery Practice Talks to Dr Alex Zuriarrain About the Brazilian Butt Lift

In this episode, Zuriarrain talks about the need for better communication with patients about the risks associated with BBL procedures and how he is using ultrasound technology to improve patient safety. 

Join Plastic Surgery Practice Co-Chief Editors Alison Werner and Keri Stephens as they talk to board-certified plastic surgeon Alex Zuriarrain, MD, FACS, of Zuri Plastic Surgery in Miami, about one of the fastest growing cosmetic procedures: the Brazilian Butt Lift, or BBL.  

Zuriarrain talks about the ideal BBL candidate, what’s influencing the shape patients are asking for, and the need for patients to have realistic expectations. In addition, he talks about the need for plastic surgeons to really communicate to patients that this is a dangerous procedure. Patients not only need to know the mortality rate associated with the BBL procedure, but also that complications happen—even to the best surgeons. What’s more, patients need to know the limitations of fat grafting and that one round of liposuction and fat grafting may not be enough to get the final result they want. 

In this episode, Zuriarrain also shares how he is using a wireless ultrasound device to improve patient safety during procedures like the BBL. Not only does this imaging technology give him better visualization of the anatomy, but it also allows him to see where he is injecting with more clarity. 

This episode also features a discussion about how Instagram has become a huge game changer for the industry and the need that creates for better educating patients about realistic outcomes. Zurairrain goes on to share how he is expanding the med spa services he offers in his practice. His goal is to move away from referring patients to third-parties for post-op massages, IV fluid therapy, and hyperbaric oxygen therapies, and instead move those services in-house where he can better control the patient experience.

Podcast Transcript

Alison Werner:

Hi, I’m Alison Werner.

Keri Stephens:

And I’m Keri Stephens.

Alison Werner:

We are the co-chief editors of Plastic Surgery Practice. Thank you for joining us for this podcast episode. We are so excited to have Dr. Alex Zuriarrain with us today to discuss one of the fastest growing cosmetic procedures, the Brazilian butt lift. Dr. Zuriarrain is the founder of Zuri Plastic Surgery in Miami, where he specializes in aesthetic procedures of the face and body, including facelift, eyelid surgery, rhinoplasty, breast augmentation and reduction, abdominoplasty, liposuction, and of course, the Brazilian butt lift. So, Dr. Zuriarrain, thank you so much for joining us today.

Dr. Alex Zuriarrain:

Thank you so much. Thank you. It’s a pleasure to join you.

Alison Werner:

Great. Well, let’s get started. What do you think is leading the rise in BBL procedures?

Dr. Alex Zuriarrain:

Well, I think there’s been a huge cultural shift in regards to female aesthetics and what mainly women are looking for nowadays in regards to, especially the buttock in particular. For many years in plastic surgery, there was always a heavy push into what was breast aesthetics and breast augmentation surgery. As plastic surgeons, we really refined that technique over the last 30 years. So, things have really shifted now. Women still do a tremendous amount of breast augmentations, but the shift to the buttock really came about with the phenomenon of Jennifer Lopez and with the Kim Kardashian phenomenon. So, that really has changed the aesthetics of the female and the surgery has gotten much more popular and a lot of surgeons have gotten a lot better at it too.

Keri Stephens:

Of your patients that you see, what percentage typically are good candidates for this procedure if they come in and say, “Yeah, you’d be good for this”?

Dr. Alex Zuriarrain:

Yeah. So, what you’re looking for is to try to figure out, in general, if they’re a candidate. So, you want to see a lot of the anatomical characteristics that they have. You want to be able to do a physical examination. You want to be able to feel what areas would they benefit from when getting liposuction done. Have they had children in the past? Do they have any skin laxity or elasticity that’s not going to be good for liposuction, where instead they would benefit more from an abdominoplasty or a tummy tuck? So, the weight of the patient, the age, the overall physical characteristics of the patient, and what they desire and if they have realistic expectations are all super important.

Alison Werner:

Have you noticed a change in what patients have wanted? Because you talked about this procedure has been around for a while. It seems like it was as big as possible at a certain point. But have you noticed a shift towards a more natural frame?

