‘‘”Ǧ•‹–‡‘”„‹†‹–›ˆ–‡”   Žƒ’”‡ƒ•–‡ ‘•–”— –‹‘   ‹••‡”–ƒ–‹‘ˆ‘”–Š‡‡‰”‡‡‘ˆŠ‹Ž‘•‘’Š‹ƒ‡‘ –‘”ȋŠȌ   ƒ†Ǥ‡†ǤŠ”‹•–‘ˆˆ‡”ƒ ‰˜ƒŽ†•‡ 

  •–‹–—–‡‘ˆŽ‹‹ ƒŽ‡†‹ ‹‡ ‹˜‡”•‹–›‘ˆ•Ž‘ ‡’ƒ”–‡–‘ˆŽƒ•–‹ ƒ†‡ ‘•–”— –‹˜‡—”‰‡”› •Ž‘‹˜‡”•‹–› ‘•’‹–ƒŽ  University of Oslo ʹͲʹͲ © Christoffer Aam Ingvaldsen, 2020

Series of dissertations submitted to the Faculty of Medicine, University of Oslo

ISBN 978-82-8377-763-5

All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission.

Cover: Hanne Baadsgaard Utigard. Photo: Øystein Horgmo, UiO Print production: Reprosentralen, University of Oslo.

To Irene and Pål

Preface ›‹–‡”‡•–•‹‡†‹ ‹‡ƒ†”‡•‡ƒ” Šƒ”‡ƒ”‡•—Ž–‘ˆ„‘—†Ž‡••ˆƒ• ‹ƒ–‹‘ˆ‘”ƒ–—”‡Ǥ ”‘™‹‰—’ǡ›ˆƒ˜‘”‹–‡’Žƒ ‡•™‡”‡ȋƒ†’”‘„ƒ„Ž›•–‹ŽŽƒ”‡Ȍ–Š‡ƒ–—”ƒŽ ‹•–‘”› —•‡—ƒ†‘–ƒ‹ ƒŽ ƒ”†‡‹•Ž‘ǡ‘”™ƒ›Ǥ ™ƒ•‹–”‹‰—‡†„›–Š‡†‹‘•ƒ—”ƒ† ˆ‘••‹Ž‡šŠ‹„‹–‹‘•ƒ† ‘—Ž†‡ƒ•‹Ž›‹ƒ‰‹‡›•‡Žˆƒ•ƒ’ƒŽ‡‘–‘Ž‘‰‹•–Ǥ Ž‘•––”ƒ ‘ˆ–‹‡ ‹–Š‡„ƒ•‡‡–‘ˆ–Š‡—•‡—™ƒ– Š‹‰–Š‡’”‘ˆ‡••‹‘ƒŽ•‡–‹ —Ž‘—•Ž›’”‡’ƒ”‡–Š‡ ˆ‘••‹Ž•Ȃˆ”‘ƒ‡‰Ž‹‰‹„Ž‡ǡ•ƒ†Ǧ ‘˜‡”‡†”‘ –‘ƒ‡š–”ƒ‘”†‹ƒ”›•’‡ ‹‡–‡ŽŽ‹‰ƒͶͲͲ ‹ŽŽ‹‘›‡ƒ”•‘Ž†•–‘”›ǤŠ‹• —”‹‘•‹–›‹’ƒŽ‡‘–‘Ž‘‰›•—„•‡“—‡–Ž›„”‘ƒ†‡‡†‹–‘ƒ ‹–‡”‡•–‹œ‘‘Ž‘‰›ǤŠ‡†—Ž ‡––‘‡•‘ˆ‹”ƒ˜‹†––‡„‘”‘—‰Šǯ•˜‘‹ ‡ƒ†–‡˜‡ ”™‹ǯ• „Ž‘‘†Ǧ’—’‹‰‡–Š—•‹ƒ•‰ƒ˜‡‡ƒ—”‰‡–‘†‹• ‘˜‡”™‹Ž†Ž‹ˆ‡‹„‘‘•ǡ‘–‡Ž‡˜‹•‹‘ǡ ƒ†‹ƒ–—”‡Ǥ •–—†‹‡†ƒƒŽ•ǡˆ‹•Šǡƒ’Š‹„‹ƒ•ǡƒ†”‡’–‹Ž‡•Ǥ ‘”–Š‡Žƒ•–ˆ‹ˆ–‡‡ ›‡ƒ”•ǡ•–—†›‹‰„‹”†•Šƒ•„‡‡›ƒ‹‹–‡”‡•–ǤŠ‡‘Ž†ƒ†”‡–‹”‡†ǡ Š‘’‡–‘Ž‹˜‡ Ž‘•‡–‘ƒ–—”‡ƒ†ƒ‡ƒˆŽ‘”‹†Š‡”„ƒ”‹—™‹–Šƒ”‹ƒƒ†‰”ƒ† Š‹Ž†”‡Ǥ Š‡•–—†›‘ˆƒ–—”‡•Š‘™‡†‡Š‘™–Š‹‰• ƒ Šƒ‰‡ˆ”‘’”‘•ƒ‹ –‘–”—Ž› •’‡ŽŽ„‹†‹‰Ǥ›†‹‰‰‹‰†‡‡’ƒ†•›•–‡ƒ–‹ ƒŽŽ›‡š’Ž‘”‹‰ƒ—‘™ˆ‹‡Ž†ǡ‘‡‰”‘™• ƒƒœ‡†ǡ‹˜‹‰‘”ƒ–‡†ǡ’”‘˜‘‡†ǡ•‡’–‹ ƒŽǡƒ† —”‹‘—•ǤŠ‹Ž•–•–—†›‹‰ƒ––Š‡‹˜‡”•‹–› ‘ˆ•Ž‘ǡ ”‡ ‘‰‹œ‡†–Šƒ–‡†‹ ‹‡ƒ†”‡•‡ƒ” Š‘ˆˆ‡”‡†–Š‡•ƒ‡ˆ‡‡Ž‹‰•‘ˆ‡š’Ž‘”ƒ–‹‘Ǥ ˆ‘—†ƒ ƒ”‡‡”–Šƒ–‹•‡˜‡”›„‹–ƒ•‰”ƒ–‹ˆ›‹‰ƒ•›‹–‡”‡•–•‹ƒ–—”‡Ǥ  –‘„‡”ʹͲͳʹǡ •–ƒ”–‡†–‘™‘”’ƒ”–Ǧ–‹‡‹–Š‡‡’ƒ”–‡–‘ˆ—”‰‹ ƒŽ ‘Ž‘‰›ƒ– –Š‡‘”™‡‰‹ƒƒ†‹— ‘•’‹–ƒŽǤ Šƒ†ˆ‘—””‡ƒ”ƒ„Ž‡›‡ƒ”•–Š‡”‡ǤŠ‡ ‘•’‹–ƒŽ‘ˆˆ‡”‡† ‡‡š’‡”‹‡ ‡•™Š‹ ŠŠƒ˜‡†‡ˆ‹‡†‡ƒ†›‰‘ƒŽ•ƒ•ƒ‡†‹ ƒŽ†‘ –‘”Ǥ –ƒŽ•‘ ‹–”‘†— ‡†‡–‘„”‡ƒ•– ƒ ‡”’ƒ–‹‡–•™Š‘•Šƒ”‡†–Š‡‹”Š‘’‡•ƒ†ˆ‡ƒ”•Ǥƒ› ‡–‹‘‡†–Š‡‹”™‹•Šˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ  ‘–ƒ –‡†”‘ˆ‡••‘”ސ•‡–Š‹ƒ” ŠʹͲͳ͵ƒ†•Šƒ”‡†›‡ƒ‰‡”‡••–‘„‡ ‘‡ ‹˜‘Ž˜‡†‹”‡•‡ƒ” ŠǤ‹–Š‘’‡ƒ”•Š‡‹–”‘†— ‡†‡–‘”Ǥ‹†Š‘Ž†–ǡ–Š‡‹””‡•‡ƒ” Š ‰”‘—’ǡƒ†–Š‡ ˆŽƒ’’”‘ ‡†—”‡Ǥ—”‹‰–Š‹•–‹‡ǡ–Š‡˜‡”›ˆ‹”•–•–‡’•‘ˆ–Š‹•–Š‡•‹• ™‡”‡–ƒ‡Ǥ ‡’–‡„‡”‘ˆ–Š‡•ƒ‡›‡ƒ”ǡ ƒ––‡†‡†›ˆ‹”•– ‘ˆ‡”‡ ‡ǣDz ‘’Žƒ•–‹  ƒ†‡ ‘•–”— –‹˜‡—”‰‡”›dzȋȌ‹‘––‹‰ŠƒǡǤ ‰‘–ƒ–ƒ•–‡‘ˆ–Š‡‡‰ƒ‰‹‰ǡ ”ƒ’‹†Ž›‡˜‘Ž˜‹‰ǡƒ†‹’‘”–ƒ–™‘”‘ˆ–Š‡‰Ž‘„ƒŽ”‡•‡ƒ” Š ‘—‹–›ƒ‹‹‰ˆ‘” „‡––‡”„”‡ƒ•– ƒ ‡”–”‡ƒ–‡–•ƒ†”‡ ‘•–”— –‹‘•Ǥ ”‡–—”‡†Š‘‡™‹–Š‡™ˆ”‹‡†• ƒ†‡š ‹–‹‰‹†‡ƒ•ˆ‘”›ˆ—–—”‡”‡•‡ƒ” ŠǤ‘‡‘ˆ–Š‡•‡‹†‡ƒ•Šƒ˜‡„‡‡‹˜‡•–‹‰ƒ–‡† Š‡”‡Ǥ Š‹•–Š‡•‹• ‘˜‡”•ƒ•’‡ –•‘ˆ–Š‡ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ƒ†•’‡ ‹ˆ‹ ƒŽŽ›‹–• ‹’ƒ –ƒ––Š‡†‘‘”Ǧ•‹–‡Ǥ Š‘’‡‹–™‹ŽŽ„‡ƒ•ƒŽŽǡ„—–—•‡ˆ—Žǡ ‘–”‹„—–‹‘–‘–Š‡Šƒ”† ™‘”†‘‡„›’”‡†‡ ‡••‘”•ƒ† ‘ŽŽ‡ƒ‰—‡•Ǥ ”‡ƒ•– ƒ ‡”‹•ƒŽ‹ˆ‡ǦƒŽ–‡”‹‰†‹•‡ƒ•‡ǤŠ”‘—‰Š†‡†‹ ƒ–‡†”‡•‡ƒ” Š™‡ ƒƒ‡–Š‡ †‹•‡ƒ•‡„—”†‡ƒŽ‹––Ž‡Ž‹‰Š–‡”Ǥ  

Acknowledgements Š‡™‘”’”‡•‡–‡†‹–Š‹•†‘ –‘”ƒŽ–Š‡•‹•™ƒ•’‡”ˆ‘”‡†‹–Š‡‡’ƒ”–‡–‘ˆŽƒ•–‹  ƒ†‡ ‘•–”— –‹˜‡—”‰‡”›ǡ‹•Š‘•’‹–ƒŽ‡–ǡ•Ž‘‹˜‡”•‹–› ‘•’‹–ƒŽ„‡–™‡‡ʹͲͳ͵Ǧ ʹͲʹͲǤŠ‡ˆ‹”•–’ƒ’‡”™ƒ•’—„Ž‹•Š‡††—”‹‰›–‹‡ƒ•ƒ‡†‹ ƒŽ•–—†‡–ƒ––Š‡ ‹˜‡”•‹–›‘ˆ•Ž‘ǡ™Š‡”‡ƒ•–Š‡•‡ ‘†ƒ†–Š‹”†’ƒ’‡”™‡”‡™”‹––‡†—”‹‰› ‹–‡”•Š‹’Ǥ‹ ‡ —‡ʹͲͳͺǡ Šƒ˜‡Šƒ†–Š‡’”‹˜‹Ž‡‰‡–‘™‘”ƒ•ƒ Ž‹‹ ƒŽ”‡•‡ƒ” Šˆ‡ŽŽ‘™ ƒ––Š‡‹˜‡”•‹–›‘ˆ•Ž‘–‘ ‘’Ž‡–‡›”‡•‡ƒ” Š–”ƒ‹‹‰Ǥ ™‹ŽŽ„‡ˆ‘”‡˜‡”‰”ƒ–‡ˆ—Žˆ‘” –Š‹•‘’’‘”–—‹–›Ǥ ›†‘ –‘”ƒŽ–Š‡•‹•‹•–Š‡”‡•—Ž–‘ˆƒ ‘ŽŽƒ„‘”ƒ–‹˜‡‡ˆˆ‘”–ǡƒ†‹–™‘—Ž†‘–Šƒ˜‡ ‘‡ ƒ„‘—–™‹–Š‘—––Š‡‰—‹†ƒ ‡‘ˆ–ƒŽ‡–‡†ǡ‹–‡ŽŽ‹‰‡–ǡƒ†”‡•‘—” ‡ˆ—Ž ‘ŽŽ‡ƒ‰—‡•Ǥ  I wish to express my heartfelt gratitude to:  Professor Kim Alexander Tønsethǡ ‡ƒ†‘ˆŽ‹‹ ǡ’Žƒ•–‹ •—”‰‡‘ǡƒ†ƒ‹Ǧ •—’‡”˜‹•‘”ǣ‘—ƒ”‡ƒ‡š ‡’–‹‘ƒŽ Ž‹‹ ‹ƒǡ”‡•‡ƒ” Š‡”ǡƒ†Ž‡ƒ†‡”Ǥ‘”‡‹’‘”–ƒ–Ž›ǡ ›‘—’‘••‡••—‹“—‡’‡”•‘ƒŽ“—ƒŽ‹–‹‡•ƒ†„—‹Ž†—’”‡•’‡ –ƒ†‘–‹˜ƒ–‹‘–Š”‘—‰Š›‘—” ‹ Ž—•‹˜‡„‡Šƒ˜‹‘”Ǥ‘—Šƒ˜‡‘’‡‡†›‘—”†‘‘”‰‡‡”‘—•Ž›ǡƒ† ™‹ŽŽ„‡ˆ‘”‡˜‡”‰”ƒ–‡ˆ—Ž ˆ‘”›–‹‡ƒ•›‘—”Š•–—†‡–ǤŽ–Š‘—‰Š „‡‰ƒ›”‡•‡ƒ” Š ƒ”‡‡”ƒ•ƒʹʹǦ›‡ƒ”Ǧ‘Ž†ǡ ‹‡š’‡”‹‡ ‡†‡†‹ ƒŽ•–—†‡–ǡ›‘—Šƒ˜‡ƒŽ™ƒ›••Š‘™ƒ†‡‰”‡‡‘ˆˆƒ‹–Šǡ—†‡”•–ƒ†‹‰ǡ ƒ†ˆ”‹‡†•Š‹’–Šƒ–Šƒ˜‡„”‘—‰Š–‘—––Š‡„‡•–‹‡Ǥ‘—Šƒ˜‡ƒŽŽ‘™‡†›‹†‡ƒ•–‘ˆŽ‘™ ƒ†‰‡–Ž› Šƒ‡Ž‡†–Š‡‹–‘ƒ• ‹‡–‹ˆ‹ ˆ‘”ƒ–Ǥ•ƒ•—’‡”˜‹•‘”ǡ›‘—Šƒ˜‡ƒ ”‡ƒ”ƒ„Ž‡ƒ„‹Ž‹–›–‘’—•Š‹–Š‡”‹‰Š–†‹”‡ –‹‘Ǥ‘—ƒ”‡›”‘Ž‡‘†‡ŽǤ Dr. med. Tyge Tind Tindholdtǡ ’Žƒ•–‹ •—”‰‡‘ƒ† ‘Ǧ•—’‡”˜‹•‘”ǣ‘—”†‘ –‘”ƒŽ–Š‡•‹• ™ƒ•ƒ•‘Ž‹†ˆ‘—†ƒ–‹‘—’‘™Š‹ Š  ‘—Ž†„—‹Ž†›”‡•‡ƒ” ŠǤŠƒ›‘—ˆ‘”‡–”—•–‹‰ ‡™‹–Š–Š‡–ƒ•‘ˆ ‘–‹—‹‰›‘—”•–—†‹‡•Ǥ‹ ‡ʹͲͳ͵ǡ›‘—Šƒ˜‡™‹ŽŽ‹‰Ž›•Šƒ”‡†›‘—” ‹’”‡••‹˜‡‘™Ž‡†‰‡ƒ†‡‰ƒ‰‡†™‹–Š›‹†‡ƒ•Ǥ‘—”•—’‡”˜‹•‹‘Šƒ•„‡‡’‘•‹–‹˜‡ǡ ’”‡ ‹•‡ǡ‡–Š—•‹ƒ•–‹ ǡƒ†˜‹–ƒŽŽ›‹’‘”–ƒ–Ǥ Šƒ˜‡‡–ƒ›‘ˆ›‘—”ˆ‘”‡” ‘ŽŽ‡ƒ‰—‡• ‘˜‡”–Š‡’ƒ•–›‡ƒ”•ǡƒ†–Š‡›Šƒ˜‡ƒŽŽ†‡• ”‹„‡†ƒ’Žƒ•–‹ •—”‰‡‘™‹–Š‘—–•–ƒ†‹‰ ™‹ŽŽ’‘™‡”ǡ‘™Ž‡†‰‡ǡƒ† Ž‹‹ ƒŽ•‹ŽŽ•Ǥ‘—”“—ƒŽ‹–‹‡•ƒ•ƒ”‡•‡ƒ” Š‡”ƒ†•—’‡”˜‹•‘” ƒ”‡‡“—ƒŽŽ›‹’”‡••‹˜‡Ǥ ƒˆ‘”‡˜‡”‰”ƒ–‡ˆ—Žˆ‘”–Š‡‡š ‡ŽŽ‡–•—’‡”˜‹•‹‘›‘—Šƒ˜‡ ’”‘˜‹†‡†Ǥ Dr. med. Hans Erik Høgevoldǡ’Žƒ•–‹ •—”‰‡‘ǣŠƒ›‘—ˆ‘”•Šƒ”‹‰›‘—”™‹•†‘ƒ† ™‹†‡’‡”•’‡ –‹˜‡•†—”‹‰†‹• —••‹‘•ƒ†‹†–‡”‡˜ƒŽ—ƒ–‹‘•Ǥ‘—Šƒ˜‡”‡’‡ƒ–‡†Ž› ‡’Šƒ•‹œ‡†–Š‡‹’‘”–ƒ ‡‘ˆ”‡•‡ƒ” Š‹ Ž‹‹ ƒŽ‡†‹ ‹‡™Š‹ Š Šƒ˜‡ˆ‘—†˜‡”› ‡ ‘—”ƒ‰‹‰Ǥ ™‹ŽŽƒŽ™ƒ›•Ž‹•–‡‡š–”ƒ ƒ”‡ˆ—ŽŽ›–‘›‘—”ƒ†˜‹ ‡Ǥ Dr. med. Thomas Bergǡ’Žƒ•–‹ •—”‰‡‘ƒ† ‘Ǧƒ—–Š‘”ǣ‘—™‡”‡ƒ‡› ‘–”‹„—–‘”‹ –Š‡•‡ ‘†’ƒ’‡”Ǥ Š‹‰ŠŽ›ƒ’’”‡ ‹ƒ–‡›‘—”‡š’‡”‹‡ ‡†• ‹‡–‹ˆ‹ ‰—‹†ƒ ‡Ǥ‘—™‹ŽŽ„‡ –Š‡’‡”ˆ‡ –•—’‡”˜‹•‘”ˆ‘”ƒŠ•–—†‡–Ǥ Department of Radiology, Rikshospitalet, Oslo University Hospitalǣ Šƒ›‘—ˆ‘” ‘—”ˆ”—‹–ˆ—Ž ‘ŽŽƒ„‘”ƒ–‹‘Ǥ ‡•’‡ ‹ƒŽŽ›™ƒ––‘•Šƒ”‡›‰”ƒ–‹–—†‡–‘Dr. Gerhard Bosse ƒ†Dr. Georg Mynarek™Š‘™‡”‡‹•–”—‡–ƒŽ‹ƒŽŽƒ•’‡ –•‘ˆ–Š‡•‡ ‘†’ƒ’‡”Ǥ Professor Are Hugo Prippǡ•–ƒ–‹•–‹ ‹ƒǣ‘—ƒ”‡ƒ•–ƒ–‹•–‹ ƒŽ‘”ƒ Ž‡Ǥ ƒ’’”‡ ‹ƒ–‡›‘—” ‰‡—‹‡ˆ”‹‡†Ž‹‡••ǡƒ†‹–Šƒ•„‡‡ƒƒ••‹˜‡’Ž‡ƒ•—”‡–‘™‘”™‹–Š›‘—Ǥ Master Øystein Horgmoǡ•‡‹‘”’Š‘–‘‰”ƒ’Š‡”ƒ† ‡ƒ†‘ˆ–Š‡‡†‹ ƒŽŠ‘–‘‰”ƒ’Š› ƒ† ŽŽ—•–”ƒ–‹‘‡”˜‹ ‡•ǡ ƒ —Ž–›‘ˆ‡†‹ ‹‡ǡ‹˜‡”•‹–›‘ˆ•Ž‘ǣŠƒ›‘—ˆ‘”—•‹‰ ›‘—”‡š ‡’–‹‘ƒŽ–ƒŽ‡–ǡ ”‡ƒ–‹˜‹–›ǡƒ†•‹ŽŽ•–‘˜‹˜‹†Ž›‹ŽŽ—•–”ƒ–‡›†‘ –‘”ƒŽ–Š‡•‹•Ǥ‘— Šƒ˜‡ƒƒ‰‡†–‘–”ƒ•ˆ‘” ‘’Ž‡š ‘–‡–ƒ†•—”‰‡”›‹–‘ƒ’’‡ƒŽ‹‰˜‹•—ƒŽ•Ǥ ‹‰ŠǦ “—ƒŽ‹–›‡†‹ ƒŽ‹ŽŽ—•–”ƒ–‹‘•Ž‹‡›‘—”•’”‘‘–‡• ‹‡ ‡ƒ†—†‡”•–ƒ†‹‰Ǥ Dr. med. William Winterǡ”ƒ†‹‘Ž‘‰›”‡•‹†‡–ƒ–ƒ†‡”„‹Ž–‹˜‡”•‹–›‡†‹ ƒŽ‡–‡” ƒ†ˆ‘”‡” Žƒ••ƒ–‡ǣ‘—”‹†’‡”•‘ƒŽ‹–›ǡ ‘”†‹ƒŽ‰‡‡”‘•‹–›ǡƒ†’ƒŽƒ–ƒ„Ž‡„ƒ”„‡“—‡ ™‡”‡‹’‘”–ƒ–ˆ‘”›™‡ŽŽǦ„‡‹‰†—”‹‰–Š‡‡š Šƒ‰‡•‡‡•–‡”ƒ–‹˜‡”•‹–›‘ˆ ƒŽ‹ˆ‘”‹ƒ ”˜‹‡ Š‘‘Ž‘ˆ‡†‹ ‹‡ǤŠƒ›‘—ˆ‘”• ‹‡–‹ˆ‹ †‹• —••‹‘•ǡ‡†‹–‘”‹ƒŽŠ‡Ž’ǡ ƒ†’”‘‘ˆ”‡ƒ†‹‰Ǥ ƒŽ‘‘‹‰ˆ‘”™ƒ”†–‘Š‘•–‹‰›‘—‹•Ž‘ǡƒ†˜‹•‹–‹‰›‘—‹ ƒ•Š˜‹ŽŽ‡Ǥ All patients™Š‘ƒ‰”‡‡†–‘’ƒ”–‹ ‹’ƒ–‡‹–Š‡ Ž‹‹ ƒŽ•–—†‹‡•Ǥ Š‘’‡‘—”‡ˆˆ‘”–•†—”‹‰ –Š‡•‡›‡ƒ”•Šƒ˜‡„‡‡‘ˆŠ‡Ž’–‘•‘‡‘ˆ›‘—Ǥ Irene, Pål, Annelin, Aleksander, and Torunǣ Šƒ˜‡— Š–‘–Šƒ›ˆƒ‹Ž›ˆ‘”ǡƒ„‘˜‡ ƒŽŽ›‘—”Ž‘˜‡ƒ†•—’’‘”–Ǥ‘—”•ƒ ”‹ˆ‹ ‡•‘˜‡”–Š‡›‡ƒ”•Šƒ˜‡ƒ†‡‹–’‘••‹„Ž‡ˆ‘”‡–‘ ˆ—Žˆ‹ŽŽ›‰‘ƒŽ•ǤŠƒ›‘—ˆ‘”ƒ‹‰•—”‡–Šƒ– ƒŽ™ƒ›•Šƒ˜‡ƒ™‘†‡”ˆ—ŽŠ‘‡™ƒ‹–‹‰ ˆ‘”‡Ǥ Mariaǡ ’ƒ••‹‘ƒ–‡Ž‹ˆ‡ ‘’ƒ‹‘ƒ†„‡•–ˆ”‹‡†ǣ‘—„”‹‰Ž‘˜‡ǡ’—”’‘•‡ǡƒ†’‡ƒ ‡–‘ ›Ž‹ˆ‡ǤŠƒ›‘—ˆ‘”•Š‘™‹‰‡ƒ††‹• ‘˜‡”‹‰ƒŽ‘‰™‹–Š‡™Šƒ–Ž‹ˆ‡‹•ƒŽŽƒ„‘—–Ǣ ˆ”‘–‡‡ƒ‰‡›‡ƒ”•–‘ƒ†—Ž–Ž‹ˆ‡Ȃƒ†„‡›‘†Ǥ        •Ž‘ǡ ‡„”—ƒ”›ʹͲʹͲ    ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ Š”‹•–‘ˆˆ‡”ƒ ‰˜ƒŽ†•‡

