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"The gaunt appearance patients experience is due not only to volume loss, but it may also cause changes in the facial skin, including a reduction in collagen, elastin and essential nutrients

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Measurements of serum vitamin B 12 may not reliably detect deficiency, and measurement of serum homocysteine and/or methylmalonic acid should be used to confirm deficiency in asymptomatic high-risk patients with low normal levels of vitamin B 12