Dr. Alex Zuriarrain:

Yeah. I think there’s a little bit of everything. Just like breasts, I think there was a time where it was like the bigger the breasts, the better. That was the days of like Baywatch and Pamela Anderson. Those days are long gone. They’re long gone in breasts. Nowadays, everybody’s looking for a B cup, maybe a small C cup breast, for the most part. You do have outliers in everything, of course, in every specialty and in every procedure in plastic surgery. But for the most part, yeah. People are specifically coming to see me saying that they do not want a Kim Kardashian butt. They do not want-

Alison Werner:

Really?

Dr. Alex Zuriarrain:

… a specific … Yeah. They don’t want that. They want shape and they’re not looking for large volume.

Alison Werner:

Oh, okay. So, what [crosstalk 00:04:00] pictures are they bringing into you then? Because it does seem like influencer culture comes in and people come in with their preconceived ideas, what they want. What kind of pictures are they bringing you now when they are bringing you pictures?

Dr. Alex Zuriarrain:

They bring me a lot of pictures from Instagram. Instagram it’s very heavy on promoting this, actually. Instagram has completely changed the plastic surgery industry-

Alison Werner:

Really?

Dr. Alex Zuriarrain:

… like many others. Yeah. But for us it’s been a huge game changer. Part of it is that they want to look a certain way and it depends the kind of influencer that they follow and what draws their attention. But people in my practice, they don’t come to me specifically for large size. They’re looking more for shape mainly. Then yeah. I look at pictures. I’m happy to entertain them. But for the most part, it’s more of a realization in my conversations with them that what they’re looking at on social media is not what they’re going to get. That’s not the result that they’re going to get. It takes a lot of education and a lot of time spent with the patient helping them realize that what you see on Facebook and Instagram is not real. It’s not real life. It’s not what I can get you to look like necessarily.

Alison Werner:

Yeah. What do you think for your peers? What do you think is best practices in terms of communicating with patients about those expectations?

Dr. Alex Zuriarrain:

Well, first thing is the surgery is very dangerous. It’s about a one in 3,000 mortality. It’s a very dangerous operation. Before you even think about having the surgery done, you really need to do your research on who is going to do it, what technologies are they using to do the procedure, to do the fat grafting in the buttock. In Miami, we do so much volume of these surgeries that we’ve gotten sometimes a little bit of a reputation because the more surgery you do, the more complications you have. That is just a statistical number. Just like the more you drive, the more chances you’re going to get into a car accident. The more planes you take, the more chances you’re going to get on a plane that’s going to crash.

Dr. Alex Zuriarrain:

That’s just statistics, and it goes with any surgical procedure. So, it’s very important that as practitioners of this specialty and of this particular procedure that we spend a lot of time educating the patient on, first of all, the mortality rate, second of all, the limitations of fat grafting, third of all, that not everything you inject, you get to keep. It’s not all yours. Some of that fat does die and it does get absorbed by the body.

Keri Stephens:

About how much of that fat dies?

Dr. Alex Zuriarrain:

30% dies in six months.

Keri Stephens:

Okay. Okay.

Dr. Alex Zuriarrain:

Yeah.

Keri Stephens:

That’s interesting.

Dr. Alex Zuriarrain:

So, a lot of times, another very important concept that we educate the patients on is that one round of liposuction and fat grafting may not be enough to get you where you want to go. Okay? Sometimes, you need to do a second round and you need to space them out a year apart and give yourself enough time to heal and to recover and all that. Then if you want to push the envelope again, then by all means, we can try again and get some more fat out and try to do some tweaking and improvements and things like that. Same thing for breasts. You have a woman that comes in, she is an A cup or less and she wants to go to a C cup or more, and she’s not going to get from an A cup to a C cup in one operation. Typically, you need to bridge that gap. So, you put in the biggest implant you can and you give her six months to a year for that breast skin to stretch and accommodate, and then you bring in and you switch it up to a bigger implant.

Keri Stephens:

Really? I didn’t even know that. That’s so interesting.

Dr. Alex Zuriarrain:

Yeah. Yeah, yeah. So, there’s a lot of preconceived notions about plastic surgery, for sure.

Alison Werner:

Yeah, definitely. In the reading I’ve done, I hadn’t heard anything about needing additional surgeries. But no, that absolutely makes sense. So, definitely sounds like that’s not maybe penetrating the public perception of this procedure.