Table of contents   Š‡•‹•ƒ–ƒ‰Žƒ ‡  ‘’—Ž§”˜‹–‡•ƒ’‡Ž‹‰•ƒ‡†”ƒ‰’¤‘”•  ‹•–‘ˆ’ƒ’‡”•  „„”‡˜‹ƒ–‹‘• 

1. Background 1 Why write this thesis? 1 Breast cancer in Norway 1  Breast reconstruction 1 ‡‡”ƒŽƒ•’‡ –•‘ˆ„”‡ƒ•–”‡ ‘•–”— –‹‘     ͳǦʹ  ”‡ƒ•–”‡ ‘•–”— –‹‘‘†ƒŽ‹–‹‡•      ʹǦͷ  ”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Š ˆŽƒ’    ͷǦͺ  ”‡‘’‡”ƒ–‹˜‡’Žƒ‹‰‹ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘  ͺ Š‡ ˆŽƒ’’”‘ ‡†—”‡ͺǦͳͲ  ‡ ‘†ƒ”›’”‘ ‡†—”‡•ƒˆ–‡” ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘  ͳͲǦͳͳ Abdominal wall anatomy 11 ‹ƒ†•—„ —–ƒ‡‘—•–‹••—‡•      ͳͳ —• Ž‡•ƒ†ƒ’‘‡—”‘•‡•       ͳͳǦͳʹ ‡••‡Ž•ƒ†˜ƒ• —Žƒ”‡–™‘”•      ͳ͵ǦͳͶ ‡”˜‡•ͳͶǦͳͷ Abdominoplasty 15 ‡‡”ƒŽƒ•’‡ –•‘ˆƒ„†‘‹‘’Žƒ•–›     ͳͷ  Š‡ƒ„†‘‹‘’Žƒ•–›’”‘ ‡†—”‡      ͳͷǦͳ͸

2. Aims 17-18

3. Material and methods 19 –—†›†‡•‹‰ȋ’ƒ’‡” Ǧ Ȍͳͻ  ’’”‘˜ƒŽ•ȋ’ƒ’‡” Ǧ Ȍ       ͳͻ  ‘™‡”ƒ†•ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•ȋ’ƒ’‡” Ǧ Ȍ   ͳͻ  ƒ–‹‡–•ȋ’ƒ’‡” Ǧ ȌͳͻǦʹͲ –ƒ–‹•–‹ ƒŽ‡–Š‘†•ȋ’ƒ’‡” Ǧ Ȍ      ʹͲ ‹ ”‘ ‹” —Žƒ–‹‘ȋ’ƒ’‡” ȌʹͲǦʹͳ  ‹ƒ† —–ƒ‡‘—•˜ƒ• —Žƒ–—”‡ȋ’ƒ’‡” Ȍ    ʹͳ ƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘‹ƒ‰‹‰ȋ Ȍȋ’ƒ’‡” Ȍ   ʹͳǦʹʹ  ‡ƒ•—”‡‡–•ƒ† ƒŽ —Žƒ–‹‘•ȋ’ƒ’‡” Ȍ    ʹʹǦʹ͵ –ƒ†ƒ”†‹œ‡†œ‘‡•ȋ’ƒ’‡” Ȍʹ͵ǦʹͶ  –ƒ†ƒ”†‹œ‡†œ‘‡•ȋ’ƒ’‡” Ȍ      ʹͶǦʹͷ ‘’—–‡†–‘‘‰”ƒ’Š›ȋȌȋ’ƒ’‡” Ȍ     ʹͷǦʹ͸ ƒ†‹‘Ž‘‰‹ ƒŽƒ••‡••‡–ȋ’ƒ’‡” Ȍ     ʹ͸ —‡•–‹‘ƒ‹”‡•ȋ’ƒ’‡” Ȍʹ͸

4.Results 27-31

5. Discussion of main findings 32-51

6. Methodological considerations 52-70 ‘•–ǦŠ‘ ’‘™‡”ƒ†•ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•    ͹ͲǦ͹ͳ  ‘•–ǦŠ‘  ‘’ƒ”‹•‘‘ˆ”‡•’‘†‡–•ƒ†‘Ǧ”‡•’‘†‡–•  ͹ʹ 7. Ethical co nsiderations 73-74 8. Conclusions 75-76 9. Clinical implications and future research 77-91 10. References 92-104 Paper I-III Appendix ’”‘–‘ ‘Ž Clinical photographs Thesis at a glance

PAPER I PAPER II PAPER III Aim ••‡••’‡”ˆ—•‹‘†›ƒ‹ • ”‘˜‹†‡ƒ‘”‡ ‘’Ž‡–‡ ‘’ƒ”‡’ƒ–‹‡–Ǧ”‡’‘”–‡† ‹–Š‡—†‡”‹‡† ’‹ –—”‡‘ˆ†‘‘”Ǧ•‹–‡ ‘—– ‘‡‡ƒ•—”‡• ƒ„†‘‹ƒŽˆŽƒ’ƒ† ‘”„‹†‹–›ƒˆ–‡” ˆŽƒ’ ȋ•Ȍ„‡–™‡‡  –Š‡”‡„›’”‡†‹ –ƒ”‡ƒ• „”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Š ˆŽƒ’ƒ†ƒ„†‘‹‘’Žƒ•–› •—• ‡’–‹„Ž‡–‘‡ ”‘•‹•Ǥ ƒ‡’Šƒ•‹•‘”‡ –—• ȋȌ’ƒ–‹‡–•™‹–Šƒ —• Ž‡•ǡ†‹ƒ•–ƒ•‹•”‡ –‹ ‡’Šƒ•‹•‘ƒ„†‘‹ƒŽ ƒ„†‘‹‹•ȋȌǡƒ† ‘—– ‘‡•Ǥ Š‡”‹ƒȀ„—Ž‰‹‰Ȁ•‡”‘ƒ ˆ‘”ƒ–‹‘Ǥ Patients & ”‘•’‡ –‹˜‡ Ž‹‹ ƒŽ•–—†› ”‘•’‡ –‹˜‡ Ž‹‹ ƒŽ•–—†› ‡–”‘•’‡ –‹˜‡ǡ Methods ™‹–ŠʹͲ ˆŽƒ’ ™‹–ŠͳͶ ˆŽƒ’’ƒ–‹‡–•Ǥ “—‡•–‹‘ƒ‹”‡Ǧ„ƒ•‡†•–—†› ’ƒ–‹‡–•Ǥ—ƒ–‹–ƒ–‹˜‡ ‘‘”Ǧ•‹–‡‘”„‹†‹–›™ƒ• ™Š‡”‡͵Ͷ ˆŽƒ’ƒ†͵Ͳ ’‡”ˆ—•‹‘ƒ’’‹‰™‹–Š ƒ••‡••‡†„› ‘’ƒ”‹‰ ’ƒ–‹‡–•™‡”‡ƒ•‡†–‘ Žƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘ ”‘—–‹‡’”‡‘’‡”ƒ–‹˜‡ ‘’Ž‡–‡–™‘•–—†›Ǧ•’‡ ‹ˆ‹  ‹ƒ‰‹‰ƒ–•‡˜‡•‡– ƒ‰‹‘‰”ƒ’Š›™‹–Š “—‡•–‹‘ƒ‹”‡•ǤŠ‡ˆ‹”•– ‹–‡”˜ƒŽ•Ǥ‡ƒ•—”‡‡–• ƒ„†‘‡’‡”ˆ‘”‡†–™‘ “—‡•–‹‘ƒ‹”‡ ‘˜‡”‡† ™‹–Š‹ˆ‘—”•–ƒ†ƒ”†‹œ‡† ›‡ƒ”•’‘•–‘’‡”ƒ–‹˜‡Ž›Ǥ ƒ„†‘‹ƒŽ•ǡ™Š‡”‡ƒ• œ‘‡• ‘˜‡”‹‰–Š‡•‹ ‡ƒ•—”‡‡–•™‹–Š‹ˆ‘—” –Š‡•‡ ‘†™ƒ• ‘ ‡”‡† „‡–™‡‡–Š‡š‹’Š‘‹† •–ƒ†ƒ”†‹œ‡†œ‘‡•ȋœ‘‡• ™‹–Š‰‡‡”ƒŽ•Ǥ ’”‘ ‡••ƒ†–Š‡—’’‡” ǦǢ ”ƒ‹ƒŽ–‘ ƒ—†ƒŽȌ‘ˆ ‹ ‹•‹‘ƒŽ„‘—†ƒ”›‘ˆ–Š‡ –Š‡”‡ –—•—• Ž‡•ƒ† ˆŽƒ’ȋœ‘‡•ͳǦͶǢ ”ƒ‹ƒŽ–‘ ™‡”‡—†‡”–ƒ‡ǡƒ†–Š‡ ƒ—†ƒŽȌǤ ƒ„†‘‹ƒŽ™ƒŽŽ™ƒ• ƒ••‡••‡†ˆ‘”Š‡”‹ƒ•ǡ „—Ž‰‹‰ǡƒ†•‡”‘ƒ•Ǥ Results ”‡‘’‡”ƒ–‹˜‡Ž›ǡƒ Š‡‘’‡”ƒ–‡†”‡ –—•—• Ž‡ Š‡ ‰”‘—’™ƒ• •‹‰‹ˆ‹ ƒ–Ž›Š‹‰Š‡” Šƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž› •‹‰‹ˆ‹ ƒ–Ž›‘”‡•ƒ–‹•ˆ‹‡† ’‡”ˆ—•‹‘™ƒ•”‡‰‹•–‡”‡† ‹ ”‡ƒ•‡†ƒ–‡”‘’‘•–‡”‹‘” ™‹–Š–Š‡‹”„‘†‹‡•™Š‡ ‹œ‘‡•͵ƒ†Ͷ™Š‡ †‹ƒ‡–‡”ȋȌ‹–™‘ †”‡••‡†ƒ†–Š‡”‡™ƒ•ƒ ‘’ƒ”‡†™‹–Šœ‘‡ͳǤ œ‘‡•ƒ††‡ ”‡ƒ•‡† –”‡†‘ˆ ˆŽƒ’’ƒ–‹‡–• ˆ–‡”—†‡”‹‹‰–Š‡ –”ƒ•˜‡”•‡†‹ƒ‡–‡”ȋȌ‹ „‡‹‰‘”‡•ƒ–‹•ˆ‹‡†™‹–Š ƒ„†‘‹ƒŽ•‹ǡ–Š‡ ‘‡œ‘‡ ‘’ƒ”‡†™‹–Š –Š‡ƒ’’‡ƒ”ƒ ‡‘ˆ–Š‡ ’‡”ˆ—•‹‘‹œ‘‡•ͳǦ͵ ’”‡‘’‡”ƒ–‹˜‡ ƒ„†‘‡Ǥ‘•‹‰‹ˆ‹ ƒ– ‹ ”‡ƒ•‡†•‹‰‹ˆ‹ ƒ–Ž›Ǥ ‡ƒ•—”‡‡–•Ǥ‘’ƒ”‹‰ †‹ˆˆ‡”‡ ‡™ƒ•ˆ‘—† ˆ–‡”–Š‡ƒ„†‘‹ƒŽ –Š‡‘’‡”ƒ–‡†ƒ†‘Ǧ ‘’ƒ”‹‰‘—– ‘‡• Ž‘•—”‡ǡ–Š‡’‡”ˆ—•‹‘ ‘’‡”ƒ–‡†”‡ –—•—• Ž‡•ǡ ‘ ‡”‹‰—„‹Ž‹ —•ǡ †”‘’’‡†‹ƒŽŽˆ‘—”œ‘‡•Ǥ –Š‡ˆ‘”‡”Šƒ†ƒ —• Ž‡ˆ— –‹‘ǡ’ƒ‹ǡ ‘•–‘’‡”ƒ–‹˜‡Ž›ǡ–Š‡ •‹‰‹ˆ‹ ƒ–Ž›†‡ ”‡ƒ•‡† • ƒ””‹‰ǡƒ† ‘–‘—”ǤŠ‡ ’‡”ˆ—•‹‘‘ˆ‡ƒ Šœ‘‡ ‹‘‡œ‘‡Ǥ—’”ƒ—„‹Ž‹ ƒŽ  ‰”‘—’™ƒ•‘”‡ •–ƒ„‹Ž‹œ‡†ƒ–ƒ•‹‰‹ˆ‹ ƒ–Ž› ™ƒ••‹‰‹ˆ‹ ƒ–Ž› ™‘””‹‡†ƒ„‘—––Š‡‹”Š‡ƒŽ–Š Š‹‰Š‡”Ž‡˜‡Ž ‘’ƒ”‡† †‡ ”‡ƒ•‡†™‹–Š•—”‰‡”›ǡ –Šƒ–Š‡‰”‘—’ ™‹–Š’”‡‘’‡”ƒ–‹˜‡˜ƒŽ—‡•Ǥ ™Š‡”‡ƒ•‹ˆ”ƒ—„‹Ž‹ ƒŽ ’‘•–‘’‡”ƒ–‹˜‡Ž›Ǥ’ƒ–‹‡–• ‘–‹••—‡‡ ”‘•‹•™ƒ• ™ƒ••‹‰‹ˆ‹ ƒ–Ž›‹ ”‡ƒ•‡†Ǥ Šƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž›‘”‡ ‘„•‡”˜‡†Ǥ ‘‡™Š‡”‹ƒ‘”„—Ž‰‹‰ ƒŽ–‡”‡†„‘†›‹ƒ‰‡ƒ†  ™‡”‡ˆ‘—†Ǥ™‘’ƒ–‹‡–• ‹ ”‡ƒ•‡†•‡š—ƒŽ†‡•‹”‡  Šƒ†•‡”‘ƒˆ‘”ƒ–‹‘‹ –Šƒ ˆŽƒ’’ƒ–‹‡–•Ǥ  –Š‡ƒ„†‘‹ƒŽ™ƒŽŽǤ Š‡”‡™ƒ•‘•‹‰‹ˆ‹ ƒ–  †‹ˆˆ‡”‡ ‡ ‘ ‡”‹‰  Šƒ‰‡•‹•‡ŽˆǦ‹ƒ‰‡ǡ•‘ ‹ƒŽ  ”‡Žƒ–‹‘•Š‹’•ǡ„‡‹‰ƒ‡†  ™‹–Š’ƒ”–‡”ǡƒ†‘˜‡”ƒŽŽ •ƒ–‹•ˆƒ –‹‘Ǥ Conclusion Ž–Š‘—‰Š’‡”ˆ‘”ƒ–‘”•ƒ”‡  ˆŽƒ’Šƒ”˜‡•–‹‰  ˆŽƒ’’ƒ–‹‡–•™‡”‡ †‹˜‹†‡††—”‹‰ ”‡•—Ž–‡†‹•‹‰‹ˆ‹ ƒ– ‡“—ƒŽŽ›ƒ••ƒ–‹•ˆ‹‡†™‹–Š–Š‡ —†‡”‹‹‰‘ˆ–Š‡ Šƒ‰‡•–‘–Š‡”‡ –—• ƒ„†‘‡ƒ•’ƒ–‹‡–•ǡ ƒ„†‘‹ƒŽ•‹ǡ–Š‡”‡ —• Ž‡•ƒ†Ǥ ™‹–Šƒ–”‡†‘ˆŠ‹‰Š‡” •‡‡•–‘„‡ƒ”‡ƒ –‹˜‡ ›‡–”›‘ˆ–Š‡–™‘ •ƒ–‹•ˆƒ –‹‘‹–Š‡  Š›’‡”‡‹ƒ–Šƒ–‡š ‡‡†• Š‡‹ƒ„†‘‡••‡‡‡†ǡ ‰”‘—’ǤŠ‡”‡•—Ž–•†‘‘– –Š‡„Ž‘‘†•—’’Ž›†‡Ž‹˜‡”‡† Š‘™‡˜‡”ǡ–‘„‡™‡ŽŽ •—’’‘”––Š‡‹†‡ƒ‘ˆ „›–Š‡’‡”ˆ‘”ƒ–‘”•ǤŠ‡ ’”‡•‡”˜‡†ƒ†–Š‡‘˜‡”ƒŽŽ ’”‘‰”‡••‹˜‡Ž›‘†‹ˆ›‹‰–Š‡ •–—†›†‹†‘–ˆ‹†ƒ› †‘‘”Ǧ•‹–‡‘”„‹†‹–›™ƒ•  ˆŽƒ’’”‘ ‡†—”‡–‘ ‘–”ƒ‹†‹ ƒ–‹‘• Ž‹‹–‡†ǤŠ‡•–—†›†‹†‘– ‹’”‘˜‡–Š‡ ‘ ‡”‹‰ —””‡– ƒ••‡••–Š‡ˆ— –‹‘ƒŽ‹’ƒ – ƒ„†‘‹‘’Žƒ•–›‘—– ‘‡•Ǥ —†‡”‹‹‰–‡ Š‹“—‡Ǥ ‘ˆ–Š‡‘”’Š‘Ž‘‰‹ ƒŽ Šƒ‰‡•‘„•‡”˜‡†Ǥ Populærvitenskapelig sammendrag på norsk

Følgende sammendrag gir en forenklet og kortfattet oppsummering av doktorgrads- arbeidet rettet mot lesere uten medisinsk bakgrunn. Avhandlingen har i tillegg en rekke figurer (deriblant figur 2 og figur 4) som illustrerer den omtalte kirurgien. Bakerst i avhandlingen er en serie fotografier som viser hvordan en brystrekonstruksjon kan se ut måneder og år etter operasjonen.

