fund raisers, taught chess, organized social activities, 10/2002 The He is very nice and straight forward. Expert Guest Commentator Plastic Surgeon, Activities: University of New York at Stony Brook School of Medicine after graduating from As received his Doctorate of Medicine with Recognition in Research from the State Since she was young, Taryn Quinterri always wanted to have a bigger butt. Surgery. Dr. Tansar Mir MD | 521 Park Avenue | New York, NY 10065 | (212) 606-8150 | www.tmirmd.com Dr. Mir gives all of his patients his undivided attention and thoroughly explains all aspects of their surgery. "They feel tired, They get back pain, they get burning and itching in their butt. Simpson RL, MH Hanna. youre like most people, you might have a hard time wrapping your head around "It's an epidemic that's actually getting worse as social media is becoming more popular," Dr. Tansar Mir, a New York-based plastic surgeon whose practice includes silicone removals, told ABC News. medical degree from SUNY at Stony Brook School of Medicine (2004). Your consultation with Dr. Mir will be not only be informative and educational, but also enjoyable. Stony While Mir, MD Plastic & Reconstructive Surgery. qualified medical doctor, preferably with the benefit of the patients medical Do Not Sell or Share My Personal Information. weight, and skin condition. To do this we will link your MailOnline account with your Facebook account. Surgery at Lenox Hill Hospital, New York, NY and his residency/fellowship in 521 Park Ave. Should that be the case, it is Oct 2010; 126 (4). Reviews are only removed at the reviewer's request or if they violate our. Brook, Dept of Dermatology, October 2003, Adler, It is a risky surgery as well. Dr. Adame and Galaz, who allegedly performed Quinterri's procedure, would eventually be charged with the murder of Karissa Rajpaul, who died while receiving silicone butt-augmenting injections in 2019. Plastic surgeon Dr. Alexander Ramrez Folleco during a consultation with Taryn Quinterri. are undergoing medical treatment, weve got the perfect list of things to do in It is here where he performs his elective, cosmetic plastic surgical procedures. Nassau Surgical Society Plastic Surgeon Manhattan | Dr. Tansar Mir MD | New York City One should not act based solely on calcium into the bones. Dr Mir gives me a lot confidence and I feel so comfortable with him. show your love and support. we understand that you might not be able to think straight when your loved ones and supplements are required by people under special circumstances. you ever wondered why we need to take vitamins and supplements when our body N.E.U.R.O.N., Trinity College, CT, June, 1999, Position: makes you feel weak and dizzy. that you care. I made the stupidest biggest mistake of silicone injections 12 years ago. Dr. Mir understands the impact doctors can have serving the world community. A new episode of "IMPACT x Nightline" looks at the dark side of butt augmentation procedures, a trend that is only getting more popular. posters for presentation at numerous conferences. They must stick to Connecticut woman says doctor billed her $56,000 to fix - PIX11 assistance with even the most basic of activities or tasks such as walking to bone-related diseases such as osteoporosis. let us know. Add to that the I have had the best experience and cant say enough good things about Dr. Mir and his staff. Dr. Mir and his team have been published in national medical journals on this topic as well as others. with Dr. Mir has also He took the time to explain everything to me, was always available and never rushed me out of my appointments. Dr. Mir completed his internship and residency in General Surgery at Lenox Hill Hospital, New York, NY and his residency/fellowship in Plastic & Reconstructive Surgery with the Long Island Plastic Surgical Group through Nassau University Medical Center. the fact that your loved one may not be in the best of health for the next few Tel: (212) 606-8150, 416 N Bedford Dr. #306 Plastic and Reconstructive Surgeon who is certified by the American Board of Reviews you can trust, from real people like you. Dr Mir is the right doctor if you want a successful procedure. Plastic Surgeon Dr. Tansar Mir MD, serving Manhattan, New York City, and the surrounding area. information about the plastic surgery issues so that the public and patients Has Anyone Who Got the Silicone Butt Injections Tried to Remove It ,If You can choose on each post whether you would like it to be posted to Facebook. Mirs pioneering efforts have been well documented and chronicled on numerous Dont choose a doctor that doesnt have a lot of experience with silicone injection removal or it could make the situation worse. Thats when patients start researching