Dr. Alex Zuriarrain:

No. No. A lot of people have a one and done mentality, which in plastic surgery, is not realistic. I tell everybody that I meet with in person, Rome was not built in a day. I cannot change 35 years or 40 years or 50 years of gravity, of multiple pregnancies, of weight fluctuations, of hormonal changes. I can’t fix all of that in one day in one surgery. Not if you want to get the best result. It’s just not possible. So, I think we need to educate the public through these venues, like podcasts. On my website, I try to do that as well, but YouTube and other video and audio outlets that get to the public somehow to educate them that they shouldn’t expect to have their dream bodies in one operation.

Keri Stephens:

That’s really interesting, and I don’t think the general public has any clue about that. Is that something your fellow plastic surgeons are telling you too? Like, “My patients come in with these completely unrealistic expectations. They think it’s a one and done.”

Dr. Alex Zuriarrain:

Yeah. Yeah.

Keri Stephens:

Yeah. How also do the patients respond when you tell them it’s not one and done?

Dr. Alex Zuriarrain:

Yeah. That’s the part where it gets a little bit tricky because I’m a private practice surgeon. I’m not taking insurance, I’m not taking Blue Cross Blue Shield or I’m not taking government insurance. So, I always have to preface it with this is not about money. It really isn’t. This is not about the financial aspects of it. This is trying to get you the best possible result that I can get for you based on what your expectations are. It has everything to do with your expectations.

Dr. Alex Zuriarrain:

My colleagues and I have been a little bit disconnected because of COVID. So, all of our meetings have been virtual and you don’t get to really sit down and have a conversation with your colleagues because you’re just too busy in these virtual meetings that you don’t … You’re listening to these lectures and you’re, getting your continuing medical education requirements taken care of, but you’re not networking and we weren’t able to really connect. So, actually, I’m going to San Diego to the American Society of Aesthetic Plastic Surgery meeting. Actually, it’s next month, I think, around this time. That’ll the first meeting that I go to since COVID with all of my colleagues in one conference center. So-

Alison Werner:

Yeah. Yeah.

Dr. Alex Zuriarrain:

… it’s going to be really-

Alison Werner:

That definitely changes the conversation. Yeah. No, definitely. So, let’s talk a little bit about the key safety issues of BBL. What should patients know?

Dr. Alex Zuriarrain:

Well, patients shouldn’t know that the safety record, the track record of the surgeon is very important. But they should also know that anybody can have a complication under general anesthesia. Okay?

Alison Werner:

True.

Dr. Alex Zuriarrain:

I have surgeons that are way, way more experienced than I am and have been in practice way longer than I have, and they’ve had a death related to this procedure. No surgeon can have a big enough ego to absolve himself of the possibilities that your patient can have a complication. That is not ethical, that’s not professional, and it’s not realistic. It’s not logical. So, patients need to know that complications happen. They need to know that it’s very much a statistical … It’s a numbers game. They need to know that. They need to know that it’s not anything specifically that they did or necessarily that the surgeon did, but sometimes these things happen.

Dr. Alex Zuriarrain:

It’s almost like a perfect storm that just comes together and things can go wrong. Things can go wrong, and it happens in every part of surgery and every specialty of surgery. The problem is that plastic surgery is in the news and we’re on TV and we’re on Instagram and we’re on social media and the gallbladder that’s done at the hospital at 3:00 in the morning, that doesn’t get the front page news. That doesn’t get Instagram. Nobody cares if somebody died from a gallbladder surgery. I hate to say it that way.

Alison Werner:

Yeah. Yeah. No, it’s very true.

Dr. Alex Zuriarrain:

I hate to put it that way.

Dr. Alex Zuriarrain:

But because it happened in the hospital, the hospital lawyers cover everything up. It doesn’t get to the public eye. The surgeons who work in the hospitals are backed by these groups of attorneys that take care of everything for them. They take care of their PR, their media, what the message that goes out of the hospital, where us who are solo private practitioners that are not surrounded by this public relations team, we don’t get to control that message necessarily. No, the other important aspect too is that people don’t expect to have complications when they have plastic surgery. They think that this is like getting their nails done, getting their hair done, and this is like a spa. Yeah, we may make it feel like a spa to you, but this is surgery, 100% legit, general anesthesia surgery.