Bakgrunn ƒ‰‡„”›•–”‡ˆ–‘’‡”‡”–‡˜‹‡”‰Œ‡‘‰¤”„”›•–”‡‘•–”—•Œ‘Ǥ”›•–‡–ƒ ”‡‘•–”—‡”‡•˜‡†„”—ƒ˜ȋ•‹Ž‹‘Ȍ’”‘–‡•‡”‡ŽŽ‡”˜‡†„”—ƒ˜’ƒ•‹‡–‡•‡‰‡–˜‡˜Ǥ ‹•–‡˜–‡‡–‘†‡ƒŽŽ‡•ˆ‘”ƒ—–‘Ž‘‰„”›•–”‡‘•–”—•Œ‘Ǥ‡†‡ƒ—–‘Ž‘‰ „”›•–”‡‘•–”—•Œ‘•Œ§”‡”ƒ—–‡–˜‘Ž—ƒ˜˜‡˜ȋƒŽ–‡Žƒ’’Ȍ‘‰„”—‡”†‡––‡–‹Ž¤ ‡”•–ƒ––‡„”›•–˜‡˜‡–•‘Šƒ”„Ž‹––ˆŒ‡”‡–—†‡””‡ˆ–‹”—”‰‹‡Ǥ‡˜ˆ”ƒ†‡‡†”‡†‡Žƒ˜ ƒ‰‡„”—‡•–›’‹•–‹Ž•Ž‹‡„”›•–”‡‘•–”—•Œ‘‡”Ǥ  Ǽ‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›’‡”ˆ‘”ƒ–‘”ǽǦŽƒ’’‡ȋ Ȍ‡”‹†ƒ‰‡’‘’—Ž§” ‘‰—–„”‡†–ƒ—–‘Ž‘‰„”›•–”‡‘•–”—•Œ‘„¤†‡‹‘”‰‡‘‰˜‡”†‡ˆ‘”ޘ”‹‰Ǥ ǦŽƒ’’‡ „‡•–¤”ƒ˜Š—†ǡˆ‡––‘‰„Ž‘†ƒ”ˆ”ƒƒ‰‡‘‰˜‡‹‡”‘–”‡–Ž‹‰‡‹Ž‘Ǥƒ’’‡„Ž‹”•¤”‡– —–‹•‹Š‡ŽŠ‡–ǡ‘‰†‡”‡––‡”•›††‹‹„”›•–”‡‰‹‘‡ˆ‘”¤‰Œ‡‘’’„›‰‰‡„”›•–‡–Ǥ ’‡”ƒ•Œ‘•‘”¤†‡–’¤ƒ‰‡„Ž‹”•ƒ–‹†‹‰Ž—‡–Ǥ‹•Š‘•’‹–ƒŽ‡–‘’‡”‡”‡”‘–”‡–ͷͲ ’ƒ•‹‡–‡”¤”Ž‹‰‡††‡‡‡–‘†‡Ǥ  ‘”†‡Ž‡‡†¤„”—‡’ƒ•‹‡–‡•‡‰‡–˜‡˜‡”ƒ–ƒ‘’’¤”‡–ƒ–—”Ž‹‰‘‰ Žƒ‰˜ƒ”‹‰”‡•—Ž–ƒ–Ǥƒ‡”•–ƒ––‡”ǼŽ‹–‡†Ž‹–ǽǡ‘‰—‰¤”‘’Ž‹ƒ•Œ‘‡‡•‘‡ ȋ•‹Ž‹‘Ȍ’”‘–‡•‡‡†ˆÞ”‡”Ǥ –‹ŽŽ‡‰‰‡”†‡–ƒ‰‡’ƒ•‹‡–‡”•‘˜‡”†•‡––‡” ‘’’•–”ƒ‹‰‡ƒ˜ƒ‰‡Ȃ‡•–‡’¤•ƒ‡¤–‡•‘˜‡†‡‘”†‹§”„—’Žƒ•–‹Ǥ  Ž‡’‡‡†ƒ—–‘Ž‘‰„”›•–”‡‘•–”—•Œ‘‡”•ƒ†‡•‘‘’’•–¤”†‡”ƒ ŠÞ•–‡”˜‡˜‡–ˆ”ƒǤ ƒ‰‡”‡‰‹‘‡‡”†‡–„Žƒ–ƒ‡–ˆƒ”‡ˆ‘”Ž‘ƒŽ‡•¤”‘’Ž‹ƒ•Œ‘‡”ǡ —•‡Ž•ƒ†‡ǡ„”‘—–˜‹Ž‹‰‘‰•Œ‡‡†‡ƒ””†ƒ‡Ž•‡ǤŽ‹•ƒ†‡‘–ƒŽ‡••‘ †‘‘”•–‡†•‘”„‹†‹–‡–Ǥ  ‡–‡”˜‹–‹‰ƒ–‰”ƒ†‡ƒ˜†‘‘”•–‡†•‘”„‹†‹–‡–„‡‰”‡•‡••¤›‡•‘—Ž‹‰Ǥ ‘” ¤Ž›‡•‡††‡––‡ǡ‡”†‡–Þ†˜‡†‹‰‡††‡†‹‡”–ˆ‘”•‹‰•‘˜—”†‡”‡” •ƒ†‡‘ˆƒ‰‡–‹ƒ‰‡”‡‰‹‘‡‡––‡”ŠÞ•–‹‰ƒ˜ ǦŽƒ’’‡”ǡ•ƒ–†‹•—–‡”‡”¤”•ƒ‡‡ –‹Žƒ–•Ž‹‡•ƒ†‡”‘’’•–¤”Ǥ¤†‡¤–‡ƒ†‡‹”—”‰‹•‡–‡‹‡–‹Ž’ƒ••‡•‘‰ ‡–‘†‡’‘–‡•‹‡Ž–ˆ‘”„‡†”‡•Ǥ  Mål —”†‡”‡‰”ƒ†‡ƒ˜†‘‘”•–‡†•‘”„‹†‹–‡–‡––‡”„”›•–”‡‘•–”—•Œ‘‡† ǦŽƒ’’‘‰ ƒ”–Ž‡‰‰‡—Ž‹‰‡ˆ‘”„‡†”‹‰‡”ƒ˜†ƒ‰‡•’”‘•‡†›”‡Ǥ‘‘”•–‡†•‘”„‹†‹–‡–„Ž‹”˜—”†‡”– ‰Œ‡‘–”‡‹†‹˜‹†—‡ŽŽ‡•–—†‹‡”‡†ˆ‘—•’¤ƒ‰‡Š—†‡•„Ž‘†‰Œ‡‘•–”ޏ‹‰ ȋ•‹”—Žƒ•Œ‘••–—†‹‡Ȍǡ•–”—–—”‡ŽŽ‡„—˜‡‰‰•‡†”‹‰‡”ȋǦ•–—†‹‡Ȍ‘‰’ƒ•‹‡–‡• –‹Žˆ”‡†•Š‡–‡†ƒ‰‡ȋ•’Þ””‡•Œ‡ƒ•–—†‹‡ȌǤ Metoder 1) Sirkulasjonsstudie (artikkel 1):”—‡‡–Žƒ•‡”‹•–”—‡–ȋŽƒ•‡”‘’’Ž‡” ’‡”ˆ—•‹‘‹ƒ‰‹‰Ȍ–‹Ž¤‰Œ‡‘ˆÞ”‡•‹”—Žƒ•Œ‘••–—†‹‡”ƒ˜ƒ‰‡”‡‰‹‘‡–‹Ž  Ǧ’ƒ•‹‡–‡”ˆÞ”ǡ—†‡”‘‰‡––‡”‘’‡”ƒ•Œ‘‡Ǥ¤Ž‹‰‡‡ƒƒ˜†‡‡ ‘”¤†‡”‡†”‡†—•‡”–„Ž‘†‰Œ‡‘•–”ޏ‹‰‘‰ˆÞŽ‰‡Ž‹‰ˆƒ”‡ˆ‘” ‘’Ž‹ƒ•Œ‘‡”Ǥ 2) CT-studie (artikkel 2): ƒ‡Ž‹‰‡Ǧ„‹Ž†‡”ƒ˜ƒ‰‡”‡‰‹‘‡–‹Ž Ǧ ’ƒ•‹‡–‡”–ƒ––ˆÞ”‘‰–‘¤”‡––‡”‘’‡”ƒ•Œ‘‡ˆ‘”¤ƒ˜†‡‡•–”—–—”‡ŽŽ‡‡†”‹‰‡”‹ ƒ‰‡”‡‰‹‘‡Ȃ•Ž‹•‘—•‡Ž•ƒ†‡ǡ„”‘ǡƒ•ƒŽ‹‰‡”ƒ˜•¤”˜§•‡Ȁ„Ž‘†ǡ ǤǤ 3) Spørreskjemastudie (artikkel 3): Œ‡‘ˆÞ”‡‡•’Þ””‡•Œ‡ƒ—†‡”•Þ‡Ž•‡ •‘•ƒ‡Ž‹‰‡”’ƒ•‹‡–”ƒ’’‘”–‡”–‡—–ˆƒŽŽ•¤Ž‡ŽŽ‘ Ǧ‘‰ „—’Žƒ•–‹’ƒ•‹‡–‡”ˆ‘”¤˜—”†‡”‡Š˜‘”˜‹†– Ǧ‹”—”‰‹‡‹•–Þ””‡‰”ƒ†„Þ” ‡––‡”Ž‹‰‡„—’Žƒ•–‹‡”Ǥ

Resultater 1) Sirkulasjonsstudie (artikkel 1): ‹Ž–”‘••ˆ‘”ƒ–„Ž‘†ƒ”•‘ˆ‘”•›‡” ƒ‰‡Š—†‡—––‡•—†‡” Ǧ‹”—”‰‹‡ǡ‘„•‡”˜‡”‡•‡ލ‹‰‹Š—†‡• „Ž‘†‰Œ‡‘•–”ޏ‹‰ƒŽŽ‡”‡†‡†ƒ‰‡‡––‡”‘’‡”ƒ•Œ‘Ǥ ‡„›‰†‡ǡ ‘’‡•ƒ–‘”‹•‡‡ƒ‹•‡”‹ƒ”•›•–‡‡–ˆ‘”Š‹†”‡”Žƒ˜ „Ž‘†‰Œ‡‘•–”ޏ‹‰‘‰•¤Ž‡†‡•†‡‡˜‡–—‡ŽŽ‡‘’Ž‹ƒ•Œ‘‡‡†‡––‡ƒ ‡†ˆÞ”‡Ǥ 2) CT-studie (artikkel 2): ‡–”‡‰‹•–”‡”‡••–”—–—”‡ŽŽ‡‡†”‹‰‡”‹„—˜‡‰‰‡–‘¤” ‡––‡”‘’‡”ƒ•Œ‘‡ǣͳȌ‡”‡––‡ƒ‰‡—•Ž‡‡„Ž‹”–›‡”‡‘‰•ƒŽ‡”‡†‡”ƒ Šƒ”ŽÞ•‡–—–„Ž‘†ƒ”‡‡‘‰ʹȌ˜•–ƒ†‡‡ŽŽ‘†‡”‡––‡ƒ‰‡—•Ž‡‡„Ž‹” ‹†”‡‘˜‡”ƒ˜Ž‡ǡ‘‰•–Þ””‡—†‡”ƒ˜Ž‡Ǥ‹Ž–”‘••ˆ‘”†‹••‡‘„•‡”˜ƒ•Œ‘‡‡ ˆ”‡•–¤”„—˜‡‰‰‡•›‡–”‹•‘‰†‡–‡”ˆ¤–‡‰–‹Ž†‘‘”•–‡†•‘”„‹†‹–‡–Ǥ 3) Spørreskjemastudie (artikkel 3):  Ǧ’ƒ•‹‡–‡‡‡”–‹Ž•˜ƒ”‡†‡ˆ‘”Þ›† ‡†ƒ‰‡•‘„—’Žƒ•–‹’ƒ•‹‡–‡‡Ǥ‡–•‡•‡–”‡†Š˜‘” Ǧ’ƒ•‹‡–‡‡ ‡”‡”ˆ‘”Þ›†‡†ƒ‰‡•—–•‡‡†‡•ƒ‡Ž‹‰‡–‡†„—’Žƒ•–‹’ƒ•‹‡–‡‡Ǥ

Konklusjon   ǦŽƒ’’‡‡”‡„”›•–”‡‘•–”—•Œ‘•–‡‹‡†Ž‹–‡†‘‘”•–‡†•‘”„‹†‹–‡–‘‰ŠÞ› ’ƒ•‹‡––‹Žˆ”‡†•Š‡–Ǥƒ‰‡•‡–‘†‡‡”‰‘†‘‰ˆ‘”•‹‰•ƒ”„‡‹†‡–ƒ˜†‡‡”‹‰‡ —‹††‡Ž„ƒ”‡ˆ‘”„‡†”‹‰•„‡Š‘˜Ǥ –‡”‡••ƒ–ˆ‘”•‹‰‰ŒÞ”‡•ƒ•Œ‘ƒŽ–‘‰‹–‡”ƒ•Œ‘ƒŽ– Š˜‹Ž‡–’‘–‡•‹‡Ž–ƒˆ‘”„‡†”‡ Ǧ‹”—”‰‹‡›––‡”Ž‹‰‡”‡Ǥ

List of papers

Š‹•†‘ –‘”ƒŽ–Š‡•‹•‹•„ƒ•‡†‘–Š‡ˆ‘ŽŽ‘™‹‰’ƒ’‡”•ǡ™Š‹ Š™‹ŽŽ„‡”‡ˆ‡””‡†–‘„›–Š‡‹” ‘ƒ—‡”ƒŽ•ǣ  Paper I ‰˜ƒŽ†•‡ǡސ•‡–Šǡ”‹’’ ǡ‹†Š‘Ž†–ǤMicrocirculatory Evaluation of the Abdominal Skin in Breast Reconstruction with Deep Inferior Epigastric Artery Perforator Flap. Žƒ•–‡ ‘•–”—”‰ Ž‘„’‡ǤʹͲͳ͸ ‡„ͳͲǢͶȋʹȌǣ‡͸ͳ͸

Paper II ‰˜ƒŽ†•‡ǡ‘••‡ ǡ›ƒ”‡ ǡ‡”‰ǡ‹†Š‘Ž†–ǡސ•‡–ŠǤDonor-site Morbidity After DIEAP Flap Breast Reconstruction – A 2-Year Postoperative Computed Tomography Comparison. Žƒ•–‡ ‘•–”—”‰ Ž‘„’‡ǤʹͲͳ͹ —Ž ʹͷǢͷȋ͹Ȍǣ‡ͳͶͲͷ

Paper III ‰˜ƒŽ†•‡ǡ‹†Š‘Ž†–ǡސ•‡–ŠǤDIEAP Flap Patients Equally as Satisfied with the Abdomen as Abdominoplasty Patients. Žƒ•–‡ ‘•–”—”‰ Ž‘„’‡Ǥ ʹͲͳͺǢ͸ǣ‡ͳͺ͹͸  

Abbreviations

Abbreviation Full word/phrase   —–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘   —–‘Ž‘‰‘—•ˆƒ–‰”ƒˆ–‹‰ ˆŽƒ’ –‡”‘Žƒ–‡”ƒŽ–Š‹‰ŠˆŽƒ’ AP Abdominoplasty ˆŽƒ’ „†‘‹ƒŽ’‡”ˆ‘”ƒ–‘”‡š Šƒ‰‡ˆŽƒ’  ”‡ƒ•– ‘•‡”˜‹‰–Š‡”ƒ’›   ‘†›ƒ••‹†‡š  ‘Ž‘”‘’’Ž‡”—Ž–”ƒ•‘‘‰”ƒ’Š› CT Computed tomography CTA Computed tomography angiography   ‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”› DIEAP Deep inferior epigastric artery perforator DIEAP flap Deep inferior epigastric artery perforator flap  ˆŽƒ’ ‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’  ’Žƒ–Ǧ„ƒ•‡†”‡ ‘•–”— –‹‘  –”ƒ Žƒ•• ‘””‡Žƒ–‹‘ ‘‡ˆˆ‹ ‹‡– ˆŽƒ’ ˆ‡”‹‘”‰Ž—–‡ƒŽƒ”–‡”›’‡”ˆ‘”ƒ–‘”ˆŽƒ’ IMA Internal mammary artery  –‡”ƒŽƒƒ”›ƒ”–‡”›’‡”ˆ‘”ƒ–‘” IMV Internal mammary vessel  ‘—”ƒŽ‘ˆŽƒ•–‹ ǡ‡ ‘•–”— –‹˜‡Ƭ‡•–Š‡–‹ —”‰‡”› ˆŽƒ’ ƒ–‹••‹—•†‘”•‹ˆŽƒ’   ƒ•‡”‘’’Ž‡”ˆŽ‘™‡–”› LDPI Laser Doppler perfusion imaging/imager  ˆŽƒ’ ƒ–‡”ƒŽ‹–‡” ‘•–ƒŽƒ”–‡”›’‡”ˆ‘”ƒ–‘”ˆŽƒ’   ‹‹ƒŽ Ž‹‹ ƒŽŽ›‹’‘”–ƒ–†‹ˆˆ‡”‡ ‡   ƒ‰‡–‹ ”‡•‘ƒ ‡‹ƒ‰‹‰ •ǦˆŽƒ’ —• Ž‡Ǧ•’ƒ”‹‰ˆŽƒ’ȋ•‡„‡Ž‘™Ȍ ˆŽƒ’ ”‘ˆ—†ƒƒ”–‡”›’‡”ˆ‘”ƒ–‘”ˆŽƒ’   ‘•–Ǧ‘ Ž—•‹˜‡”‡ƒ –‹˜‡Š›’‡”‡‹ƒ PROM Patient-reported outcome measure  Žƒ•–‹ ƒ†‡ ‘•–”— –‹˜‡—”‰‡”›ȋ ‘—”ƒŽȌ PU Perfusion unit(s)  —’‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›  ˆŽƒ’ —’‡”‹‘”‰Ž—–‡ƒŽƒ”–‡”›’‡”ˆ‘”ƒ–‘”ˆŽƒ’   —’‡”ˆ‹ ‹ƒŽ‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”› SIEA flap Superficial inferior epigastric artery flap SIEV Superficial inferior epigastric vein  Š‘”ƒ ‘†‘”•ƒŽ˜‡••‡Ž TRAM flap Transverse rectus abdominis myocutaneous flap  ˆŽƒ’ ”ƒ•˜‡”•‡—’’‡”‰”ƒ ‹Ž‹•ˆŽƒ’  ”‡“—‡–Ž›—•‡†ƒ„„”‡˜‹ƒ–‹‘•‹bold. 1 Background