on In this manner, Dr. Kenneth Hughes is able to minimize the total possible deformity caused by removal and reduce the need for reconstructive surgery with fat transfer or implants. situation, you will essentially divert your focus on ways to be there for them Quinterri recognizes she could potentially be suffering from the implications of her decision for the rest of her life. Taryn Quinterri during an interview with ABC News. These procedures are already dangerous when done by proper, licensed doctors in the US. Silicone Injections Videos - RealSelf Needless to say, patients are often distressed worrying about their financial with the fact that your loved ones are going through a tough time is the best way These issues can strike at any time, with some not emerging until years later. vitamins and supplements for them. 'If a doctor says your blood levels are too low or you have diabetes or whatever, don't do it.'. your loved ones on their doctors appointments also helps you give off positive Dr. Mir is an excellent surgeon. Taking in an easy-to-understand way. The silicone led to dead fat, scar tissue, and nodules. International missionary work is something very dear to Dr. Mir and he hopes to continue to make many more future trips to underserved countries. I was also tired a lot and just had a general Not feeling well daily. board-certified Plastic and Reconstructive Surgeon who is certified by the A Brazilian Butt Lift, or BBL as it is often referred to, is a surgery where a doctor moves fat from the abdomen and hip to a person butt. Cardi B (left) revealed on Instagram Live last week that she had 95 percent of her silicone BBL implants removed as she feared long-term health risks. He particularly enjoys traveling, tennis, concerts, professional sports and spending time with his nephew and nieces. received his Doctorate of Medicine with Recognition in Research from the State Dr. Tansar Mir, MD Plastic Surgeon 16 Years Experience 521 Park Ave., New York, NY 4.7 33 reviews Connect with Dr. Mir Get a consultation Pricing Website Phone: (518) 302-2968 Total years in practice: 16 Dr. Mir is a double board certified Plastic Surgeon (American Board of Surgery as well as American Board of Plastic Surgery). Dr. Tansar Mir MD | 521 Park Avenue | New York, NY 10065 | (212) 606-8150 | www.tmirmd.com Dr. Tansar Mir MD | 139 Plandome Road | Manhasset, NY 11030 | (516) 439-5160 Whether You only need to expose your skin for He then completed five years of General Surgery residency at Lenox Hill Hospital in NYC followed by Plastic & Reconstructive Surgery Residency at Nassau University Medical Center/ Long Island Plastic Surgical Group. In this day and age, surgery, diseases, conditions, and illnesses "Often it's not even a physician, it's people who are not medically trained," Dr Glasberg said. the internet. Reviews you can trust, from real people like you. Dakotas life, see this video. Watch as plastic surgeon Dr. Tansar Mir performs her silicone removal surgery. The Anyways I havent have any serious problems yet, no discoloration, no dents or black spots but for some reason every 2 to 3 years my left hip reacts to the material and become swollen, sometimes I get mild lower back pain. It The Use of Tissue wondering about all the possibilities and the different ways in which you can because they are essential for healthy body growth and development. To see how the procedure transformed Dakota's life, see this video. In September 2018, after years of pain, she finally had the silicone taken out by Dr. Tansar Mir, a plastic surgeon on the Upper East Side. we tell you the best and most thoughtful ways in which you can show your love The vein thrombosis (DVT) is a rare complication. NY . "I wanted to be thicker," she told ABC News. Taryn Quinterri, from Arizona, told ABC that she is one of the women who elected to get these synthetic implants for her BBL. Dr. Tansar Mir is a nationally renowned double board certified Plastic Surgeon (American Board of Surgery as well as American Board of Plastic Surgery) expert in silicone removal surgery from the buttocks and other parts of the body. acid supplements are prescribed by doctors to pregnant women. body will lack essential vitamins and nutrients required for healthy growth. Since to Dr. Mir and he hopes to continue to make many more future trips to People If there is an Tansar N. Mir is a plastic & reconstructive surgeon in New York. Buttock Reconstruction - Beverly Hills, CA | Tansar Mir, MD University of New York at Stony Brook School of Medicine after graduating from He is compassionate and sensitive to all of his patients needs and enjoys interacting with them. Some The views expressed in the contents above are those of our users and do not necessarily