Alison Werner:

Yeah. Yeah. Yeah. Well, that was the point I was going to make, or I was going to ask you about, because it’s like you said, it’s like there’s risks when you have your gallbladder out. There’s risks when you have an appendix out. So, this is anesthesia we’re talking about in a surgical procedure. When you’re talking to your peers or when you talk to your peers, what do you guys talk about in terms of best practices for making a BBL surgery as safe as possible? Is there equipment or technology you’re using that really helps you in that facet?

Dr. Alex Zuriarrain:

Yeah. So, I have been using a wireless ultrasound device that some of my colleagues have been using as well for a few years. For me, it’s changed the game in terms of safety. I can have much better visualization of the anatomy. I can see where I’m injecting with more clarity. It takes the blind aspect of the surgery, it removes that blind aspect to it and it gives you a little bit more confidence. There is a task force that was implemented also a few years ago and there was a group of plastic surgeons that got together. They studied cadavers. So, they went to the cadaver lab. They looked specifically at the patients who had died after undergoing one of these operations. They did cross-sectional anatomy studies and they found some correlations among these patients that unfortunately had this devastating complication, but they were able to come up with a set of recommendations on how to try to mitigate the risk, albeit that it’s not perfect.

Dr. Alex Zuriarrain:

We don’t have any real true long term studies on Brazilian butt lift, Brazilian butt lift complications, wireless ultrasound use during fat grafting. We don’t have really good longterm data. The American Society of Plastic Surgeons is trying to obtain longterm data to get the public more informed and to get us as surgeons better recommendations on safety, on what else we could do, what else we could possibly do to make the surgery safer. I honestly think that no matter what happens, this is always going to be a dangerous surgery. It’s always going to be a difficult operation. No matter how much we try to make it safe, it’s just part of the deal. It’s just you’re literally injecting fat directly into the buttock and anybody can hit a blood vessel inadvertently and cause an immediate absorption of fat into the systemic vasculature and cause a major complication.

Alison Werner:

Wow.

Keri Stephens:

Are patients typically afraid? Do they go in with knowing these risks? Or a typical patient that comes to you wanting a BBL, are they aware of the potential safety implications of the procedure?

Dr. Alex Zuriarrain:

I think the public has gotten pretty well educated in regards to the dangers of this operation. We could always do more to educate the public. There’s no question about that. I think because of all the things that have happened with the mortalities and the deaths that have happened within the last five to seven years, I think it’s become much more mainstream news that this is a pretty dangerous surgery. Nonetheless, I’d still think some people are just naive to that. They trust the surgeon and the track record of the surgeon and they just go for it. They don’t really question very much. They don’t ask too much about safety. They just want the results. They want to look the best that they can look. They want that before and after effect.

Dr. Alex Zuriarrain:

So, they’re willing to undergo the operation with … Even if you appropriately counsel somebody as to the risks, at the end, it’s up to them. They sign a consent form, and the consent form clearly says death is on the list of possibilities. So, nobody’s hiding that from you. You are signing, understanding that that is a possibility. So, you’re an adult. I tell people, “Look. I’m like a lifeguard. We go to the beach.” I tell them it’s like swimming without a lifeguard. You could drown. You could drown. But I’ll try to be there for you as best as I can to avoid you from drowning. But you got to swim at your own risk sometimes. You just have to make your own decisions and you got to live by your decisions, for better or for worse.

Alison Werner:

Yeah, exactly. You just mentioned that you’re an adult. What age range are you seeing for patients coming in for the procedure and is there an ideal age?

Dr. Alex Zuriarrain:

Yeah. Well, I’ll tell you what. In my experience, the younger, the better.

Alison Werner:

Really? Okay.

Dr. Alex Zuriarrain:

Yeah. The younger, the better, and I’ll tell you why. The collagen content of the human body begins to degrade rather precipitously after you’re 18 to 21. You start to have a steady degradation. You start to have also increase in skin elasticity, in skin acidity, and you don’t really bounce back as well from a liposuction procedure than a young patient. A young patient, you do liposuction and they are tight as a drum. Their skin is very tight and they heal very quickly. You do that to a 40 year old, it’s not the same. It not the same. The results aren’t the same. The skin quality is not the same. There’s a lot of factors involved.