Why write this thesis? ƒ›„”‡ƒ•– ƒ ‡”’ƒ–‹‡–•†‡•‹”‡„”‡ƒ•–”‡ ‘•–”— –‹‘•ƒ•ƒƒ–—”ƒŽ’ƒ”–‘ˆ–Š‡‹”ˆ‹‰Š– ƒ‰ƒ‹•– ƒ ‡”ƒ†”‡–—”–‘‘”ƒŽŽ‹ˆ‡Ǥ ’Žƒ•–‹ ƒ†”‡ ‘•–”— –‹˜‡•—”‰‡”›ǡ‹–‹• ‘‘’”ƒ –‹ ‡–‘”‡ ‘•–”— –ƒ„”‡ƒ•–—•‹‰–Š‡’ƒ–‹‡–ǯ•‘™–‹••—‡ǤŠ‹•‹• ƒŽŽ‡† ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ›Šƒ”˜‡•–‹‰ƒ–‹••—‡ˆŽƒ’ǡ‘•–Ž› ‘–ƒ‹‹‰•‹ƒ† ˆƒ–ǡ–Š‡„”‡ƒ•–‹•”‡ ‘•–”— –‡†™‹–Š–‹••—‡–Šƒ–”‡•‡„Ž‡•™Šƒ–Šƒ•„‡‡•—”‰‹ ƒŽŽ› ”‡‘˜‡†‹–Š‡‘ ‘Ž‘‰‹ ƒŽ–”‡ƒ–‡–ǤŠ‡”‡•—Ž–‹•ƒƒ–—”ƒŽǡŽ‘‰ǦŽƒ•–‹‰„”‡ƒ•– ”‡ ‘•–”— –‹‘™‹–Š•‡˜‡”ƒŽƒ†˜ƒ–ƒ‰‡•ǤŠ‹Ž‡‹–’‘••‡••‡•ƒ›ƒ†˜ƒ–ƒ‰‡•ǡŠ‘™‡˜‡”ǡ ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘†‘‡•ƒŽ•‘ ƒ””›–Š‡’‘–‡–‹ƒŽˆ‘”Šƒ”Ǥ†‡”•–ƒ†‹‰ –Š‡†ƒƒ‰‡ ƒ—•‡†‹ˆŽƒ’Šƒ”˜‡•–‹‰‹•‹•–”—‡–ƒŽ‹–Š‡’”‘ ‡••‘ˆ‹’”‘˜‹‰„”‡ƒ•– ”‡ ‘•–”— –‹‘•ƒˆ‡–›ƒ†‘—– ‘‡•Ǥ Š‡†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›’‡”ˆ‘”ƒ–‘”ȋ ȌˆŽƒ’ǡ‘‡‘ˆƒ›„”‡ƒ•– ”‡ ‘•–”— –‹‘‘’–‹‘•ǡ‹•ƒ–‹••—‡ˆŽƒ’ˆ”‘–Š‡Ž‘™‡”ƒ„†‘‡Ǥ –Šƒ•„‡‡ƒ”‘—†ˆ‘”ƒ “—ƒ”–‡” ‡–—”›ǡƒ†‹• —””‡–Ž›ƒ‘‰–Š‡‘•– ‘‘Ž›’‡”ˆ‘”‡†ˆŽƒ’•‹’‘•–Ǧ ƒ•–‡ –‘›„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ˜‡”–Š‡’ƒ•–ˆ‘—”›‡ƒ”•ȋʹͲͳ͸ǦʹͲͳͻȌǡ‘—” ‡’ƒ”–‡–Šƒ•‹ƒ˜‡”ƒ‰‡”‡ ‘•–”— –‡†ͷͲ’ƒ–‹‡–•ƒ—ƒŽŽ›—•‹‰–Š‹•–‡ Š‹“—‡Ǥ  Š‡’‡”ˆ‘”‹‰•— Š”‡ ‘•–”— –‹˜‡•—”‰‡”›ǡ‘—”‰‘ƒŽ‹•–‘’”‘˜‹†‡–Š‡„‡•– ”‡ ‘•–”— –‹‘•™‹–Š‹‹ƒŽ”‹••ǤŠ‹•–Š‡•‹•ˆ‘ —•‡•‘–Š‡Žƒ––‡”ƒ†‹˜‡•–‹‰ƒ–‡•–Š‡ ”‹••ƒ••‘ ‹ƒ–‡†™‹–Š ˆŽƒ’Šƒ”˜‡•–‹‰ƒ––Š‡†‘‘”Ǧ•‹–‡Ǥ— Š†‘‘”Ǧ•‹–‡‘”„‹†‹–› Šƒ•–‘„‡‹‹‹œ‡†ǡƒ•’ƒ–‹‡–•ƒˆ‡–›‹•‘ˆ’”‹‡‹’‘”–ƒ ‡‹‡Ž‡ –‹˜‡•—”‰‡”›ǡ ”‡ˆŽ‡ –‹‰–Š‡ƒš‹‘“Primum, non nocere”‘”“First, do no harm”ǤȋͳȌ  Breast cancer in Norway ͵ͷʹͶ‘”™‡‰‹ƒ™‘‡™‡”‡†‹ƒ‰‘•‡†™‹–Š„”‡ƒ•– ƒ ‡”‹ʹͲͳͺǤȋʹȌ –‹•–Š‡‘•– ‘‘ ƒ ‡”†‹•‡ƒ•‡ƒ‘‰™‘‡Ǥ ‘”–—ƒ–‡Ž›ǡͷǦ›‡ƒ””‡Žƒ–‹˜‡•—”˜‹˜ƒŽ‹‘”™ƒ› ‹•‡•–‹ƒ–‡†–‘„‡ͻͲǤ͹ΨǤȋʹȌŠ‡•‡Š‹‰Š‹ ‹†‡ ‡ƒ†•—”˜‹˜ƒŽ”ƒ–‡•”‡•—Ž–‹ƒ •—„•–ƒ–‹ƒŽ—„‡”‘ˆ’ƒ–‹‡–•‘’–‹‰ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ  Breast reconstruction General aspects of breast reconstruction ”‡ƒ•–”‡ ‘•–”— –‹‘‹•—“—‡•–‹‘ƒ„Ž›ƒ ‘’Ž‡šƒ†ˆƒ• ‹ƒ–‹‰•—”‰‹ ƒŽˆ‹‡Ž†Ǥ –‹• –”—‡–ƒ‹Ž‘”Ǧƒ†‡‡†‹ ‹‡†‡’‡†‡–‘ƒ™‹†‡ƒ””ƒ›‘ˆˆƒ –‘”•ǡ•— Šƒ•ǣ–Š‡’ƒ–‹‡–ǡ–Š‡ ƒ ‡”†‹•‡ƒ•‡ǡƒ†–Š‡‡†‹ ƒŽ†‘ –‘”•‹˜‘Ž˜‡†Ǥ ‹˜‹‰ƒˆ—ŽŽ‘˜‡”˜‹‡™‘ˆ–Š‹•ˆ‹‡Ž†‹•ˆƒ” „‡›‘†–Š‡• ‘’‡‘ˆ–Š‹•‹–”‘†— –‹‘ǤŠ‡ˆ‘ŽŽ‘™‹‰–‡š–™‹ŽŽǡŠ‘™‡˜‡”ǡ’‹’‘‹––Š‡ ˜‡”›„ƒ•‹ •‡‡†‡†–‘—†‡”•–ƒ†–Š‡„ƒ ‰”‘—†‘ˆ–Š‹•–Š‡•‹•ǣ  Š‡•‹œ‡‘ˆ–Š‡„”‡ƒ•–†‡ˆ‡ –‹•ƒƒŒ‘”ˆƒ –‘”‰—‹†‹‰–Š‡ Š‘‹ ‡‘ˆ„”‡ƒ•– ”‡ ‘•–”— –‹‘‘†ƒŽ‹–›ǤŠ‡•‹œ‡‹•†‡–‡”‹‡†„›–Š‡‘ ‘Ž‘‰‹ ƒŽ–”‡ƒ–‡–’”‘˜‹†‡† ’”‹‘”–‘”‡ ‘•–”— –‹‘ǤŠ‡”‡ƒ”‡–™‘ƒ‹ƒ’’”‘ƒ Š‡•–‘•—”‰‹ ƒŽŽ›”‡‘˜‡ƒ ƒŽ‹‰ƒ–„”‡ƒ•––—‘”ǣ

1 1 ͳȌ ƒ•–‡ –‘›ȋ”‡‘˜‹‰–Š‡„”‡ƒ•– ‘’Ž‡–‡Ž›Ȍ ʹȌ „”‡ƒ•– ‘•‡”˜‹‰–Š‡”ƒ’›ȋȌȋ”‡‘˜‹‰–Š‡„”‡ƒ•–’ƒ”–‹ƒŽŽ›Ȍ  ƒ•–‡ –‘›‹•ǡƒ–—”ƒŽŽ›ǡ–Š‡‘•–—–‹Žƒ–‹‰‘’–‹‘‘ˆ–Š‡–™‘ƒ†Ž‡ƒ˜‡•–Š‡ Žƒ”‰‡•–†‡ˆ‡ –„‡Š‹†ǤŠ‡’ƒ–‹‡–‡†•—’Šƒ˜‹‰ƒDzˆŽƒ– Š‡•–dz‘‘‡‘”„‘–Š•‹†‡ȋ•ȌǤ› ’‡”ˆ‘”‹‰ƒǡŠ‘™‡˜‡”ǡ‘‡–”‹‡•–‘”‡‘˜‡ƒ•Ž‹––Ž‡„”‡ƒ•––‹••—‡ƒ•’‘••‹„Ž‡™Š‹Ž‡ •–‹ŽŽ’”‘˜‹†‹‰–Š‡’ƒ–‹‡–•™‹–Šƒ••ƒˆ‡–”‡ƒ–‡–ƒ••‡‡™‹–Šƒƒ•–‡ –‘›Ǥ ʹͲͳͺǡ ͺʹǤͳΨ‘ˆ ƒ ‡”’ƒ–‹‡–•™‹–Š–—‘”Ž‡••–Šƒ͵Ͳ‹•‹œ‡—†‡”™‡–‹‘—” ‘—–”›ǤȋʹȌ  ‡•’‹–‡–Š‡ˆƒ ––Šƒ–‹•’”‘˜‡•ƒˆ‡ƒ†’”‡•‡”˜‡•‘”‡„”‡ƒ•–˜‘Ž—‡ȋ͵ǡͶȌǡ ƒ•–‡ –‘› ‘–‹—‡•–‘’Žƒ›ƒ˜‹–ƒŽ”‘Ž‡‹–Š‡–”‡ƒ–‡–ƒŽ‰‘”‹–Š‘ˆ„”‡ƒ•– ƒ ‡”ǤȋͷȌ Š‡”ƒ–‡‘ˆƒ•–‡ –‘‹‡•Šƒ˜‡‹ˆƒ –‹ ”‡ƒ•‡†”‡ ‡–Ž›Ǥȋ͸ǡ͹ȌŠ‡‹ ”‡ƒ•‡‘ˆ ƒ•–‡ –‘›—„‡”•‹‰Š–„‡ ƒ—•‡†„›ˆƒ –‘”•ǡ•— Šƒ•ǣȋ͸ǡͺȌ ͳȌ ‹ ”‡ƒ•‡††‡–‡ –‹‘‘ˆ—Ž–‹ˆ‘ ƒŽ–—‘” ʹȌ —ˆƒ˜‘”ƒ„Ž‡„”‡ƒ•–Ǧ–‘Ǧ–—‘”•‹œ‡”ƒ–‹‘ ͵Ȍ ‰‡‡–‹ †‹•’‘•‹–‹‘ȋ”‡•—Ž–‹‰‹’”‘’Š›Žƒ –‹ „‹Žƒ–‡”ƒŽƒ•–‡ –‘›Ȍ ͶȌ ‹’”‘˜‡†„”‡ƒ•–”‡ ‘•–”— –‹‘‘†ƒŽ‹–‹‡•  •™‹–ŠƒŽŽ•‘”–•‘ˆ•—”‰‡”›ǡ–Š‡†‹ˆˆ‡”‡–„”‡ƒ•–”‡ ‘•–”— –‹‘‘†ƒŽ‹–‹‡•Šƒ˜‡ ’‘–‡–‹ƒŽ ‘’Ž‹ ƒ–‹‘•ȋͻȌƒ†ˆ— –‹‘ƒŽ‹’ƒ –•ȋͳͲȌǤƒ–‹‡–•‡‡†–‘„‡™‡ŽŽ ‹ˆ‘”‡†‹–Š‡•‡ƒ––‡”•„‡ˆ‘”‡‘’–‹‰ˆ‘”ƒ„”‡ƒ•–”‡ ‘•–”— –‹‘–‡ Š‹“—‡ǤŠ‡› ƒǡ ˆ‘”„‡––‡”‘”™‘”•‡ǡƒ ‡••ƒ›”‹ƒ†‘ˆ‹ˆ‘”ƒ–‹‘•‘—” ‡•”‡‰ƒ”†‹‰’”‘•ƒ† ‘•‘ˆ „”‡ƒ•–”‡ ‘•–”— –‹‘ǤȋͳͳǦͳ͵Ȍ ‡”‡ǡ–Š‡’”‘ˆ‡••‹‘ƒŽ•’Žƒ›ƒ‹•–”—‡–ƒŽ’ƒ”–‹ ‘””‡ –Ž›‹ˆ‘”‹‰ƒ†•–‡ƒ†‹Ž›‰—‹†‹‰–Š‡’ƒ–‹‡–Ǥ  Š‡’”‘ ‡••‘ˆ Š‘‘•‹‰ƒ„”‡ƒ•–”‡ ‘•–”— –‹‘‹•‹Š‡”‡–Ž›ƒ”†—‘—•ƒ† ‘’Ž‹ ƒ–‡†Ȃ„‘–Šˆ‘”–Š‡’ƒ–‹‡–ǡ”‡Žƒ–‹˜‡•ǡƒ†’Žƒ•–‹ •—”‰‡‘Ǥ‘‡‘ˆ–Š‡ƒ› ˆƒ –‘”•–Šƒ––Š‡’ƒ–‹‡–ƒ†’Žƒ•–‹ •—”‰‡‘Šƒ˜‡–‘ ‘•‹†‡”ƒ”‡ǣȋ͸Ȍ ͳȌ ‰‡‡–‹ †‹•’‘•‹–‹‘ ʹȌ ‘ ‘Ž‘‰‹ ƒŽƒ•’‡ –•‘ˆ–Š‡–—‘” ͵Ȍ ‡‘ǦȀƒ†Œ—˜ƒ––”‡ƒ–‡– ͶȌ –‹‹‰ȋ‹‡†‹ƒ–‡Ȁ’”‹ƒ”›˜‡”•—•†‡Žƒ›‡†Ȁ•‡ ‘†ƒ”›Ȍ ͷȌ ƒ•–‡ –‘›’ƒ––‡”ȋ‡Ǥ‰Ǥ•‹Ǧ•’ƒ”‹‰ƒ•–‡ –‘›˜‡”•—•ƒ„Žƒ–‹‘Ȍ ͸Ȍ „”‡ƒ•–•‹œ‡ ͹Ȍ †‘‘”Ǧ•‹–‡ȋ‹ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘Ȍ ͺȌ ‡‡†Ȁ™‹•Š–‘’‡”ˆ‘”•›‡–”‹œƒ–‹‘•—”‰‡”›‘ ‘–”ƒŽƒ–‡”ƒŽ„”‡ƒ•– ͻȌ ’ƒ–‹‡–ǯ• ‘†‹–‹‘ȋ ǡ’ƒ•–‡†‹ ƒŽŠ‹•–‘”›ǡ•‘‹‰ǡ†‡•‹”‡†’”‡‰ƒ ›ǡ‡– ǤȌ ͳͲȌ ’ƒ–‹‡–ǯ•’”‡ˆ‡”‡ ‡•ƒ†‰‘ƒŽ• ͳͳȌ •—”‰‡‘ǯ••‹ŽŽ•ƒ†„”‡ƒ•–”‡ ‘•–”— –‹‘‘†ƒŽ‹–‹‡•ƒ˜ƒ‹Žƒ„Ž‡  ’‘”–ƒ–Ž›ǡ‘’”‘ ‡†—”‡‘—–•Š‹‡•–Š‡‘–Š‡”•‹ƒŽŽ ‹” —•–ƒ ‡•Ǥ‡ ƒ—•‡ ‡”–ƒ‹’ƒ–‹‡–•†‘Š‘™‡˜‡” Ž‡ƒ”Ž›„‡‡ˆ‹–ˆ”‘ ƒ”‡ˆ—Ž’”‘ ‡†—”ƒŽ•‡Ž‡ –‹‘ǡ•—ˆˆ‹ ‹‡– –‹‡ƒ†‡ˆˆ‘”–•Š‘—Ž†„‡‹˜‡•–‡†–‘‹†‡–‹ˆ›–Š‡ǤŠ‡ˆ‘ŽŽ‘™‹‰•‡ –‹‘‰‹˜‡•ƒ •›‘’•‹•‘ˆ–Š‡ƒ‹ ƒ–‡‰‘”‹‡•‘ˆ„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ  Breast reconstruction modalities  Implant-based reconstruction (IBR) 2 2 Š‡—•‡‘ˆ’‡”ƒ‡–‹’Žƒ–•‹•’”‡•—ƒ„Ž›–Š‡‡ƒ•‹‡•–ƒ†„›ˆƒ”–Š‡‘•–—•‡† „”‡ƒ•–”‡ ‘•–”— –‹‘–‡ Š‹“—‡ǤȋͳͶǡͳͷȌ’”‡”‡“—‹•‹–‡ˆ‘” ‹•ƒƒ†‡“—ƒ–‡•‹ ‡˜‡Ž‘’‡ǤŠ‡”‡ˆ‘”‡ǡƒ•–‡’™‹•‡–‹••—‡‡š’ƒ•‹‘™‹–Š•‹‡š’ƒ†‡”•‹•—•‡†‘ƒ ”‡‰—Žƒ”„ƒ•‡ǤŠ‡•‡•‹‡š’ƒ†‡”• ƒƒŽ•‘„‡—•‡†ƒ•Dz•’ƒ ‡”•dzƒˆ–‡”•‹Ǧ•’ƒ”‹‰ ƒ•–‡ –‘›—–‹Ž ‘’Ž‡–‹‘‘ˆƒ†Œ—˜ƒ––Š‡”ƒ’›Ǥȋ͸Ȍ  ‹•‘ˆ–‡ Š‘•‡ƒˆ–‡”ƒ•–‡ –‘›‹‘Ǧ‹””ƒ†‹ƒ–‡†’ƒ–‹‡–•„‡ ƒ—•‡‘ˆ–Š‡ •‹’Ž‡‘’‡”ƒ–‹˜‡’”‘ ‡†—”‡ƒ†–Š‡•Š‘”–’‘•–‘’‡”ƒ–‹˜‡”‡Šƒ„‹Ž‹–ƒ–‹‘’‡”‹‘†Ǥ ƒŽ•‘ ƒ†˜ƒ–ƒ‰‡‘—•Ž›‡Ž‹‹ƒ–‡•–Š‡’‘–‡–‹ƒŽ ‘’Ž‹ ƒ–‹‘•ƒ––Š‡†‘‘”Ǧ•‹–‡ƒ••‡‡™‹–Š ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ–Š‡‘–Š‡”Šƒ†ǡ ‹•Ž‹‡Ž›–‘†‡˜‡Ž‘’‹’Žƒ–Ǧ ”‡Žƒ–‡† ‘’Ž‹ ƒ–‹‘•ȋ‡Ǥ‰Ǥ ƒ’•—Žƒ” ‘–”ƒ –‹‘ƒ†‹’Žƒ–”—’–—”‡Ȍ™‹–ŠƒŠ‹‰Š”‹•‘ˆ ”‡‘’‡”ƒ–‹‘Ǥȋͳ͸ǡͳ͹Ȍ  Autologous breast reconstruction (ABR) —–‘Ž‘‰‘—•ˆŽƒ’•‹„”‡ƒ•–”‡ ‘•–”— –‹‘ƒ‹ƒ–”‡•–‘”‹‰–Š‡ƒ•–‡ –‘›†‡ˆ‡ –™‹–Š ƒƒ‡•–Š‡–‹ ƒŽŽ›‰‘‘†ƒ†Ž‘‰ǦŽƒ•–‹‰”‡•—Ž–ǤȋͳͺȌ††‹–‹‘ƒŽŽ›ǡŠƒ•–Š‡„‡‡ˆ‹–‘ˆ ”‡’Žƒ ‹‰DzŽ‹‡™‹–ŠŽ‹‡dzǡ™‹–ŠƒˆŽƒ’”‡•‡„Ž‹‰–Š‡’ƒ–‹‡–ǯ•„”‡ƒ•––‹••—‡ǤŠ‹•ƒ•’‡ – ’”‘„ƒ„Ž›Ž‡ƒ†•–‘‹’”‘˜‡†ˆ‡‡Ž‹‰‘ˆ”‡•–‘”ƒ–‹‘‘ˆ–Š‡•‡Žˆƒ†‹ ”‡ƒ•‡†’ƒ–‹‡– •ƒ–‹•ˆƒ –‹‘ǤȋͳͻǡʹͲȌ  ”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Šƒ—–‘Ž‘‰‘—•ˆŽƒ’•‡ ‘’ƒ••‡•ƒŽ‘‰Ž‹•–‘ˆ •–ƒ†ƒ”†‹œ‡†’”‘ ‡†—”‡•ƒ†ƒ„‡™‹Ž†‡”‹‰ƒ””ƒ›‘ˆ–‡”•Ǥ—––‹‰ƒŽ‘‰•–‘”›•Š‘”–ǡ –Š‡”‡ƒ”‡–™‘ƒ‹‰”‘—’•”‡ˆŽ‡ –‹‰–Š‡•—”‰‹ ƒŽ–‡ Š‹“—‡—•‡†ǣ ͳȌ ‡†‹ Ž‡†ˆŽƒ’ȋ‡Ǥ‰Ǥǡǡ ǡ‡– ǤȌ ʹȌ ”‡‡ˆŽƒ’ȋ‡Ǥ‰Ǥˆ”‡‡ǡ ǡ ǡǡ ǡǡ ǡ ǡ‡– ǤȌ  Š‡ƒ‹†‹ˆˆ‡”‡ ‡„‡–™‡‡–Š‡–™‘‰”‘—’•Ǣ’‡†‹ Ž‡†˜‡”•—•ˆ”‡‡ˆŽƒ’ǡ ƒ„‡ ‡š’Žƒ‹‡†‹–Š‡ˆ‘ŽŽ‘™‹‰™ƒ›ǣ’‡†‹ Ž‡†ˆŽƒ’ ‘•‹•–•‘ˆ•‹ƒ†•—„ —–ƒ‡‘—•–‹••—‡ ƒ Š‘”‡†„›ƒ’‡†‹ Ž‡‘ˆ–‹••—‡–Š”‘—‰Š™Š‹ Š‹–”‡ ‡‹˜‡•‹–•„Ž‘‘†•—’’Ž›Ǥˆ”‡‡ˆŽƒ’‹•ƒ •‹‹Žƒ”„Ž‘ ‘ˆ–‹••—‡™Š‡”‡–Š‡˜ƒ• —Žƒ”’‡†‹ Ž‡Šƒ•„‡‡•‡˜‡”‡†™Š‹ Š‡ƒ„Ž‡•–Š‡ ˆŽƒ’–‘„‡ˆ”‡‡Ž›‘˜‡†ƒ†”‡ƒ––ƒ Š‡†ƒ–ƒ†‹•–ƒ–”‡ ‹’‹‡–Ǧ•‹–‡„›‹ ”‘˜ƒ• —Žƒ” ƒƒ•–‘‘•‹•ǤȋʹͳȌ  Š‡ƒ‹†”ƒ™„ƒ ‘ˆ—•‹‰ƒ—–‘Ž‘‰‘—•–‹••—‡‹•–Š‡ ‘ŽŽƒ–‡”ƒŽ†ƒƒ‰‡ ƒ—•‡†ƒ– –Š‡†‘‘”Ǧ•‹–‡ȋ‡Ǥ‰ǤŽ‘••‘ˆ•–”‡‰–ŠȀˆ— –‹‘ǡ’ƒ‹ǡ• ƒ””‹‰ǡ™‘—††‡Š‹• ‡ ‡ǡ•‡”‘ƒǡ Š‡ƒ–‘ƒǡ‹ˆ‡ –‹‘ǡ‡ ”‘•‹•ǡŠ‡”‹ƒˆ‘”ƒ–‹‘ǡ‡– ǤȌǤ ‘”–—ƒ–‡Ž›ǡƒ—„‡”‘ˆ †‡˜‡Ž‘’‡–•Šƒ˜‡‘ —””‡†–‘•‹ ‡–Š‡ͳͻͺͲ•–‘”‡†— ‡–Š‡‡š–‡–‘ˆ•— Š†‘‘”Ǧ •‹–‡‘”„‹†‹–›Ǥȋ͸Ȍƒ„Ž‡ͳ‰‹˜‡•ƒŠ‹•–‘”‹ ‘˜‡”˜‹‡™‘ˆ–Š‡†‡˜‡Ž‘’‡–•‹ƒ—–‘Ž‘‰‘—• ˆŽƒ’•Šƒ”˜‡•–‡†ˆ”‘–Š‡ƒ„†‘‡ǤȋʹʹȌ  Table 1. Developments in autologous flaps harvested from the abdomen