reflect the views of MailOnline. procedures include breast augmentation, rhinoplasty, and liposuction. Plastic Surgeon Dr. Tansar Mir MD, serving Manhattan, New York City, and the surrounding area. New York, NY 10065 (3 other locations) Is this you? Next week I will complete my second month after my surgery Im driving my car and doing my life the most normal, and also I feel very in general, Im energetic and healthy and also so happy with my new bottom! meaning that the scar is unusually red and raised. this particular procedure. and palate. in Primary Breast Augmentation: Predicting Outcomes. the required amount will not quicken the recovery process. even result in death. EXCLUSIVE: Woman stricken with illness because of botched butt Tansar, Determining the Expression and Function of Epidermal Cell Integrins your loved one with a serious illness or medical condition might have a team of Plastic Reconstructive Surgery. Watch as plastic surgeon Dr. Tansar Mir Dr. Mirs approach to facial rejuvenation focuses on accentuating ones features in a natural and aesthetically pleasing manner. support system that will always be there for them no matter what. He put my fears at ease. true for patients who are suffering from serious diseases and may be bedridden. Beverly Hills, CA 90210. Accompanying Dr. Mir graduated with a BA in Neuroscience from Franklin & Marshall College and then went on to receive his medical degree from SUNY at Stony Brook School of Medicine. a condition when blood pools directly under the skin, with swelling and pain. The patient also a history of spinal surgeries in the exact same area. I came to New York back in February where I met Dr Mir. Not only is your mind University, Certificate 521 Park Avenue New York, NY 10065 Main (212) 606-8150 Fax (212) 644-8655 Are you Tansar Mir, MD? Dr. Mir Dr. Mir is a double board-certified Plastic and Reconstructive Surgeon who is certified by the American Board of Surgery and the American Board of Plastic Surgery. are, however, certain risks associated with such procedures. New York . Dr. Tansar Naveed Mir, MD ; Featured Providers Near You . Reviews are only removed at the reviewer's request or if they violate our. After six months, she developed a rash on her butt cheeks. News,andThe Wall Street Journal. * Everyone is different, and there's no guarantee you'll have the same experience or results as someone else. All reviews meeting our. there is something you can do to lend support. most people do not require vitamin D supplements because their bodies make Consultations require an in office visit, call for more information! There national and international media outlets includingCNN, The Today Show, are suffering from a serious illness, condition or disease. who are bedridden and who wear clothing that does not expose their skin to the Initially, I did not have any issues with the product, but about 8-9 years ago, I started suffering from lower back pain, pain when I sat on hard surfaces, extreme itchiness in the lower back and buttocks, and it Today makes 26 days exactly since I had my surgery and what a journey it has been . Well ask you to confirm this for your first post to Facebook. Dr Tansar Mir took a look at Dakota, seeing that the silicone had migrated, and offered to take care of the silicone removal for free. Dr. Tansar Mir is a double board certified Plastic and Reconstructive Surgeon. Surgery, Plastic Surgery. Neuroscience, Miami, Fl, October, 1999, Adler, Dr. Tansar Mir is a native New Yorker and was inducted into his high Claim your profile (212) 606-8150 . doctors prescribe this supplement to children who are in the growing age. performed multiple pro bono surgeries on ill patients, 2/2011-2/2011 Doctors Television Show: Earlier this year we met Dakota who was disfigured by It is at these hospitals where Dr. Mir performs reconstructive surgery including breast reconstruction, abdominal wall reconstruction, skin cancer reconstruction and hand surgery. 20 Jan 2018 . Mirathttps://tansarmirmd.home.blog/. silicone removal surgery. Your consultation with Dr. Mir will be not only be informative and educational, but also enjoyable. Dr. Tansar Mir MD | 521 Park Avenue | New York, NY 10065 | (212) 606-8150 | www.tmirmd.com Dr. Tansar Mir MD | 139 Plandome Road | Manhasset, NY 11030 | (516) 439-5160 also a common issue in all plastic surgeries. Part of the Daily Mail, The Mail on Sunday & Metro Media Group, Lookfantastic - Lookfantastic discount code, Treat yourself to offers on make-up and accessories, Get the right equipment and sportswear for less, Save money on outlet and full-price orders, Holland and Barrett - Holland and Barrett promotions, Click through to find the latest voucher codes, Feel good with amazing savings with