Dr. Alex Zuriarrain:

I always stay away from operating on women less than 21 years old. I don’t think that they’re psychologically ready for it. I don’t think that they really understand or have the maturity to understand the implications and the possible complications of the surgery. I’ve had on a couple occasions moms come with their daughters and they’ve been 100% on board and they’re super about their daughter having the procedure and they’re there. So, if I see somebody that has a really good support system like that, like a mother who’s really involved and I have the time to explain to them all the risks, then I may waiver and I may go down to maybe 18 years old. But it’s very rare for me.

Dr. Alex Zuriarrain:

I don’t like to go below 21 and I think it’s just better for their … A lot of these, a lot of these girls are getting wrapped up in their teenage years and 18, 19, 20 with these Instagram and social media and they’re lost. They’re completely, completely lost in this world. It’s like this Facebook thing that’s now no longer Facebook. Right? It’s Meta. Right? So, what does Meta even mean? Meta means living in an alternative universe. Meta means we’re no longer going to be talking face to face as humans anymore. We’re going to be in this ulterior world where we’re not going to even represent each other anymore. We’re going to have these little avatars that are going to do … I can’t even wrap my head around it, but that is where we’re going, literally. That’s where we’re going.

Keri Stephens:

It’s crazy. Yeah.

Alison Werner:

Well, and it’s going to totally change the-

Dr. Alex Zuriarrain:

So, I’m about to-

Alison Werner:

[crosstalk 00:21:52] coming in. Yeah.

Dr. Alex Zuriarrain:

Yeah. So, I don’t know. I don’t know.

Alison Werner:

Yeah. How do the results hold up over time? You talked about the fact that you need more than likely more than one procedure. But once you’ve gotten through those procedures, how do the results hold up? What can patients expect.

Dr. Alex Zuriarrain:

Amazing. They’re phenomenal. Whatever you keep in terms of the fat that was injected, whatever you keep at six months, at six months, that’s yours forever. You go to the grave with that. That’s yours. That fat is yours. You’re not going to lose it. It’s not going to go away. This isn’t a filler material. This isn’t silicone. We’re not using Fix-a-Flat like they do in some places. These crazy stories that you hear of these garage … Go to some garage and they’re filling your buttock with all kinds of synthetic … It’s unbelievable. The results are phenomenal, and the shaping that you get, the body contouring that you get is unparalleled. You cannot get that with exercise. You just, you can’t.

Keri Stephens:

Really?

Dr. Alex Zuriarrain:

You can’t. Yes. I’ve seen it. I’ve seen it. I’ve done it. I’ve done side by side comparisons with sisters and twins and you cannot beat the body contouring from liposuction because there are certain fat deposits in the human body that will not react to exercise. They will not react. Your genetics are super important. Your genetics make up a very large part of your shape. Your body shape is really, really determined by your genetics.

Keri Stephens:

So, these patients come in for the BBL. What is the recovery like and does your facility, do you offer aftercare services? What is the recovery like for these patients?

Dr. Alex Zuriarrain:

Recovery’s brutal. Amongst all the surgeries that I perform, the BBL is the most brutal recovery because liposuction burns. It’s a different type of pain. It’s not the pain of an incision or the pain of a cut. It’s a full body burn because you’re literally bringing in this cannula in and out and sucking high volumes of fat, but you’re doing it globally. So, you’re doing it the whole back, the whole abdomen, the whole flanks, the whole entire waistline. So, it’s like a general body pain. So, it’s intense. It’s intense. I don’t sugarcoat it. I tell all my patients the same thing. I say, “Get ready because this is going to be probably one of the worst pains you’ve ever had in your life, for sure.”

Dr. Alex Zuriarrain:

I can’t compare it to pregnancy or anything like that, but it’s a different type of pain. Pregnancy pain is one thing. Liposuction pain is totally different. Totally different. So, the recovery is a lot of massages. You need about 15 massages. You need to wear compression garments. It’s a hell of a time getting in and out of the compression garments. I feel bad for them because it’s so painful. But the results are, they’re awesome. They come back three months later, four months later and they’re like, “Oh, my God. I’m so happy I did it.” But the first week after is hell. It’s literally hell.

Alison Werner:

Okay. Wow. Do you offer that massage in your practice to keep the patient engaged with the practice? Or how do you keep the patient, keep that relationship going, if you want to do that?