Year Flap name (original) Flap name Plastic surgeon(s) Ref (current) (country) ͳͻ͹ͻ ”‡‡ƒ„†‘‹‘’Žƒ•–› ”‡‡ˆŽƒ’ ‘Ž•–”ڏȋ™‡†‡Ȍ ȋʹ͵Ȍ ˆŽƒ’ ͳͻͺʹ ”ƒ•˜‡”•‡ƒ„†‘‹ƒŽ ‡†‹ Ž‡†ˆŽƒ’ ƒ”–”ƒ’ˆ‡–ƒŽǤ ȋʹͶȌ ‹•Žƒ†ˆŽƒ’ ȋȌ

3 3 ͳͻͺͷ ‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹  •Ǧ ”‹‡†ƒ‡–ƒŽǤ ȋʹͷȌ ˆ”‡‡ˆŽƒ’ ȋȌ ͳͻͻͳ ”‡‡ƒ„†‘‹‘’Žƒ•–›  ˆŽƒ’ ”‘––‹‰ȋȌ ȋʹ͸Ȍ ˆŽƒ’ ͳͻͻͶ ‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹   ˆŽƒ’ ŽŽ‡ƒ†”‡‡ ‡ ȋʹ͹Ȍ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’ ȋȌ   ‡”‡Žƒ–‹˜‡Ž›”‡ ‡–†‡˜‡Ž‘’‡–‹•’‡”ˆ‘”ƒ–‘”ˆŽƒ’”‡ ‘•–”— –‹‘ǤȋʹͺȌ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’‹•ƒ–›’‡‘ˆˆ”‡‡ˆŽƒ’™Š‡”‡–Š‡˜ƒ• —Žƒ”’‡†‹ Ž‡ ‘•‹•–•‘ˆ‹•‘Žƒ–‡† ’‡”ˆ‘”ƒ–‘”•ȋ‹•–‡ƒ†‘ˆ–Š‡‹”•‘—” ‡˜‡••‡ŽȌǤȋʹͳȌ’‡”ˆ‘”ƒ–‘” ƒ„‡•‡‡ƒ•ƒƒ”–‡”› –Šƒ–„”ƒ Š‡•‘ˆˆƒŽƒ”‰‡” ƒŽ‹„‡”•‘—” ‡ƒ”–‡”›ƒ†’‡”ˆ‘”ƒ–‡••–”— –—”‡•‘‹–•™ƒ›–‘ –Š‡–‹••—‡•‹–•—’’Ž‹‡•™‹–Š—–”‹‡–„Ž‘‘†Ǥ ‹‰—”‡ͳ‹ŽŽ—•–”ƒ–‡•†‹ˆˆ‡”‡––›’‡•‘ˆ ’‡”ˆ‘”ƒ–‘”•ƒ†Š‘™–Š‡›’‹‡” ‡–Š”‘—‰Š‘˜‡”Ž›‹‰•–”— –—”‡•Ȃˆ‘”‡šƒ’Ž‡–Š‡”‡ –—• —• Ž‡•ƒ†Ȁ‘”ˆƒ• ‹ƒ‡Ǥ

 Fig. 1 Perforators: Five perforators (1-5) pierce through the abdominal wall structures on their way to subcutaneous tissues and skin. Note the different perforator locations, the structures they perforate, and varying branching pattern. According to the Gent Consensus, these perforators are named: 1) Direct perforator, 2)+3) Indirect muscle perforators, 4) Indirect perimysial perforator (travels within the perimysium between muscle fibres), and 5) indirect septal perforator.(29) Illustration: Øystein Horgmo, University of Oslo    ›—•‹‰’‡”ˆ‘”ƒ–‘”•ǡ ‘‘Ž›Ž‘ ƒ–‡† Ž‘•‡”–‘–Š‡•‹–Šƒ–Š‡•‘—” ‡˜‡••‡Žǡ Ž‡••†‹••‡ –‹‘‹•‡‡†‡†–‘‹•‘Žƒ–‡–Š‡’‡†‹ Ž‡Ǥ‘•‡“—‡–Ž›ǡ–Š‡‡š–‡–‘ˆ‹ƒ–”‘‰‡‹ 

4 4 †ƒƒ‰‡ƒ††‘‘”Ǧ•‹–‡‘”„‹†‹–›ƒ”‡’‘–‡–‹ƒŽŽ›”‡†— ‡†Ǥ††‹–‹‘ƒŽƒ†˜ƒ–ƒ‰‡•‘ˆ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’•ƒ”‡–Š‡Ž‘‰‡”’‡†‹ Ž‡•’”‘˜‹†‡†ƒ†ˆ”‡‡†‘‘ˆ‘”‹‡–ƒ–‹‘‘ˆ–Š‡ ’‡†‹ Ž‡‹–•‡Žˆȋ ‘’ƒ”‡†–‘–Š‡‘”‡ ‘ˆ‹‡†’‡†‹ Ž‡†ˆŽƒ’•ȌǤȋʹͺȌŠ‡ ˆŽƒ’ •–—†‹‡†‹–Š‹•–Š‡•‹•‹•ƒ‡šƒ’Ž‡‘ˆƒ’‡”ˆ‘”ƒ–‘”ˆŽƒ’ǤŠ‡’”‘ ‡†—”‡‹•‡š’Žƒ‹‡†‹ †‡–ƒ‹ŽŽƒ–‡”Ǥ

Autologous fat grafting (AFG) ‘Ž—‡”‡•–‘”ƒ–‹‘•™‹–Šˆƒ–‹Œ‡ –‹‘•‡’‹”‹ ƒŽŽ›•–ƒ”–‡†‘”‡–ŠƒͳͲͲ›‡ƒ”•ƒ‰‘–‘ ‘””‡ – ‘–‘—”†‡ˆ‘”‹–‹‡•ƒ‹Ž›‘–Š‡ˆƒ ‡ƒ†„”‡ƒ•–Ǥȋ͵ͲȌ ƒ††‹–‹‘–‘”‡•–‘”‹‰ ˜‘Ž—‡ǡ‹–Šƒ•ƒŽ•‘”‡‰‡‡”ƒ–‹˜‡’‘–‡–‹ƒŽ‘™‹‰–‘–Š‡’”‡•‡ ‡‘ˆ•–‡ ‡ŽŽ•Ǥȋ͵ͳȌ—‡–‘ –Š‹•ƒ†‘–Š‡”—‹“—‡“—ƒŽ‹–‹‡•ǡ‹ ”‡ƒ•‹‰Ž›‘”‡‹–‡”‡•–‹••‡‡‰Ž‘„ƒŽŽ›‹–Š‡—•‡‘ˆ ƒ—–‘Ž‘‰‘—•ˆƒ–‰”ƒˆ–‹‰ȋ ȌǤ   ‡ ‘’ƒ••‡•–‡ Š‹“—‡•‘ˆ˜‘Ž—‡”‡•–‘”ƒ–‹‘„›–Š‡—•‡‘ˆ–Š‡’ƒ–‹‡–ǯ•ˆƒ–Ǥ ‹”•–ǡ‘‡’‡”ˆ‘”•ƒŽ‹’‘•— –‹‘ȋ‘•– ‘‘Ž›ˆ”‘–Š‡ƒ„†‘‡ȌǤ‡ ‘†ǡ‘‡ ”‡‹Œ‡ –•–Š‡ˆƒ––‘ƒ—‰‡––Š‡†‡•‹”‡†ƒ”‡ƒǤ˜‡”–Š‡Žƒ•–†‡ ƒ†‡•ǡ Šƒ•‰‡‡”ƒŽŽ› „‡‡—•‡†ƒ•”‡ˆ‹‡‡–•—”‰‡”›–‘ ‘””‡ –’‘•–Ǧ•—”‰‹ ƒŽ‹””‡‰—Žƒ”‹–‹‡•ƒ––Š‡ Š‡•–ǤŠ‹• Šƒ••Š‘™–‘„‡ƒ’‘™‡”ˆ—Žƒ†Œ— ––‘‹’”‘˜‡–Š‡ƒ‡•–Š‡–‹ ƒŽƒ’’‡ƒ”ƒ ‡‘ˆ–Š‡„”‡ƒ•–ǡ „‘†›‹ƒ‰‡ǡƒ†• ƒ”“—ƒŽ‹–›Ǥȋ͵ʹǦ͵ͶȌ –Šƒ•ƒŽ•‘„‡‡•— ‡••ˆ—ŽŽ›—•‡†–‘ƒŽŽ‡˜‹ƒ–‡ ’‡”•‹•–‡–’ƒ‹ƒˆ–‡”ƒ•–‡ –‘›ȋ͵ͶȌƒ†–‘‡Šƒ ‡–Š‡ƒ’’‡ƒ”ƒ ‡‘ˆ–Š‡†‘‘”Ǧ•‹–‡ ȋ͵͵ǡ͵ͷȌǤ  Š‡—•‡‘ˆ ‹ ‘’Ž‡–‡„”‡ƒ•–”‡ ‘•–”— –‹‘ǡŠ‘™‡˜‡”ǡŠƒ•Š‹•–‘”‹ ƒŽŽ›‘– „‡‡”‡‰—Žƒ”Ž›—•‡†Ǥ‡–ǡƒ‰”‘™‹‰„‘†›‘ˆŽ‹–‡”ƒ–—”‡†‡• ”‹„‡•de novo „”‡ƒ•– ”‡ ‘•–”— –‹‘™‹–Šƒ•‡”‹‡•‘ˆ”‡’‡ƒ–‡†ǡŽƒ”‰‡Ǧ˜‘Ž—‡Ž‹’‘–”ƒ•ˆ‡”•Ǥȋ͵͸Ǧ͵ͺȌ ––ƒ‡•ƒ– Ž‡ƒ•–ˆ‘—”–‘•‹š’”‘ ‡†—”‡•‹–Š‡ ‘—”•‡‘ˆ–™‘›‡ƒ”•ˆ‘”ƒ ‘’Ž‡–‡„”‡ƒ•– ”‡ ‘•–”— –‹‘Ǥȋ͵͸Ȍ‡•’‹–‡–Š‡†”ƒ™„ƒ •‘ˆ”‡’‡ƒ–‡†’”‘ ‡†—”‡•ǡ ‹‰Š–„‡ ‹ ”‡ƒ•‹‰Ž›—•‡††—‡–‘‹–•–‡ Š‹ ƒŽˆ‡ƒ•‹„‹Ž‹–›ǡ„‹‘ ‘’ƒ–‹„‹Ž‹–›ǡƒ ‡’–ƒ„Ž‡”‹••ǡƒ† Ž‘™†‘‘”Ǧ•‹–‡‘”„‹†‹–›Ǥȋ͵ͳȌ  Breast reconstruction with DIEAP flap Š‡ ˆŽƒ’‹•ƒ’‡”ˆ‘”ƒ–‘”ˆŽƒ’Šƒ”˜‡•–‡†ˆ”‘–Š‡Ž‘™‡”ƒ„†‘‡Ǥ –Šƒ•„‡ ‘‡ƒ –”—‡™‘”Š‘”•‡ƒ†‹• —””‡–Ž›–Š‡ˆ‹”•– Š‘‹ ‡ˆ‘”„‘–Š—‹Žƒ–‡”ƒŽƒ†„‹Žƒ–‡”ƒŽ Ǥȋ͵ͻȌš’Žƒ‹‡†‹ƒ•‹’Ž‡ƒ‡”ǡ–Š‡ˆŽƒ’ ‘•‹•–•‘ˆƒ„†‘‹ƒŽ•‹ǡ •—„ —–ƒ‡‘—•–‹••—‡ǡƒ†ƒ˜ƒ• —Žƒ”’‡†‹ Ž‡™Š‹ Š‹•–‘–ƒŽŽ›–”ƒ•‡ –‡†ˆ”‘‹–•‘”‹‰‹ ƒ†–Š‡”‡ƒ––ƒ Š‡†ƒ–ƒ†‹•–ƒ–•‹–‡ǤŠ‡ ˆŽƒ’‹•˜‡”•ƒ–‹Ž‡‹–‡”•‘ˆ’‘–‡–‹ƒŽ —•‡•ǡŠ‘™‡˜‡”ǡ”‡•–‘”‹‰ƒƒ•–‡ –‘›†‡ˆ‡ –‹•–Š‡‘•– ‘‘™ƒ›‘ˆ—•‹‰–Š‡ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’‹”‡ ‘•–”— –‹˜‡•—”‰‡”›Ǥ ‹‰—”‡ʹ‹ŽŽ—•–”ƒ–‡•–Š‡ ‘ ‡’–‘ˆ ˆŽƒ’ „”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ ƒ††‹–‹‘ǡ’Ž‡ƒ•‡•‡‡DzŽ‹‹ ƒŽ’Š‘–‘‰”ƒ’Š•dz‹–Š‡ˆ‹ƒŽ•‡ –‹‘ ‘ˆ–Š‹•†‘ –‘”ƒŽ–Š‡•‹•ˆ‘”’”‡Ǧƒ†’‘•–‘’‡”ƒ–‹˜‡’Š‘–‘‰”ƒ’Š•‘ˆƒ ˆŽƒ’’ƒ–‹‡–Ǥ 

5 5  Fig. 2 The concept of DIEAP flap breast reconstruction: Tissue is harvested from the lower abdomen with a perforator pedicle. The free flap is reattached at the recipient-site replacing the breast defect. The donor-site defect is closed. Nipple-areola complex can be reconstructed later. Illustration: Øystein Horgmo, University of Oslo   Š‡ƒ‡‘ˆ–Š‡ˆŽƒ’†‡• ”‹„‡•–Š‡ƒ”–‡”›™Š‹ Š•—’’Ž‹‡•–Š‡ˆŽƒ’™‹–Š„Ž‘‘†Ȃ–Š‡†‡‡’ ‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›ȋ ȌǤ‘•–’—„Ž‹•Š‡†ƒ”–‹ Ž‡•—•‡–Š‡ƒ„„”‡˜‹ƒ–‹‘Dz dz ˆŽƒ’Ȃ™‹–Š‘—––Š‡‘ˆƒ”–‡”›Ǥ‡Šƒ˜‡ Š‘•‡–‘—•‡ ǡ„‘–Š‹ƒ”–‹ Ž‡•ƒ†–Š‡•‹•ǡ ƒ•™‡„‡Ž‹‡˜‡–Š‹•‹•‘”‡ƒ —”ƒ–‡Ǥ ˆŽƒ’ƒ† ˆŽƒ’ƒ”‡‹‘–Š‡”™‘”†•–™‘ ƒ‡•ˆ‘”–Š‡˜‡”›•ƒ‡’‡”ˆ‘”ƒ–‘”ˆŽƒ’Ǥ  Š‡ „”ƒ Š‡•‘ˆˆ–Š‡‡š–‡”ƒŽ‹Ž‹ƒ ƒ”–‡”›ǤȋͶͲȌ ”‘–Š‡†‘”•ƒŽ•‹†‡‘ˆ–Š‡ ”‡ –—•„‡ŽŽ‹‡•ǡ’‡”ˆ‘”ƒ–‘”•ˆ”‘–Š‡ ‡‹–Š‡”Šƒ˜‡ƒ‹–”ƒ—• —Žƒ”‘”‡š–”ƒ—• —Žƒ” ‘—”•‡‘–Š‡‹”™ƒ›–‘–Š‡ƒ„†‘‹ƒŽ•—„ —–ƒ‡‘—•–‹••—‡ƒ†•‹ǤȋͶͳȌƒ˜‡”ƒ‰‡ǡ ‡ƒ ŠˆŽƒ’Šƒ•ƒ’’”‘š‹ƒ–‡Ž›•‹š’‡”ˆ‘”ƒ–‘”•ǡ™Š‹ Š ƒ„‡†‹˜‹†‡†‹–‘ƒŽƒ–‡”ƒŽȋ͸͸ΨȌ

6 6 ƒ†‡†‹ƒŽȋ͵ͶΨȌ”‘™ǤȋͶʹȌ‡••‡Ž•™‹–Šƒ ƒŽ‹„‡”‘ˆ‘‡‹ŽŽ‹‡–‡”‘”‘”‡ƒ”‡—•—ƒŽŽ› ‘•‹†‡”‡†ƒ•ƒ’‡”ˆ‘”ƒ–‘”ƒ†ƒ’’‡†ǤȋͶ͵Ȍ  ‹‰—”‡͵†‡’‹ –•–Š‡ ǡ‹–•‡†‹ƒŽƒ†Žƒ–‡”ƒŽ”‘™ǡƒ†–Š‡‹–”ƒ—• —Žƒ”ƒ† ‡š–”ƒ—• —Žƒ” ‘—”•‡•‘ˆ ’‡”ˆ‘”ƒ–‘”•Ǥ 

Fig. 3 The deep inferior epigastric artery (DIEA): The DIEA branches off the external iliac artery in the inguinal region. Behind the rectus muscles it typically divides into a medial and lateral row. The perforators branch off these rows and pierce through muscles and aponeuroses on their way to subcutaneous tissues and skin. Perforators can have an intramuscular or an extramuscular course as illustrated. Used with kind permission from Prof. M. Saint-Cyr (Divison of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, USA)