Cult Beauty, Save money on your favourite brands this month. "A few simple steps to reduce cancer risks," a new article by Plastic I got my butt injections 13 years ago n everything was fine till I started having discoloration n lower back pain n I couldnt seat or stand for long it was the worst thank god I found him n I just had it removed on Nov 30, 2018 n I had it done in Lenox hospital n they were great as well no complains n I went through my insurance n I did my research for 4 years n the other d My story begins 12 years ago. This condition is commonly known as anemia. "He pretty much saved my life," she said.. Doctors can't pay to have reviews removed or hidden. First 2 of 24 1 2 3 4 "You just got to go the legal route," she said. Taking more than Surgery and the American Board of Plastic Surgery. and cater to their every need when they are going through physical and In addition to surgical procedures, Dr. Mir also performs many less invasive procedures, such as Botox and dermal fillers such as Juvderm, Radiesse, and Restylane, fat transfer, laser skin resurfacing, laser hair removal, mole removal, repair of torn earlobes and chemical peels. information found on the internet, but instead review the issues with a 'In August I got surgery and I removed 95 percent of my biopolymers if you don't know what it is, it's a** shots. It transports oxygen from the America's 'butt lift epidemic': Doctors warn against 'deadliest type plastic surgeons are trained to keep the scars to a minimum, but they are Dr. HE IS THE BEST !!!!!! weeks. in Neuroscience from Franklin & Marshall Many people try to The negative effects include all want to look and feel our best. color. Dr. Mir is a double board-certified This may include frequent headaches, difficulty sleeping and concentrating, fatigue, unusual mood swings, and an upset stomach. Dr. Mirs extensive research experience includes serving as a research assistant in the lab of Richard A. Clark, PhD while attending medical school. Damage some surgeries may adversely affect internal organs, such as school (Farmingdale High School) Wall of Fame in 2014. She feared the silicone would migrate into different parts of her body and kill her. I want to believe its not som Dr. Mir is a double board certified Plastic Surgeon (American Board of Surgery as well as American Board of Plastic Surgery). amount of skin exposed and the time of the day significantly affect the . It is present in the red blood cells. Tansar N. Mir, an experienced plastic & reconstructive surgeon based in New Both Adame and Galaz appeared in court in September and pled not guilty to murder and practicing medicine without a certification. assisted in congenital and reconstructive surgeries including cleft friend or family member, you can also help them believe that they have a strong Care must be taken not to overdose. Seroma Mir T, Taryn Quinterri (right), from Arizona, said she thought her silicone implants would kill her. Dr. Mir completed his internship and residency in General Surgery at Lenox Hill Hospital, New York, NY and his residency/fellowship in Plastic & Reconstructive Surgery with the Long Island Plastic Surgical Group through Nassau University Medical Center. have a support system that they can count on when the going gets tough. with Recognition in Dr. Tansar Mir received his Doctorate of Medicine with Recognition in Research from the State University of New York at Stony Brook School of Medicine after graduating from Franklin & Marshall College in Lancaster, Pennsylvania with his Bachelor of Arts in Neuroscience. Save up to $60 by joining ASPIRE Galderma Rewards*, Reviews are written by real people and providers can't pay to have reviews removed. Dr. Shwetambara Parakh, MD . I love Dr Mir.. other parts of the body (such as the lungs, causing pulmonary embolism). For a better experience, please enable JavaScript. hematoma occurs ina few percent of breast augmentation surgeries, and Can't wait . Mother of the UK's most premature twins who were given ZERO chance of survival says they are going from GP appointments crisis laid bare as figures show family doctors are cramming in up to 60 patients per day. These can become infected and may have to be drained. Since it is easy for patients to feel like they are troubling those around them mentioned earlier, treatments for serious illnesses can cause a fortune. Dr. Tansar Mir was also selected as one of 40 Forty Under Forty exemplary graduates from Stony Brook University in 2016, an honor only bestowed upon 5 medical students out of over 2000. By accepting the 209e-210e, Mir T, I highly recommend Dr. Mir. Dr Roxanne Grawe, who went by Dr Roxy and posted goofy videos dancing in her scrubs, is accused of livestreaming operations and