Dr. Alex Zuriarrain:

Yeah. We can talk about that. So, in my particular practice, the building that I currently operate in, which is my building and I built it out as of approximately a year ago, I gutted the building and I built it from scratch, and I wanted to have a very premier practice in South Miami, which I grew up in this area. In Miami, this is, for me, one of the nicest areas to practice. I’m not in a high rise building. I’m not on the 51st floor, I’m on ground floor, and I wanted to give my patients the best experience possible. But I haven’t gotten to the point, and this is the next stage in my practice, where I’m now acquiring a separate space, completely separate from the main operating building where I’m going to start providing massages and IV fluid therapy and hyperbaric oxygen therapies and more of that kind of med spa services that I currently, I give referrals. I refer to other people in Miami who they can have their massages with, but I can’t control that experience. So, I want to be able to control it better.

Keri Stephens:

That’s interesting, and that could be a really good way to give the med spa side. yeah. That seems to be where a lot of the plastic surgeons we’ve talked to are really getting into that side, and I’m not going to say double dipping, but there’s such a crossover, I’m sure, with the med spa and the aesthetic plastic surgery side. But yeah.

Dr. Alex Zuriarrain:

Yeah. Yeah.

Keri Stephens:

So, one of the things Allison and I were talking about is what if someone decides, “You know what? I don’t like this. I want to reverse a look,” how do they do that? I’m sure that’s probably not something you see a lot because I’m sure they’re happy with their outlooks. But what if they decide, “Oh, no. You know what? I don’t like having a bigger butt”?

Dr. Alex Zuriarrain:

It’s happened to me probably three times in the last five to seven years. It’s not common at all. At all. I’ve done thousands of these surgeries, like thousands, and three out of two or, or 3,000 patients is nothing. So, what do you do? Well, the option is to go back to surgery. The option is to liposuction the buttock. The buttock is like a half moon. If you look at the female form when laying completely prone or face down, and you look at a profile view, it’s basically like a half moon shape. The hard thing with that shape is to try to remove fat equally from both sides and not cause some sort of cosmetic deformity where they’re flat here, but then they have more projection here, or they have too much volume here and not enough here.

Dr. Alex Zuriarrain:

So, in summary, it’s a very difficult thing to do. I never enjoy doing them. I’m never satisfied with them. I never feel like I get to reduce them as much as I would like to reduce them or that I get to reduce them with such precision. There’s not a lot of precision. As plastic surgeons, we’re very precise. If you go into plastic surgery is because you’re probably a very OCD, Type A, super meticulous type of person. If you’re not that type of personality, I don’t think you belong in plastic surgery. I think that you should go maybe do some other type of surgery, but not plastic surgery because this requires an insane amount of meticulous focus. That’s one of the operations where it just leaves you with not a great taste in your mouth because you’re not being very precise. You don’t have a lot of control.

Keri Stephens:

I have a last question I think really sums this up and I think this is a perfect way to end. But what excites you most about the future of plastic surgery?

Dr. Alex Zuriarrain:

I think it’s what excited me when I started looking into it as a resident. This is the most amazing specialty in surgery, in academic surgery, in existence. This is the specialty that has had the most advances, then maybe neurosurgery and maybe orthopedics. So, between the three of us, we’ve had the most intense advancement since we were developed as a specialty. Every day, something new comes out. Every day, I learn something different. Every day, we push the envelope. The most exciting thing that I think that I’ll ever be a part of is being a plastic surgeon. There’s nothing that I’d rather do. There’s no other specialty.

Dr. Alex Zuriarrain:

This comes from being a general surgeon. I spent five years training as a general surgeon. I did a full specialty. I spent trauma surgery, pediatric surgery, cancer surgery. Everything that you can imagine under the umbrella of surgery, I did all that and then I said, “I want to be a plastic surgeon,” and that’s what I did. It was because also of the freedom to practice in this country without having an insurance company holding you hostage, holding you hostage. I believe in the American dream, I believe in small businesses, I believe in you being the person who decides your destiny, and I was not going to allow for insurance companies or the federal government to limit the way that I wanted to either build my business or build my practice as a surgeon.

Alison Werner:

Well, thank you so much, Dr. Zuriarrain. We really appreciate what you’ve shared with us today and we hope it’s really informative for our listeners. To check out the latest of plastic surgery news, please visit plasticsurgerypractice.com and until next time, take care.

Published at Wed, 30 Mar 2022 18:28:54 +0000