 Š‡—„‡”‘ˆ’‡”ˆ‘”ƒ–‘”•‹ ‘”’‘”ƒ–‡†‹–Š‡ˆŽƒ’˜ƒ”‹‡•ˆ”‘‘‡•‹‰Ž‡ ’‡”ˆ‘”ƒ–‘”–‘—Ž–‹’Ž‡’‡”ˆ‘”ƒ–‘”•ȋ”ƒ”‡Ž›‘”‡–Šƒ–Š”‡‡ȌǤƒ•‡†‘–Š‡Ž‘ ƒ–‹‘‘ˆ–Š‡ „‡•–’‡”ˆ‘”ƒ–‘”ȋ•Ȍǡ–Š‡ˆŽƒ’‹•‰‡‡”ƒŽŽ›†‡•‹‰‡†ƒ•ƒˆ—•‹ˆ‘”ˆŽƒ’’‘•‹–‹‘‡†‹–Š‡ ‹†Ž‹‡„‡–™‡‡–Š‡•—’”ƒ’—„‹  ”‡ƒ•‡ƒ†–Š‡—„‹Ž‹ —•ȋ˜‡”–‹ ƒŽŽ›Ȍƒ†„‡–™‡‡„‘–Š •—’‡”‹‘”ƒ–‡”‹‘”‹Ž‹ƒ •’‹‡•ȋŠ‘”‹œ‘–ƒŽŽ›ȌǤ –‡ƒ•—”‡•ͳʹǦͳͷ ‹Š‡‹‰Š–ƒ†͵ͲǦͶͷ ‹™‹†–ŠȂ–Š‡ˆ‘”‡”„‡‹‰Ž‹‹–‡†„›–Š‡–‡•‹‘ ƒ—•‡††—”‹‰ƒ„†‘‹ƒŽ†‡ˆ‡ – Ž‘•—”‡ǤȋʹͳȌŠ‡ˆ”‡‡ˆŽƒ’†‹••‡ –‡†™‡‹‰Š•ƒ„‘—–‘‡‹Ž‘‰”ƒǡŠ‘™‡˜‡”ǡ‹–‹•‘”ƒŽŽ› –”‹‡†„‡ˆ‘”‡”‡ƒ––ƒ Š‹‰‹––‘–Š‡ Š‡•–”‡‰‹‘ǤȋͶͶȌ  ––Š‡”‡ ‹’‹‡–Ǧ•‹–‡ǡ–Š‡‘Ž†ƒ•–‡ –‘›• ƒ”‹•”‡•‡ –‡†ƒ†–Š‡•‹–‡‹•’”‡’ƒ”‡† „‡ˆ‘”‡–Š‡ ˆŽƒ’‹•‡”–‹‘ǤŠ‡˜ƒ• —Žƒ”ƒƒ•–‘‘•‹• ƒ„‡’‡”ˆ‘”‡†—•‹‰–Š‡ ‹–‡”ƒŽƒƒ”›˜‡••‡Ž•ȋ Ȍ‘”ǡŽ‡•• ‘‘Ž›ǡ–Š‡–Š‘”ƒ ‘†‘”•ƒŽ˜‡••‡Ž•ȋȌǤ

7 7  ‡–Š‡ƒ”–‡”‹ƒŽƒ†˜‡‘—•ƒƒ•–‘‘•‡•Šƒ˜‡„‡‡’‡”ˆ‘”‡†ǡ–Š‡ˆŽƒ’‹•†‡„—Ž‡†ǡ ‘–‘—”‡†ǡ‹•‡–ǡƒ†•‡ —”‡†Ȃˆ‹ƒŽ‹œ‹‰ƒ‡™„”‡ƒ•–Ǥ‘”‡†‡–ƒ‹Ž‡†•—”‰‹ ƒŽǦ –‡ Š‹ ƒŽ†‡• ”‹’–‹‘‘ˆ–Š‡’”‘ ‡†—”‡ǡƒ•’‡”ˆ‘”‡†‹‘—”‡’ƒ”–‡–ǡ‹•ˆ‘—†„‡Ž‘™Ǥ  ‘ƒ˜ƒ”›‹‰‡š–‡–ǡƒ„†‘‹ƒŽˆŽƒ’Šƒ”˜‡•–‹‰†‘‡•†‹•”—’––Š‡‹–‡‰”‹–›‘ˆ ƒ„†‘‹ƒŽ™ƒŽŽǤŠ‡‹ƒ–”‘‰‡‹ †ƒƒ‰‡ ƒ—•‡†ƒ›”‡•—Ž–‹ƒ•›‡–”›ǡ„—Ž‰‹‰ǡƒ† Š‡”‹ƒˆ‘”ƒ–‹‘ǤȋͶͷǡͶ͸Ȍ‡˜‡”ƒŽ•–—†‹‡•Šƒ˜‡•Š‘™ǡŠ‘™‡˜‡”ǡ–Šƒ––Š‡ ˆŽƒ’ ”‡†— ‡•–Š‡†‘‘”Ǧ•‹–‡‘”„‹†‹–› ‘’ƒ”‡†™‹–Š‘–Š‡”ˆ”‡‡ˆŽƒ’•Šƒ”˜‡•–‡†ˆ”‘–Š‡ ƒ„†‘‡ǤȋͶ͹ǦͷͳȌŠ‹•‹‰Š–„‡–Š‡”‡ƒ•‘ˆ‘”‹–•’‘’—Žƒ”‹–›ƒ‘‰‹ ”‘•—”‰‹ ƒŽ ˆƒ ‹Ž‹–‹‡•™‘”Ž†™‹†‡ǤŠ‡ ˆŽƒ’•ǯ„‡‡ˆ‹–‘ˆ‹‹‹œ‹‰†‘‘”Ǧ•‹–‡‘”„‹†‹–›‹• ”‡Ž‡˜ƒ–ƒ•‹ ”‡ƒ•‹‰Ž›‘”‡‡’Šƒ•‹•‹•’—–‘”‡†— ‹‰–Š‡ˆ— –‹‘ƒŽƒ†ƒ‡•–Š‡–‹  †‡ˆ‡ –•ƒ––Š‡†‘‘”Ǧ•‹–‡ǤȋͷͲȌ  •ƒƒ––‡”‘ˆˆƒ –ǡ–‹••—‡Šƒ”˜‡•–‹‰ˆ”‘–Š‡ƒ„†‘‡‹• ‘•‹†‡”‡†ƒ ƒ†˜ƒ–ƒ‰‡ǡƒ†–Š‡ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘‹• ‘‘Ž›’”‡•‡–‡†ƒ•ƒDz–™‘Ǧ ‹Ǧ‘‡dz’”‘ ‡†—”‡ǤŠ‹•”‡ˆŽ‡ –•–Š‡ƒ„†‘‹‘’Žƒ•–›ȋȌ’‡”ˆ‘”‡†Ǥ‹††ƒ‡–ƒŽǤ ”‡’‘”–‡†–Šƒ–Šƒ˜‹‰ƒ•‹—Ž–ƒ‡‘—•™ƒ•–Š‡ƒ‹”‡ƒ•‘‘ˆ Š‘‘•‹‰ƒ ˆŽƒ’ ”‡ ‘•–”— –‹‘‹ͶͲΨ‘ˆ–Š‡‹”’ƒ–‹‡–‰”‘—’ǤȋͷʹȌŠ‡”‡–‘„‡––‡””‡‘˜‡‡š ‡••‹˜‡ •‹ƒ†ˆƒ––Šƒˆ”‘–Š‡Ž‘™‡”ƒ„†‘‡ǫ  Preoperative planning in DIEAP flap breast reconstruction Š‡–‘’‘‰”ƒ’Š›‘ˆ–Š‡ ’‡”ˆ‘”ƒ–‘”•ƒ”‡ƒ’’‡†ƒ††‡Ž‹‡ƒ–‡†’”‡‘’‡”ƒ–‹˜‡Ž›Ǥ ƒ•‡†‘–Š‡‹ˆ‘”ƒ–‹‘’”‘˜‹†‡†ǡ–Š‡’Žƒ•–‹ •—”‰‡‘ ƒ•‡– Šƒ”‘ƒ†ƒ’ˆ‘”–Š‡ ’‡”ˆ‘”ƒ–‘”†‹••‡ –‹‘Ǥ•–Š‡ ’‡”ˆ‘”ƒ–‘”†‹••‡ –‹‘ ƒ„‡–Š‡‘•– ŠƒŽŽ‡‰‹‰ƒ† –‹‡Ǧ ‘•—‹‰’ƒ”–‘ˆ–Š‡™Š‘Ž‡’”‘ ‡†—”‡ǡ•— Š”‘ƒ†ƒ’• ƒ„‡„‡‡ˆ‹ ‹ƒŽ–‘–Š‡ ‘’‡”ƒ–‘”ƒ†”‡†— ‡‘’‡”ƒ–‹˜‡–‹‡ƒ†‘˜‡”ƒŽŽ ‘’Ž‹ ƒ–‹‘•Ǥȋͷ͵ȌŠ‡ˆŽƒ’ǯ• ‡–‡” ƒ ƒŽ•‘„‡’‘•‹–‹‘‡†ƒ ‘”†‹‰–‘–Š‡„‡•–’‡”ˆ‘”ƒ–‘”ȋ•Ȍˆ‘”‹†‡ƒŽˆŽƒ’’‡”ˆ—•‹‘Ǥ  Š‡”‡ƒ”‡•‡˜‡”ƒŽ‘†ƒŽ‹–‹‡•‘ˆƒ’’‹‰–Š‡’‡”ˆ‘”ƒ–‘”•ǡ•— Šƒ•Šƒ†ǦŠ‡Ž† ‘’’Ž‡”ǡ ‘Ž‘”†—’Ž‡š•‘‘‰”ƒ’Š›ǡ ‘’—–‡†–‘‘‰”ƒ’Š›ƒ‰‹‘‰”ƒ’Š›ȋȌǡƒ† ƒ‰‡–‹ ”‡•‘ƒ ‡ƒ‰‹‘‰”ƒ’Š›ǤȋͷͶǡͷͷȌǡ‘ˆ–‡ ‘„‹‡†™‹–Š͵Ǧ•‘ˆ–™ƒ”‡ǡ‹• ‘‘Ž›—•‡†‹‘—”‡’ƒ”–‡–ƒ†™‘”Ž†™‹†‡Ǥ  The DIEAP flap procedure Š‡ˆ‘ŽŽ‘™‹‰–‡š–†‡• ”‹„‡•–Š‡ ˆŽƒ’’”‘ ‡†—”‡ƒ•‹–‹•’‡”ˆ‘”‡†‹‘—” ‡’ƒ”–‡–Ǥ–™‘Ǧ–‡ƒƒ’’”‘ƒ Šȋ†‘‘”Ǧƒ†”‡ ‹’‹‡–Ǧ•‹–‡Ȍ‹• ƒ””‹‡†‘—– •‹—Ž–ƒ‡‘—•Ž›–‘”‡†— ‡‘’‡”ƒ–‹˜‡–‹‡Ǥ  Donor-site surgery ”‡‘’‡”ƒ–‹˜‡ƒ”‹‰•ƒ”‡„ƒ•‡†‘–Š‡’”‡‘’‡”ƒ–‹˜‡’Žƒȋ—•‹‰Ȍƒ†–Š‡’ƒ–‹‡–ǯ• Šƒ„‹–—•Ǥ  ‹•‹‘•ƒ”‡ƒ†‡ƒ ‘”†‹‰–‘–Š‡•‡ƒ”‹‰•ǣŠ‡ ”ƒ‹ƒŽ‹ ‹•‹‘‹•’Žƒ ‡†ƒ– –Š‡’‡”‹‡–‡”‘ˆ‘”ƒ„‘˜‡–Š‡—„‹Ž‹ —•Ǥ –‹•„‡˜‡Ž‡†—’™ƒ”†–‘‹ Ž—†‡ƒ††‹–‹‘ƒŽˆƒ– –‹••—‡‹–Š‡ˆŽƒ’ǤŠ‡ ƒ—†ƒŽ‹ ‹•‹‘‹•’‘•‹–‹‘‡†‹–Š‡•—’”ƒ’—„‹  ”‡ƒ•‡ǡ™Š‹ Š‹• ƒ’’”‘š‹ƒ–‡Ž›ͳʹǦͳ͵ ‡–‹‡–‡”•„‡Ž‘™–Š‡ ”ƒ‹ƒŽ‹ ‹•‹‘Ǥ‘–Š‹ ‹•‹‘•ƒ”‡‡š–‡†‡† Žƒ–‡”ƒŽŽ›–‘–Š‡ƒ–‡”‹‘”•—’‡”‹‘”‹Ž‹ƒ •’‹‡•–‘ƒ‡ƒ•›‡–”‹ ǡˆ—•‹ˆ‘”ˆŽƒ’‹–Š‡ Ž‘™‡”ƒ„†‘‡ǤŠ‡ˆŽƒ’‹•–Š‡”ƒ‹•‡†ˆ”‘Žƒ–‡”ƒŽ–‘‡†‹ƒŽǡ‘”ƒŽŽ›‘–Š‡ ‘–”ƒŽƒ–‡”ƒŽ•‹†‡‘ˆ–Š‡„”‡ƒ•–†‡ˆ‡ –ȋ‹’•‹Žƒ–‡”ƒŽ•‹†‡‹•‘ ƒ•‹‘ƒŽŽ›—•‡†‹ˆ–Š‡„‡•–

8 8 ’‡”ˆ‘”ƒ–‘”ȋ•Ȍ‹•Ž‘ ƒ–‡†Š‡”‡ȌǤŠ‡•—’‡”ˆ‹ ‹ƒŽ‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ˜‡‹ȋ Ȍ‹• ’”‡•‡”˜‡†Ǥ›”‘–ƒ–‹‰–Š‡ˆŽƒ’ͳͺͲι™Š‡–”ƒ•’‘•‹‰‹––‘–Š‡ Š‡•–ǡ–Š‹•˜‡‹ƒŽŽ‘™•ƒ ƒ††‹–‹‘ƒŽƒƒ•–‘‘•‹•ȋ–‘˜‡ƒ ‡’ŠƒŽ‹ ƒȌ‹ˆ˜‡‘—• ‘‰‡•–‹‘‘ —”•‹–Š‡ˆ”‡‡ ˆŽƒ’Ǥȋͷ͸ȌŠ‹•–‡ Š‹“—‡‹• ƒŽŽ‡†Dz˜‡‘—••—’‡”†”ƒ‹ƒ‰‡dzǤ  Ž›–Š‡Žƒ”‰‡•–’‡”ˆ‘”ƒ–‘”ȋ•Ȍ‘‘‡•‹†‡‹•†‹••‡ –‡†ˆ”‘–Š‡Ž‡˜‡Ž‘ˆ–Š‡ ƒ–‡”‹‘””‡ –—•ˆƒ• ‹ƒǡ–Š”‘—‰Š–Š‡—• Ž‡„‡ŽŽ›ǡƒ† ‘–‹—‡†‹ˆ‡”‹‘”Ž›—–‹Ž–Š‡ƒ‹ –”—‘ˆ–Š‡†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ˜‡••‡Ž•ƒ”‡”‡ƒ Š‡†Ǥ‘’–‹ƒŽ’‡†‹ Ž‡Ž‡‰–Š‹• ‡‹‰Š––‘–‡ ‡–‹‡–‡”•ǤŠ‡—• Ž‡†‹••‡ –‹‘‹•’‡”ˆ‘”‡†‹ƒŽ‘‰‹–—†‹ƒŽƒ‡” ƒ†ˆ‘ŽŽ‘™•–Š‡’‡”ˆ‘”ƒ–‘”‘ˆ‹–‡”‡•–ǤŽŽ•‹†‡„”ƒ Š‡•‘ˆ–Š‡’‡”ˆ‘”ƒ–‘”ƒ”‡Ž‹‰ƒ–‡†Ǥ ‡‰‡–ƒŽ‘–‘”„”ƒ Š‡•‘ˆ–Š‡‹–‡” ‘•–ƒŽ‡”˜‡•ƒ”‡ ƒ”‡ˆ—ŽŽ›’”‡•‡”˜‡†ǢŠ‘™‡˜‡”ǡ •‘‡ƒ”‡‹‡˜‹–ƒ„Ž›•‡˜‡”‡††—”‹‰–Š‡‹–”ƒ—• —Žƒ”†‹••‡ –‹‘Ǥ‡”˜‡•—–—”‡‹• ‘”ƒŽŽ›‘–’‡”ˆ‘”‡†ǤŠ‡—„‡”‘ˆ’‡”ˆ‘”ƒ–‘”•‹ Ž—†‡†‹•„ƒ•‡†‘„‘–Š ’‡”ˆ‘”ƒ–‘”ƒ†ˆŽƒ’•‹œ‡•ǤŠ‡ ‹” —Žƒ–‘”› ƒ’ƒ ‹–›‘ˆ–Š‡ Š‘•‡’‡”ˆ‘”ƒ–‘”ȋ•Ȍ‹•–‡•–‡† „› Žƒ’‹‰”‡ƒ‹‹‰’‡”ˆ‘”ƒ–‘”•ˆ‘”ͳͷ‹—–‡•Ǥ ˆ–Š‡ Š‘•‡’‡”ˆ‘”ƒ–‘”ȋ•Ȍ•‡‡–‘ „‡•ƒ–‹•ˆƒ –‘”›ǡ–”ƒ•‡ –‹‘‘ˆ–Š‡’‡”ˆ‘”ƒ–‘”•‹•’‡”ˆ‘”‡†Ǥ‘–Š–Š‡ƒ”–‡”›ƒ†‹–•‘‡ ‘”–™‘˜‡ƒ‡ ‘‹–ƒ–‡•ƒ”‡†‹˜‹†‡†ǤŠ‡ˆ”‡‡’‡”ˆ‘”ƒ–‘”ˆŽƒ’‹•–Š‡–”ƒ•ˆ‡””‡†–‘–Š‡ ”‡ ‹’‹‡–Ǧ•‹–‡ƒ†–‡’‘”ƒ”‹Ž›•‡ —”‡†Ǥ 

 Fig. 4 Raising a DIEAP flap: A myotomy in the rectus abdominis muscle has been made to free-dissect the intramuscular perforator. The segmental motor nerve (yellow) is preserved. Illustration: Øystein Horgmo, University of Oslo