focusing on the camera instead of patient care. Dr. Dr. Tansar Mir MD | 521 Park Avenue | New York, NY 10065 | (212) 606-8150 | www.tmirmd.com Was This Page Helpful? Glickman LTG, K Alizadeh. Mirs extensive research experience includes serving as a research assistant in Vitamins Dr Mir warned that these issues develop as an auto-immune response, where the body detects the silicone as a foreign substance and attack it. satisfaction ratings, and respond to consultation requests quickly. Tansar N. Mir is a plastic & reconstructive surgeon in New York. Mir provides advice. This increases the risk of complications - leading to some notable 'BBL horror stories' that have arisen in recent years. Reviews for Dr. Tansar Mir, MD | New York, NY | Surgery | Vitals 2011 Dr. Tansar Mir and MedNet Technologies, Inc. All Rights Reserved. Plastic Surgery Consultation | Manhattan | New York City Yet her desire for body modification would not only cost her thousands of dollars, she says it would lead her to seek a procedure from a mother-daughter duo, with no proper medical training, whose surgeries allegedly resulted in the death of at least one woman. Completely healed, I have no scars, Office review - very nice and straight forward, I already feel much better 1 month post-op silicone injection removal, Silicone Injections Removal from the Buttocks. Some commonly occurring issues in plastic surgery Just look for the RealSelf Dr. Kenneth Hughes handles the most complicated revision and reconstructive cases on the planet, and this is another prime example of intellectual and technical prowess of Dr. Kenneth Hughes in Los Angeles.To see more information about silicone and foreign material removal, visit Dr. Kenneth Hughes's website at https://www.hughesplasticsurgery.com/body-procedures-los-angeles/silicone-and-biopolymer-removal-from-buttocks/To contact Dr. Kenneth Hughes's office in Los Angeles about your silicone injection removalhttps://www.hughesplasticsurgery.com/contact-los-angeles-plastic-surgeon/ Deep Dr. Mirs pioneering efforts have been well documented and chronicled on numerous national and international media outlets including CNN, The Today Show, Doctor Oz, The Doctors TV Show, FOX news, CBS news, The New York Daily News, and The Wall Street Journal. Dr. Mir is a pioneer and leader in the field of silicone removal surgery as well as buttock reconstruction. I had a difficult time sitting on hard surfaces and I also developed digestive issues and issues with my bowels coming out with no warning and excessive diarrhea. Dr. Mir did a tummy tuck on me 2 years ago, he changed my life. vitamins and supplements. "I was great for like six months. MedNet-Sites - Powered by MedNet Technologies, Inc. Alicia Galaz's lawyer told ABC News "As much as Ms. Alicia Galaz would love to sit down for an interview and share her side of the story, now is not the appropriate time given the pending criminal action. Still struggling but I go get butt implants on February 5th so reconstruction surgery is scheduled with Dr. Senderoff. Doctors prescribe iron supplements to anemic patients so that their iron levels Hi everyone! handmade heartfelt cards, it is important to leave no stone unturned when it fact that most treatments today are quite costly. Am from out of state so he automatically made me understand the commitment I had to Dr. Mir did a tummy tuck on my 2 years ago.. he changed me life. Learn more about RealSelf Verified doctors. and palate and performed burn reconstruction surgeries on medical missions to If you are thinking about it, read. He firmly believes that subtle changes can provide drastic results without an unnatural flair. Franklin & Marshall College in Lancaster, Pennsylvania with his Bachelor of I definitely recommend him! how to promote better healing after surgery, the surge of silicon injections by 8/2007 Anesthesia In case your body has a low level of iron, lips/palates and burn reconstructions, 11/2002 Mir, Dr. Mir completed his internship and residency in General These figures do not include the many women who travel abroad to receive a BBL for a lower price. The Role of He then Plastic & Reconstructive Surgery with the Long Island Plastic Surgical Group The Food and Drug Administration (FDA) warns that these injectable silicon procedures can lead to severe complications or death. A I hope to fill that information Thank you for your feedback. the front door or eating, showing them unconditional love is your best bet. Buttocks enhancement procedures can cost thousands, health issues which is essentially a pocket of blood resembling a painful bruise. Moreover, newborn babies and The goal is to create the 'hourglass' body shape, with thin hips and a wide buttocks. for Volunteer Plastic & Reconstructive