9 9  ‘ —””‡––‘–Š‡ˆŽƒ’–”ƒ•’‘•‹–‹‘–‘–Š‡ Š‡•–ǡ–Š‡†‘‘”Ǧ•‹–‡•—”‰‡”› ‘–‹—‡•ƒ†–Š‡†‡ˆ‡ –‹• Ž‘•‡†Ǥ ‘”†‡”–‘ Ž‘•‡–Š‡”ƒ–Š‡”Žƒ”‰‡†‡ˆ‡ –ǡƒƒ„†‘‹ƒŽ ˆŽƒ’Šƒ•–‘„‡ƒ†‡–Š”‘—‰Š‡š–‡•‹˜‡ ”ƒ‹ƒŽ—†‡”‹‹‰ǤŠ‡—†‡”‹‹‰‹• ’‡”ˆ‘”‡†–‘–Š‡Ž‡˜‡Ž‘ˆš‹’Š‘‹†’”‘ ‡••ƒ†ƒŽ‘‰–Š‡ ‘•–ƒŽƒ”‰‹•ǤŠ‡ƒ–‡”‹‘” ”‡ –—••Š‡ƒ–Š†‡ˆ‡ –‹• Ž‘•‡†’”‹ƒ”‹Ž›™‹–Š’‘Ž›†‹‘šƒ‘‡ȋͲȌ”—‹‰•—–—”‡ǤŠ‹• ‹•’‘••‹„Ž‡†—‡–‘–Š‡ˆƒ• ‹ƒǦ•’ƒ”‹‰–‡ Š‹“—‡—•‡††—”‹‰–Š‡‹–”ƒ—• —Žƒ”’‡”ˆ‘”ƒ–‘” †‹••‡ –‹‘Ǥ‡•Š‹•‘–”‡‰—Žƒ”Ž›—•‡†Ȃ‘Ž›‹ƒˆ‡™•‡Ž‡ –‡† ƒ•‡•™‹–ŠŽƒ”‰‡ƒ–‡”‹‘” ”‡ –—••Š‡ƒ–Š‹ ‹•‹‘•ƒ†Ȁ‘”—Ž–‹’Ž‡›‘–‘‹‡•Ǥ‡ –—•’Ž‹ ƒ–‹‘‹•‘–’‡”ˆ‘”‡†Ǥ ‡‘Ǧ—„‹Ž‹ —•‹•ƒ†‡„›‡š–‡”ƒŽ‹œ‹‰–Š‡—„‹Ž‹ —•ƒ–ƒŽ‡˜‡Ž‡“—‹˜ƒŽ‡––‘‹–•ƒ–—”ƒŽ ’‘•‹–‹‘ǤŠ‡†‘‘”Ǧ†‡ˆ‡ –‹• Ž‘•‡†‹–Š”‡‡Žƒ›‡”•ȋ ƒ”’ƒǯ•ˆƒ• ‹ƒǡ†‡‡’†‡”ƒŽŽ›ǡƒ† ‹–”ƒ —–ƒ‡‘—•Ž›ȌǤ‹‡†‰‡•ƒ”‡ƒ’’”‘š‹ƒ–‡†‹ƒŽƒ–‡”ƒŽǦ–‘Ǧ‡†‹ƒŽˆƒ•Š‹‘ǡƒ† ’Ž‡ƒ–‹‰‘ˆ–Š‡ƒ„†‘‹ƒŽˆŽƒ’‹•’‡”ˆ‘”‡†–‘’”‡˜‡–†‘‰Ǧ‡ƒ”•Ǥ™‘ͳͺ ”‡ Š†”ƒ‹• ƒ”‡’Žƒ ‡†‹–Š‡†‘‘”Ǧ•‹–‡ǡƒ†Žƒ–‡””‡‘˜‡†™Š‡–Š‡’”‘†— –‹‘˜‘Ž—‡‘ˆ‡ƒ Š †”ƒ‹‹•Ž‡••–Šƒ͵Ͳ ’‡”†ƒ›Ǥ ‘’”‡••‹‘‰ƒ”‡–‹•—•‡†ˆ‘”ˆ‘—”Ǧ•‹š™‡‡• ’‘•–‘’‡”ƒ–‹˜‡Ž›Ǥ  Recipient-site surgery Š‡•—”‰‡”›ƒ†’”‡’ƒ”ƒ–‹‘‡‡†‡†ƒ––Š‡”‡ ‹’‹‡–Ǧ•‹–‡†‡’‡†‘™Š‡–Š‡”ƒ’”‹ƒ”› ‘”•‡ ‘†ƒ”›„”‡ƒ•–”‡ ‘•–”— –‹‘‹•’‡”ˆ‘”‡†Ǥ ’”‹ƒ”›”‡ ‘•–”— –‹‘•ǡ„”‡ƒ•– •—”‰‡‘ȋ•Ȍ”‡•‡ –•–Š‡„”‡ƒ•–‰Žƒ†ƒ†Ž‡ƒ˜‡•ƒ•‹‡˜‡Ž‘’‡Ǥ •‡ ‘†ƒ”› ”‡ ‘•–”— –‹‘•ǡ–Š‡ƒ•–‡ –‘›• ƒ”‹•”‡•‡ –‡†ǡƒ‡™‹ˆ”ƒƒƒ”› ”‡ƒ•‡‹• †‡ˆ‹‡†ǡ•‹‹•†‡Ǧ‡’‹–Š‡Ž‹ƒŽ‹œ‡†ȋˆ”‘–Š‡• ƒ”–‘–Š‡‹ˆ”ƒƒƒ”›ˆ‘Ž†Ȍǡƒ†ƒ•‹ ‡˜‡Ž‘’‡‹•ƒ†‡Ǥ  ‡‡”ƒŽŽ›ǡ–Š‡ •ƒ”‡—•‡†ƒ•”‡ ‹’‹‡–˜‡••‡Ž•ǤŠ‡›ƒ”‡ƒ’’”‘ƒ Š‡†ƒ––Š‡ •‡ ‘†‹–‡”•’ƒ ‡„‡–™‡‡–Š‡•‡ ‘†ƒ†–Š‹”† ƒ”–‹Žƒ‰‡•Ǥ •‘‡’ƒ–‹‡–•ǡ’ƒ”–•‘ˆ–Š‡ –Š‹”†”‹„ƒ”‡”‡‘˜‡†’ƒ”–‹ƒŽŽ›Ȁ ‘’Ž‡–‡Ž›–‘‹’”‘˜‡ƒ ‡••Ǥ†‡“—ƒ–‡Ž›•‹œ‡† ’‡”ˆ‘”ƒ–‘”•‘ˆ–Š‡ Ǣ‹–‡”ƒŽƒƒ”›ƒ”–‡”›’‡”ˆ‘”ƒ–‘”•ȋ Ȍǡ ƒƒŽ•‘„‡—•‡† ˆ‘”‹ ”‘ƒƒ•–‘‘•‹•ǡ™Š‹ Š‘„˜‹ƒ–‡–Š‡‡‡†–‘†‹••‡ ––Š‘—‰Š–Š‡”‹„•’ƒ ‡Ǥ  ‹ ”‘ƒƒ•–‘‘•‹•‹•’‡”ˆ‘”‡†‡†Ǧ–‘Ǧ‡†„›–Š‡—•‡‘ˆ‹ ”‘• ‘’‡Ǥ”–‡”‹ƒŽ ƒƒ•–‘‘•‹•‹•Šƒ†Ǧ•‡™ǡ™Š‹Ž‡ƒ ‘—’Ž‹‰†‡˜‹ ‡‹•—•‡†ˆ‘”˜‡‘—•ƒƒ•–‘‘•‹•Ǥ  ˆ–‡”–Š‡‹ ”‘ƒƒ•–‘‘•‡•Šƒ˜‡„‡‡ ‘’Ž‡–‡†ǡ–Š‡ ˆŽƒ’‹•–”‹‡†ǡ •Šƒ’‡†ǡƒ†ȋ’ƒ”–‹ƒŽŽ›Ȍ†‡Ǧ‡’‹–Š‡Ž‹ƒŽ‹œ‡†ǤŠ‡’‡†‹ Ž‡‹••‡ —”‡†ƒ†’”‘–‡ –‡†ǡ„‡ˆ‘”‡ –Š‡ˆŽƒ’‹•ƒ Š‘”‡†ƒ†–Š‡•‹‹•ˆ‹ƒŽŽ› Ž‘•‡†Ǥ‡†”ƒ‹‹•’Žƒ ‡†ƒ––Š‡”‡ ‹’‹‡–Ǧ •‹–‡Ǥ  Secondary procedures after DIEAP flap breast reconstruction ƒ††‹–‹‘–‘–Š‡‹’’Ž‡”‡ ‘•–”— –‹‘ƒ†‹’’Ž‡ƒ”‡‘Žƒ ‘’Ž‡š–ƒ––‘‘‹‰ȋ’‡”ˆ‘”‡† ‘–Š•ƒˆ–‡”–Š‡ ˆŽƒ’’”‘ ‡†—”‡Ȍǡ•‘‡’ƒ–‹‡–•—†‡”‰‘ƒ††‹–‹‘ƒŽǡ•‡ ‘†ƒ”› ’”‘ ‡†—”‡•–‘‹’”‘˜‡‘—– ‘‡•Ǥƒ•‡†‘ƒ”‡˜‹‡™‘ˆ͵͹Ͳ ƒ† ˆŽƒ’•ǡƒŒƒ– ‡–ƒŽǤ•—‰‰‡•–‡†–Šƒ–’ƒ–‹‡–••Š‘—Ž†”‡ ‘‰‹œ‡–Š‡Ž‹‡Ž‹Š‘‘†‘ˆƒ–Ž‡ƒ•–‘‡ƒ††‹–‹‘ƒŽ ’”‘ ‡†—”‡ˆ‘ŽŽ‘™‹‰‹‹–‹ƒŽ”‡ ‘•–”— –‹‘Ǥȋͷ͹ȌŠ‡‹””‡ ‘‡†ƒ–‹‘‹•„ƒ•‡†‘–Š‡ —„‡”•‘ˆ’”‘ ‡†—”‡•’‡”ˆ‘”‡†ƒ–„‘–Š†‘‘”Ǧƒ†Ȁ‘””‡ ‹’‹‡–Ǧ•‹–‡Ǥ  Ž–Š‘—‰Š‹‹ ‹‰ƒ ‘˜‡–‹‘ƒŽƒ„†‘‹‘’Žƒ•–›ȋȌǡ–Š‡ ˆŽƒ’ ƒ„†‘‹‘’Žƒ•–›˜ƒ”‹‡•‹•‡˜‡”ƒŽ™ƒ›• ‘’ƒ”‡†™‹–Š–Š‡”‘—–‹‡•–‡’•‘ˆƒǣ

10 10 ƒȌ ‹’‘•— –‹‘‹•‘–’‡”ˆ‘”‡††—‡–‘–Š‡”‹•‘ˆ’‡”ˆ‘”ƒ–‘”‹Œ—”› „Ȍ Š‡‡š–‡–‘ˆ—„‹Ž‹ ƒŽ•—”‰‡”›˜ƒ”‹‡•†‡’‡†‹‰‘’‡”ˆ‘”ƒ–‘”Ž‘ ƒ–‹‘ Ȍ ‡ –—•’Ž‹ ƒ–‹‘‹•‘–ˆ”‡“—‡–Ž›—†‡”–ƒ‡  ›˜‹”–—‡‘ˆ–Š‡†‹ˆˆ‡”‡ ‡•‹‘’‡”ƒ–‹˜‡–‡ Š‹“—‡ǡ—™ƒ–‡†ƒ‡•–Š‡–‹ ‘—– ‘‡• ȋ‡Ǥ‰Ǥ˜‹•‹„Ž‡• ƒ”•ǡ—„‹Ž‹ ƒŽ†‹•’Žƒ ‡‡–ǡƒ††‘‰Ǧ‡ƒ”•Ȍƒ”‡‘”‡ ‘‘Ž›‘„•‡”˜‡† ƒˆ–‡” ˆŽƒ’’”‘ ‡†—”‡• ‘’ƒ”‡†–‘ǤȋͷʹȌ‘‡‘ˆ–Š‡’ƒ–‹‡–•ƒŽ•‘‰‡–˜ƒ”›‹‰ †‡‰”‡‡•‘ˆŽ—„ƒ”ƒ†Ȁ‘”‡’‹‰ƒ•–”‹ ˆ—ŽŽ‡••†—‡–‘–Š‡Žƒ ‘ˆŽ‹’‘•— –‹‘„‡ˆ‘”‡Ȁƒˆ–‡” Šƒ”˜‡•–‹‰–Š‡ˆŽƒ’ǤŠ‹• ƒ„‡ ‘””‡ –‡†™‹–Š•‡ ‘†ƒ”›”‡ˆ‹‡‡–’”‘ ‡†—”‡••— Šƒ• • ƒ””‡˜‹•‹‘ǡ†‘‰Ǧ‡ƒ” ‘””‡ –‹‘ǡƒ†Ž‹’‘•— –‹‘Ǥƒ‡‡–ƒŽǤ”‡’‘”–‡†–Šƒ–ͳͳΨ‘ˆ –Š‡‹”’ƒ–‹‡–• ‘’Ž‡–‡†ƒ„†‘‹ƒŽ”‡ˆ‹‡‡–•—”‰‡”›–‘‹’”‘˜‡–Š‡ƒ‡•–Š‡–‹  ‘—– ‘‡•ƒˆ–‡”ƒ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ǤȋͷͺȌ—”‡’ƒ”–‡–‘ ƒ•‹‘ƒŽŽ› ’‡”ˆ‘”••— Š”‡ˆ‹‡‡–’”‘ ‡†—”‡•ƒ––Š‡†‘‘”Ǧ•‹–‡ǡŠ‘™‡˜‡”ǡ†ƒ–ƒŠƒ•‘–„‡‡ •›•–‡ƒ–‹ ƒŽŽ› ‘ŽŽ‡ –‡† ‘ ‡”‹‰–Š‹•ƒ––‡”Ǥ  Abdominal wall anatomy Š‹••‡ –‹‘‰‹˜‡•ƒ‘˜‡”˜‹‡™‘ˆƒ„†‘‹ƒŽ™ƒŽŽƒƒ–‘›ƒ††‡•‹‰ƒ–‡ƒƒ–‘‹ ƒŽ •–”— –—”‡•™Š‹ Šƒ”‡’‘••‹„Ž›ƒˆˆ‡ –‡†„› ˆŽƒ’•—”‰‡”›ǤŠ‡ƒ„†‘‹ƒŽ™ƒŽŽŽƒ›‡”• †‹ˆˆ‡”†‡’‡†‹‰‘ƒ„†‘‹ƒŽ”‡‰‹‘ǡƒ†–Š‡ƒ„†‘‡‹•‘ˆ–‡†‹˜‹†‡†‹–‘ƒ–‡”‹‘”ǡ Žƒ–‡”ƒŽǡƒ†’‘•–‡”‹‘” ‘’ƒ”–‡–•ǤȋͷͻȌǤ  –‡”•‘ˆ ˆŽƒ’•—”‰‡”›ǡ–Š‡ƒ–‡”‹‘” ‘’ƒ”–‡–‹•‘ˆ‰”‡ƒ–‡•– ‹’‘”–ƒ ‡ƒ†–Š‡ˆ‘ŽŽ‘™‹‰Žƒ›‡”•ƒ”‡‹˜‘Ž˜‡†ǣ•‹ǡ•—„ —–ƒ‡‘—•–‹••—‡ǡƒ–‡”‹‘” ”‡ –—••Š‡ƒ–Šǡ”‡ –—•ƒ„†‘‹‹•—• Ž‡ǡ’‘•–‡”‹‘””‡ –—••Š‡ƒ–Šǡƒ†–”ƒ•˜‡”•ƒŽ‹•ˆƒ• ‹ƒǤ ‹‰—”‡ͷ‹ŽŽ—•–”ƒ–‡•–Š‡”‡Žƒ–‹‘„‡–™‡‡–Š‡•‡•–”— –—”‡•Ǥ  ‹ƒ†•—„ —–ƒ‡‘—•–‹••—‡•ǡ—• Ž‡•ƒ†ƒ’‘‡—”‘•‡•ǡ˜‡••‡Ž•ƒ†˜ƒ• —Žƒ” ‡–™‘”•ǡƒ†‡”˜‡•‘ˆ–Š‡ƒ„†‘‹ƒŽ™ƒŽŽƒ”‡†‹• —••‡†‹–Š‡ˆ‘ŽŽ‘™‹‰ǣȋ͸ͲȌ  Skin and subcutaneous tissues  Š‡ƒ„†‘‹ƒŽ•‹‹•Ž‘‘•‡Ž›ƒ––ƒ Š‡†–‘–Š‡—†‡”Ž›‹‰–‹••—‡ǤŠ‡‡š ‡’–‹‘‹•ƒ–ƒ† ƒ”‘—†–Š‡—„‹Ž‹ —•™Š‡”‡‹–‹•ˆ‹”Ž›–‡–Š‡”‡†Ǥ‡‡ƒ–Š–Š‡•‹ǡ–Š‡”‡‹•ƒ˜ƒ”›‹‰ †‡‰”‡‡‘ˆ•—„ —–ƒ‡‘—•–‹••—‡†‡’‡†‹‰‘–Š‡„‘†›Šƒ„‹–—•Ǥ‹–Š‹–Š‹••—„ —–ƒ‡‘—• –‹••—‡–Š‡”‡ƒ”‡–™‘ˆƒ• ‹ƒ‡ǣƒ’‡”ǯ•ˆƒ• ‹ƒȋ‘•–•—’‡”ˆ‹ ‹ƒŽȌƒ† ƒ”’ƒǯ•ˆƒ• ‹ƒǤȋ͸ͳȌ ’‘‰”‘••‡šƒ‹ƒ–‹‘ǡƒ’‡”ǯ•ˆƒ• ‹ƒŽ‘‘•Ž‹‡ƒ•–ƒ†ƒ”†Žƒ›‡”‘ˆˆƒ––‹••—‡•‹–—ƒ–‡† Œ—•–ƒ–‡”‹‘”Ž›–‘–Š‡ ƒ”’ƒǯ•ˆƒ• ‹ƒǤ –Šƒ•„‡‡†‘ —‡–‡†ǡŠ‘™‡˜‡”ǡ–Šƒ––Š‹•Žƒ›‡”‹• ƒ†‹’‘•‡–‹••—‡ ‘–ƒ‹‹‰ƒ”ƒ†‘Ž›‘”‰ƒ‹œ‡†‡–™‘”‘ˆˆ‹„”‘—•–‹••—‡™‹–Š ‹–‡”•’‡”•‡†•‡’–ƒ‡Ǥȋ͸ʹȌŠ‡ ƒ”’ƒǯ•ˆƒ• ‹ƒ‹•ƒ‘”‡Dz Žƒ••‹ dzˆƒ• ‹ƒ‘ˆ ‘‡ –‹˜‡ –‹••—‡–Šƒ–•Š‘—Ž†„‡ƒ’’”‡ ‹ƒ–‡†ƒ†•—–—”‡†‹ƒ„†‘‹ƒŽ†‡ˆ‡ – Ž‘•—”‡•–‘‹‹‹œ‡ ‘’Ž‹ ƒ–‹‘”ƒ–‡•Ǥȋ͸͵ǡ͸ͶȌ  Muscles and aponeuroses ‘•–‘ˆ–Š‡•–”‡‰–Šƒ†•–ƒ„‹Ž‹–›‘ˆ–Š‡ƒ„†‘‹ƒŽ™ƒŽŽ‹•†‡”‹˜‡†ˆ”‘ƒ‰”‘—’‘ˆ ’ƒ‹”‡†›‘ƒ’‘‡—”‘–‹ •–”— –—”‡•ȋ—• Ž‡•ƒ†ƒ’‘‡—”‘•‡•ȌǤƒ’‘‡—”‘•‹•‹•ƒ „”‘ƒ†ǡ•Š‡‡–ǦŽ‹‡—• Ž‡–‡†‘Ǥƒ Š‘ˆ–Š‡ˆŽƒ‹‰ƒ„†‘‹ƒŽ—• Ž‡•ȋ‡š–‡”ƒŽ ‘„Ž‹“—‡ǡ‹–‡”ƒŽ‘„Ž‹“—‡ǡƒ†–”ƒ•˜‡”•—•ƒ„†‘‹‹•ȌŠƒ˜‡•— Šƒ’‘‡—”‘•‡•™Š‹ Š

11 11 •–”‡– Š‡†‹ƒŽŽ›ƒ†ˆ‘”–™‘”‡ –—••Š‡ƒ–Š•Ǣ‘‡ƒ–‡”‹‘”ƒ†‘‡’‘•–‡”‹‘”ǤŠ‡•‡–™‘ •Š‡ƒ–Š•ˆ‹”•–‡ Ž‘•‡–Š‡”‡ –—•„‡ŽŽ‹‡•ƒ†Žƒ–‡”ˆ—•‡‹–Š‡‹†Ž‹‡–‘ˆ‘”linea albaǤ Š‹•ˆ‹„”‘—••–”— –—”‡ƒ‹–ƒ‹•–Š‡’ƒ‹”‡†”‡ –—•—• Ž‡•ƒ–ƒ ‡”–ƒ‹’”‘š‹‹–›‘ˆ‡ƒ Š ‘–Š‡”ǤŠ‡”‡ –—•—• Ž‡• ‘˜‡”–Š‡ˆ—ŽŽŽ‡‰–Š‘ˆ–Š‡ƒ„†‘‹ƒŽ™ƒŽŽȂˆ”‘–Š‡š‹’Š‘‹† ’”‘ ‡••ƒ† ‘•–ƒŽ ƒ”–‹Žƒ‰‡• ”ƒ‹ƒŽŽ›–‘–Š‡’—„‹••›’Š›•‹•ƒ†’—„‹  ”‡•– ƒ—†ƒŽŽ›Ǥ  Š‡”‡ƒ”‡ƒƒ–‘‹ ƒŽ˜ƒ”‹ƒ–‹‘•‹–‡”•‘ˆƒ’‘‡—”‘–‹  ‘–”‹„—–‹‘•ˆ”‘–Š‡ ‘„Ž‹“—‡ƒ†–”ƒ•˜‡”•—•—• Ž‡•–‘–Š‡”‡ –—••Š‡ƒ–Š•ǤŠ‡•‡˜ƒ”‹ƒ–‹‘•ƒ”‡–Š‡”‡ƒ•‘ ˆ‘”–Š‡•‘Ǧ ƒŽŽ‡†arcuate lineǡ™Š‹ Š‹•ƒƒƒ–‘‹ ƒŽƒ”‡ƒ™Š‡”‡–Š‡’‘•–‡”‹‘””‡ –—• •Š‡ƒ–Š‹•ƒ„•‡–ǤŠ‡”‡ –—•—• Ž‡•Ž‹‡ǡ–Š‡”‡ˆ‘”‡ǡ†‹”‡ –Ž›•—’‡”ˆ‹ ‹ƒŽ–‘–Š‡ –”ƒ•˜‡”•ƒŽ‹•ˆƒ• ‹ƒ„‡Ž‘™–Š‡ƒ” —ƒ–‡Ž‹‡Ǥ‡‡ ‹‰—”‡ͷǤ–Š‹Žƒ›‡”‘ˆˆƒ–ǡ–Š‡ ‡š–”ƒ’‡”‹–‘‡ƒŽ‘”’”‡’‡”‹–‘‡ƒŽ–‹••—‡ǡ•‡’ƒ”ƒ–‡•–Š‡–”ƒ•˜‡”•ƒŽ‹•ˆƒ• ‹ƒƒ†–Š‡ ’‡”‹–‘‡—ǤŠ‡Žƒ––‡”‹•ƒ•‹‰Ž‡Žƒ›‡”‘ˆ•‡”‘•ƒ•—’’‘”–‡†„›ƒ–Š‹Žƒ›‡”‘ˆ ‘‡ –‹˜‡ –‹••—‡–Šƒ–Ž‹‡•–Š‡ƒ„†‘‹ƒŽ ƒ˜‹–›Ǥ