Surgical Mission. most common complaint of patients suffering from serious illnesses especially Someone injected me silicone, most likely industrial silicone, she claims it was medical grade silicone. Dr Scot Glasberg, a certified plastic surgeon, told News 12 that he believes Messam received illegal injections. Silicone Injection Removal - Tansar Mir, MD - Review - RealSelf He speaks honestly, clearly about the procedures and patients expectations. Dr. Tansar Mir received his Doctorate of Medicine with Recognition in Research from the State University of New York at Stony Brook School of Medicine after graduating from Franklin & Marshall College in Lancaster, Pennsylvania with his Bachelor of Arts in Neuroscience. I highly recommend Dr. Mir and his office. co-authored several publications in peer-reviewed medical journals and produced 24/7 coverage of breaking news and live events. production of vitamin D. So who needs vitamin D supplements? On top of being an amazing doctor he is also extremely nice and easy to talk to. 06/ 2004 Boys & Girls Club, Activities: We will automatically post your comment and a link to the news story to your Facebook timeline at the same time it is posted on MailOnline. Design a site like this with WordPress.com, New Article by Dr. Tansar Mir, Vitamins and Supplements Do They Really Work?, Woman Undergoes Painstaking Procedure To Reverse Botched Butt Augmentation, Supporting a Loved One When They Are Struck by a Medical Condition or undergoing Surgery, Plastic Surgeon Dr. Tansar N. Mir starts Blog about plastic surgery issues, The Blog of Dr. Tansar Mir, plastic surgeon. Neglecting your gums? Thats why doctors prescribe these vitamins Many people opt for silicone butt implants, which give the same hourglass shape but could carry even more danger. Click on the above photos to enlarge and start the slideshow view. Have Scars Some women will also go to countries in Latin America or to Turkey, where they can receive the surgery cheaply. Their legs feel heavy and numb. Dr. Tansar Mir MD | 139 Plandome Road | Manhasset, NY 11030 | (516) 439-5160, 521 Park Ave. New York, NY 10065212.606.8150, Dr. Tansar Mir MD | 521 Park Avenue | New York, NY 10065 | (212) 606-8150 |, Dr. Tansar Mir MD | 139 Plandome Road | Manhasset, NY 11030 | (516) 439-5160. available at https://tansarmirmd.home.blog/. serious scenarios, doctors might not grant you permission to take things in of Appreciation: Tansar Mir, M.D. Butt Silicone injections removed - Dr. Mir - Review - RealSelf Plastic Surgeon 521 Park Ave., New York, New York . if someone close to you is undergoing surgery or some other medical treatment, "He disinfected the. Dr. Tansar Mir provides his thoughts in a new article. Trocoscopy in Missed Diaphragm Injuries. If Uplift Internationale, Roxas, Phillipines, Position: dislike food on the basis of color, texture and shape. spend billions of dollars every year on plastic surgery. 28 reviews Get a consultation . can easily understand the underlying medical issues and procedures. Essentially, it means that a While certain injectable dermal fillers are approved for some use in the face to enhance lips and cheeks, neither silicone nor dermal fillers are approved for buttock injections. Why do doctors prescribe them? balanced diet by strictly following a diet plan, they would not need to take blood clots forms in a deep vein (often the leg), breaks off, and travels to sunlight, our bodies convert the ultraviolet radiations into vitamin D. So, Board of Surgery, Farmingdale This is If a person takes a healthy Ms Quinterri is now saving up, hoping to receive a second BBL removal procedure stateside. Doctor Oz, The Doctors TV Show, FOX news, CBS news, The New York Daily Stony Brook University: Tansar Mir, MD '04 Plastic Surgeon, Tansar Mir Plastic and Reconstructive Surgery. In 2021, U.S. doctors conducted more than 61,000 butt augmentation procedures, according to statistics from The Aesthetic Society, a figure that is up more than 37% from the year prior. CALL DR ALBERTO S. GALLERANI MD BOARD CERTIFIED PLASTIC SURGERY IN MIAMI HE REMOVES IT EVERY WEEK FROM DOZENS OF PATIENTS. assigned an underprivileged little sib to advise, teach and guide, 12/2012 American Board of Plastic Surgery, 02/2010 American Dr. Tansar Mir is a native New Yorker and was inducted into his high school (Farmingdale High School) Wall of Fame in 2014. track of their health and monitoring it in any way possible is a great way to can get them from the food we eat? The Doctors Television important for this type of medical treatment, in todays plastic surgery practices, Volunteer Plastic Surgical Fellow. Massive spontaneous hematoma from chronic enoxaparin articles, they find highly complex answers that are very difficult to