Fig. 5 The abdominal wall layers above and below the arcuate line. Camper’s and Scarpa’s fasciae are not illustrated here. Illustration: Øystein Horgmo, University of Oslo

12 12 Vessels and vascular networks Š‡„Ž‘‘†•—’’Ž›‘ˆ–Š‡ƒ„†‘‹ƒŽ™ƒŽŽ ‘•‹•–•‘ˆƒ•—’‡”ˆ‹ ‹ƒŽƒ††‡‡’˜ƒ• —Žƒ” ‡–™‘”Ǥȋ͸ͷȌ‘—‰ŠŽ›•’‡ƒ‹‰ǡ–Š‡•—’‡”ˆ‹ ‹ƒŽ‡–™‘”•—’’Ž‹‡•–‹••—‡•ƒ„‘˜‡–Š‡ ƒ–‡”‹‘””‡ –—••Š‡ƒ–Šǡ™Š‹Ž‡–Š‡†‡‡’‡–™‘”•—’’Ž‹‡•–‹••—‡•Ž‘ ƒ–‡†’‘•–‡”‹‘”Ž›Ǥ  Š‡†‡‡’˜ƒ• —Žƒ”‡–™‘” ‘•‹•–•‘ˆ–Š‡ͳȌ†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ǡʹȌ•—’‡”‹‘” ‡’‹‰ƒ•–”‹ ǡ͵Ȍ—• —Ž‘’Š”‡‹ ǡƒ†ͶȌ†‡‡’ ‹” —ˆŽ‡š‹Ž‹ƒ ƒ”–‡”‹‡•ȋ ‹‰Ǥ͸Ȍǣ  ͳȌŠ‡†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›ȋ Ȍ„”ƒ Š‡•‘ˆˆ–Š‡‡š–‡”ƒŽ‹Ž‹ƒ ƒ”–‡”› ƒ†‹•–Š‘—‰Š––‘„‡–Š‡ƒ‹„Ž‘‘†•—’’Ž›–‘–Š‡ƒ–‡”‹‘”ƒ„†‘‹ƒŽ™ƒŽŽǤȋ͸ͷȌ –‡–‡”• –Š‡’‘•–‡”‹‘””‡ –—••Š‡ƒ–Šƒ––Š‡Ž‡˜‡Ž‘ˆ–Š‡ƒ” —ƒ–‡Ž‹‡Ǥ––Š‹•’‘‹–‹••–ƒ”–• „”ƒ Š‹‰‘ˆˆ‡š–‡•‹˜‡Ž›ˆ‘”‹‰ƒŽŽ–Š‡’‡”ˆ‘”ƒ–‘”•—•‡†‹ ˆŽƒ’•—”‰‡”›Ǥ  ƒ††‹–‹‘–‘•—’’Ž›‹‰–Š‡›‘ƒ’‘‡—”‘–‹ •–”— –—”‡•ǡ–Š‡’‡”ˆ‘”ƒ–‘”•–”ƒ˜‡Ž„‡›‘†–Š‡ ƒ–‡”‹‘””‡ –—••Š‡ƒ–Šƒ†•—’’Ž›•—„ —–ƒ‡‘—•ƒ† —–ƒ‡‘—•–‹••—‡•Ǥ ‡”‡ǡƒƒ–‘‹ ƒŽ ƒ† ƒ†ƒ˜‡”‹ •–—†‹‡•Šƒ˜‡†‡‘•–”ƒ–‡†–Šƒ––Š‡ ’‡”ˆ‘”ƒ–‘”•ƒ‡–™‘’Ž‡š—•‡•ǣ ͳȌ–Š‡ˆƒ• ‹ƒŽ’Ž‡š—•ȋŒ—•–•—’‡”ˆ‹ ‹ƒŽ–‘ ƒ”’ƒǯ•ˆƒ• ‹ƒȌƒ†ʹȌ•—„†‡”ƒŽ’Ž‡š—•Ǥȋ͸͸Ȍ ƒ•‡†‘–Š‡•‡”‡ ‘”†‹‰•ǡ–Š‹‹‰‘ˆ ˆŽƒ’• ƒ„‡’‡”ˆ‘”‡†•ƒˆ‡Ž›†‡‡’–‘  ƒ”’ƒǯ•ˆƒ• ‹ƒǤŠ‹‹‰•—’‡”ˆ‹ ‹ƒŽŽ›–‘ ƒ”’ƒǯ•ˆƒ• ‹ƒ‹‰Š– ƒ—•‡”‡†— ‡†ˆŽƒ’ƒ† •‹’‡”ˆ—•‹‘Ǥȋ͸͸ȌŠ‡Ž‡ˆ–•‹†‡‘ˆ ‹‰—”‡͸•Š‘™•Š‘™–Š‡ ƒ• ‡†•ȋ„‡Š‹†–Š‡ ”‡ –—•—• Ž‡•Ȍƒ† ‘—‹ ƒ–‡™‹–Š–Š‡•—’‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›Ǥ  ʹȌŠ‡•—’‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›ȋȌ‹•ƒ–‡”‹ƒŽ„”ƒ Š‘ˆ–Š‡‹–‡”ƒŽ ƒƒ”›ƒ”–‡”›ȋ Ȍȋ‘”‹–‡”ƒŽ–Š‘”ƒ ‹ ƒ”–‡”›ȌǤ –†‡• ‡†•‘–Š‡’‘•–‡”‹‘” •—”ˆƒ ‡‘ˆ–Š‡”‡ –—•—• Ž‡•ƒ†ˆ”‡‡Ž›ƒƒ•–‘‘•‡™‹–Š–Š‡ ƒ––Š‡Ž‡˜‡Ž‘ˆ–Š‡ —„‹Ž‹ —•ǤŠ‡ ƒ†ƒ‡—’–Š‡–™‘†‘‹ƒ–’‡†‹ Ž‡•–‘–Š‡”‡ –—•—• Ž‡• ȋ˜ƒ• —Žƒ”’ƒ––‡”–›’‡ ƒ ‘”†‹‰–‘–Š‡ Žƒ••‹ˆ‹ ƒ–‹‘‘ˆ–Š‡˜ƒ• —Žƒ”ƒƒ–‘›–‘ —• Ž‡•„›ƒ–Š‡•ƒ†ƒŠƒ‹ȋ͸͹ȌȌǤ‹‡–Š‡ ǡ–Š‡Šƒ•’‡”ˆ‘”ƒ–‘”•–Šƒ–•–”‡– Š‡• ƒ–‡”‹‘”Ž›–‘•—’’Ž›•—„ —–ƒ‡‘—•–‹••—‡•ƒ†•‹ǤŠ‡›„‘–Š ‘—‹ ƒ–‡™‹–Š ‹–‡” ‘•–ƒŽǡ•—„ ‘•–ƒŽǡƒ†Ž—„ƒ”˜‡••‡Ž•Žƒ–‡”ƒŽŽ›Ǥ  ͵ȌǡͶȌŠ‡—• —Ž‘’Š”‡‹ ƒ”–‡”‹‡••—’’Ž›–Š‡‹–‡” ‘•–ƒŽ•’ƒ ‡•ƒ†—’’‡” ƒ„†‘‹ƒŽ™ƒŽŽǡ™Š‹Ž‡–Š‡†‡‡’ ‹” —ˆŽ‡š‹Ž‹ƒ ƒ”–‡”‹‡••—’’Ž›Ž‘™‡”ƒ†‘”‡Žƒ–‡”ƒŽ ’ƒ”–•‘ˆ–Š‡ƒ„†‘‹ƒŽ™ƒŽŽǤŠ‡•‡ƒ”–‡”‹‡•ƒ”‡ǡ–Š‡”‡ˆ‘”‡ǡ‘–ƒ•˜‹–ƒŽ‹ ˆŽƒ’•Ǥ  Š‡•—’‡”ˆ‹ ‹ƒŽ˜ƒ• —Žƒ”‡–™‘”‘ˆ–Š‡ƒ„†‘‹ƒŽ™ƒŽŽ‹•ˆ‘—†‹–Š‡ •—„ —–ƒ‡‘—•–‹••—‡•Ǥ – ‘•‹•–•‘ˆ„”ƒ Š‡•‘ˆ–Š‡ˆ‡‘”ƒŽƒ”–‡”›ȋ•—’‡”ˆ‹ ‹ƒŽ‹ˆ‡”‹‘” ‡’‹‰ƒ•–”‹ ǡ•—’‡”ˆ‹ ‹ƒŽ‡š–‡”ƒŽ’—†‡†ƒŽǡƒ†•—’‡”ˆ‹ ‹ƒŽ ‹” —ˆŽ‡šƒ”–‡”‹‡•ȌǤŠ‡”‹‰Š– •‹†‡‘ˆ ‹‰—”‡͸†‡’‹ –•–Š‡•‡–Š”‡‡ƒ”–‡”‹‡•ǤŠ‡•—’‡”ˆ‹ ‹ƒŽ‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ˜‡••‡Ž• ȋ Ȍ”—†‹ƒ‰‘ƒŽŽ›‹–Š‡•—„ —–ƒ‡‘—•–‹••—‡•ƒ†„”ƒ Š‡š–‡•‹˜‡Ž›‘–Š‡‹”™ƒ› –‘™ƒ”†–Š‡—„‹Ž‹ —•ǤŠ‡ƒ”–‡”› ‘–”‹„—–‡•–‘–Š‡„Ž‘‘†•—’’Ž›–‘–Š‡ƒ–‡”‘Žƒ–‡”ƒŽ ƒ„†‘‹ƒŽ™ƒŽŽǤŠ‡ •ƒ”‡Ž‘ ƒ–‡†„‡–™‡‡–Š‡–™‘•—„ —–ƒ‡‘—•ˆƒ• ‹ƒ‡ȋ͸ͺȌƒ† ƒ„‡—•‡†ƒ•ƒ˜ƒ• —Žƒ”’‡†‹ Ž‡‹ˆ”‡‡ƒ„†‘‹ƒŽˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘Ȃ–Š‡•‘Ǧ ƒŽŽ‡† ˆŽƒ’Ǥȋ͸ͻǡ͹ͲȌ  Š‡˜‡‹•‘ˆ–Š‡ƒ–‡”‹‘”ƒ„†‘‹ƒŽ™ƒŽŽ–‡†–‘ˆ‘ŽŽ‘™–Š‡ ‘—”•‡‘ˆƒ”–‡”‹‡•Ǥ Š‡›†”ƒ‹–‘–Š‡•—„ Žƒ˜‹ƒ˜‡••‡Ž•ƒ„‘˜‡–Š‡—„‹Ž‹ —•ƒ†–‘–Š‡‡š–‡”ƒŽ‹Ž‹ƒ ˜‡••‡Ž• „‡Ž‘™ǤŠ‡”‡ƒ”‡•‡˜‡”ƒŽ‘–Š‡”˜‡••‡Ž•ƒ† ‘ŽŽƒ–‡”ƒŽ•–Šƒ–Šƒ˜‡‘–„‡‡‡–‹‘‡†Ȃ •‘‡‹ŽŽ—•–”ƒ–‡†„‡Ž‘™Ǥ

13 13 Fig. 6 The deep and superficial vascular networks: Illustration of the deep vascular network (left) and superficial vascular network (right). Illustration: Øystein Horgmo, University of Oslo

Nerves •ƒ”—Ž‡‘ˆ–Š—„ǡ–Š‡͹–Š–‘ͳʹ–Š‹–‡” ‘•–ƒŽ‡”˜‡•‹‡”˜ƒ–‡–Š‡ƒ„†‘‹ƒŽ™ƒŽŽǡ™Š‡”‡ –Š‡ͳͲ–Š‡”˜‡•—’’Ž‹‡•–Š‡—„‹Ž‹ ƒŽ”‡‰‹‘ǤŠ‡”‡ –—•—• Ž‡•”‡ ‡‹˜‡‘–‘”ƒ† •‡•‘”›‹‡”˜ƒ–‹‘ˆ”‘–Š‡͸–ŠȀ͹–Š–Š‘”ƒ ‹ –‘–Š‡ͳ•–Ž—„ƒ”•’‹ƒŽ‡”˜‡•Ǥȋ͹ͳȌ‡”˜‡• ‡–‡”–Š‡ƒ„†‘‹ƒŽ™ƒŽŽ„‡–™‡‡–Š‡–”ƒ•˜‡”•—•ƒ„†‘‹‹•ƒ†‹–‡”ƒŽ‘„Ž‹“—‡

14 14 —• Ž‡•ǤŠ‡›†‹˜‹†‡‹–‘Žƒ–‡”ƒŽȋ —–ƒ‡‘—•Ȍǡƒ–‡”‹‘”ǡƒ†’‘•–‡”‹‘”„”ƒ Š‡•Ǥ  ƒ††‹–‹‘–‘–Š‡‹–‡” ‘•–ƒŽ‡”˜‡•‡–‹‘‡†ǡ–Š‡”‡ƒ”‡ƒŽ•‘‘–Š‡”‡”˜‡•–Šƒ– ’”‘˜‹†‡•„‘–Š‘–‘”ƒ†•‡•‘”›ˆ‹„‡”•–‘ ‡”–ƒ‹ƒ„†‘‹ƒŽ™ƒŽŽ•–”— –—”‡•Ǥ‘•– ‹’‘”–ƒ–‘ˆ–Š‡•‡‹•–Š‡‹Ž‹‘Š›’‘‰ƒ•–”‹ ‡”˜‡™Š‹ Š’”‘˜‹†‡•‘–‘”ˆ‹„‡”•–‘ƒŽŽ–Š”‡‡ ˆŽƒ‹‰—• Ž‡•ƒ†•‡•‘”›ˆ‹„‡”•–‘–Š‡•‹‘ˆ–Š‡‘•’—„‹•ƒ†—’’‡”ƒ†Žƒ–‡”ƒŽ –Š‹‰ŠǤŠ‡”‡ƒ‹‹‰‡”˜‡••—’’Ž›‹‰—• Ž‡•ƒ†Ȁ‘”•‹‹–Š‡ƒ„†‘‹ƒŽ”‡‰‹‘ƒ”‡ ‘–ƒ•‹’‘”–ƒ–‹–‡”•‘ˆ ˆŽƒ’•—”‰‡”›Ǥ

Abdominoplasty General aspects of abdominoplasty „†‘‹‘’Žƒ•–›ȋȌ‹•ƒ™‡ŽŽǦ‡•–ƒ„Ž‹•Š‡†ǡˆ”‡“—‡–Ž›’‡”ˆ‘”‡†’”‘ ‡†—”‡„›’Žƒ•–‹  •—”‰‡‘•™‘”Ž†™‹†‡Ǥƒ–‹‡–•‘ˆ–‡—†‡”‰‘•—”‰‡”›–‘”‡‘˜‡‡š ‡••‹˜‡•‹ƒˆ–‡” ƒ••‹˜‡™‡‹‰Š–Ž‘••ƒ†Ȁ‘”–‘ ‘””‡ –ƒ„†‘‹ƒŽ„—Ž‰‹‰Ȁƒ•›‡–”›™Š‹ Š ƒ—•‡ ˆ— –‹‘ƒŽ•›’–‘•Ǥƒ›ƒŽ•‘™ƒ––‘ƒ Š‹‡˜‡ƒ‘”‡›‘—–Šˆ—Žǡ’”‡Ǧ’”‡‰ƒ › ƒ„†‘‡Ǥ  Š‡”‡‹•ƒ™‹†‡ƒ””ƒ›‘ˆ†‹ˆˆ‡”‡––‡ Š‹“—‡•˜ƒ”›‹‰‹–Š‡†‡‰”‡‡‘ˆ Ž‹’‘•— –‹‘ǡ‹ ‹•‹‘’Žƒ ‡‡–ƒ†Ž‡‰–Šǡ—†‡”‹‹‰ǡ‡š ‹•‹‘ǡƒ† Ž‘•—”‡Ǥȋ͹ʹȌ  ‹•‹‘•ƒ”‡‰‡‡”ƒŽŽ› ‘ˆ‹‡†–‘–Š‡’ƒ–‹‡–•ǯ—†‡”‰ƒ”‡––‘ ‘ ‡ƒŽ• ƒ”–‹••—‡Ǥ  Š‡”‡ƒ”‡ƒ›’‘–‡–‹ƒŽ ‘’Ž‹ ƒ–‹‘•ƒˆ–‡”ƒǤȋ͹͵Ǧ͹ͷȌ ˆƒ –ǡŠƒ•–Š‡ Š‹‰Š‡•–”‹•‘ˆ•›•–‡‹  ‘’Ž‹ ƒ–‹‘•ƒ‘‰ƒ‡•–Š‡–‹ •—”‰‹ ƒŽ’”‘ ‡†—”‡•™Š‡”‡ –Š”‘„‘‡„‘Ž‹•‹•–Š‡‘•–†”‡ƒ†ˆ—ŽǤȋ͹ʹȌ‡•’‹–‡„‡‹‰ƒ••‘ ‹ƒ–‡†™‹–Š”‹••ǡƒ ‰”‘™‹‰„‘†›‘ˆ”‡•‡ƒ” ŠŠƒ•†‘ —‡–‡†–Šƒ–•‹‰‹ˆ‹ ƒ–Ž›‹’”‘˜‡•“—ƒŽ‹–›‘ˆ Ž‹ˆ‡Ǥȋ͹͸ǡ͹͹Ȍ — –‹‘ƒŽ•›’–‘•ǡ•— Šƒ•Ž‘™„ƒ ’ƒ‹ȋ͹ͺȌƒ†—”‹ƒ”›‹ ‘–‹‡ ‡ ȋ͹ͺǦͺͳȌǡŠƒ˜‡ƒŽ•‘„‡‡‹’”‘˜‡†Ǥ  The abdominoplasty procedure Š‡ˆ‘ŽŽ‘™‹‰–‡š–†‡• ”‹„‡•‹„”‹‡ˆ–Š‡ƒ„†‘‹‘’Žƒ•–›ȋȌ’”‘ ‡†—”‡ƒ•‹–‹• ’‡”ˆ‘”‡†‹‘—”‡’ƒ”–‡–ǣ  Š‡‹•’‡”ˆ‘”‡†‹•—’‹‡’‘•‹–‹‘—†‡”‰‡‡”ƒŽƒ‡•–Š‡•‹ƒǤ—‡• ‡– Ž‹’‘•— –‹‘‹•’‡”ˆ‘”‡†‹‘•–’ƒ–‹‡–•Ǥ‹’‘•— –‹‘‹•”‘—–‹‡Ž›’‡”ˆ‘”‡†‹–Š‡ ˆŽƒ•ƒ†—’’‡”ƒ„†‘‡ǡƒ†–Š‡Ž‘™‡”ƒ„†‘‡‹•‡Ž‡ –‡† ƒ•‡•Ǥ  ˆ–‡”Ž‹’‘•— –‹‘ǡ–Š‡Ž‘™‡”ƒ„†‘‹ƒŽ•‡‰‡–‹•‹ ‹•‡† —”˜‹Ž‹‡ƒ”Ž›ˆ”‘–Š‡ ”‹‰Š–ƒ–‡”‹‘”•—’‡”‹‘”‹Ž‹ƒ •’‹‡–‘‹–• ‘–”ƒŽƒ–‡”ƒŽ ‘—–‡”’ƒ”–ǤŠ‡‹ ‹•‹‘‹•’Žƒ ‡† ͷǦ͹ •—’‡”‹‘”–‘–Š‡ƒ–‡”‹‘” ‘‹••—”‡ƒ† ƒ””‹‡†–Š”‘—‰Š–‘–Š‡Ž‡˜‡Ž‘ˆ–Š‡ ƒ–‡”‹‘””‡ –—••Š‡ƒ–ŠǤ‹‹Žƒ”–‘ ˆŽƒ’•—”‰‡”›ǡ ”ƒ‹ƒŽ—†‡”‹‹‰‘ˆ–Š‡ ’ƒ‹ —Ž—•‹•’‡”ˆ‘”‡†–‘–Š‡Ž‡˜‡Ž‘ˆ–Š‡š‹’Š‘‹†’”‘ ‡••ƒ†ƒŽ‘‰–Š‡ ‘•–ƒŽƒ”‰‹Ǥ Š‹Ž‡—†‡”‹‹‰ ”ƒ‹ƒŽŽ›ǡ–Š‡—„‹Ž‹ —•ƒ†‹–••–ƒŽƒ”‡‹†‡–‹ˆ‹‡†ǡ‹ ‹•‡†ǡƒ†ˆ”‡‡† ˆ”‘–Š‡—†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’ǤŠ‡‡š ‡••’ƒ‹ —Ž—•‹•‡š ‹•‡†ǡƒ†–Š‡™‘—†‹• Ž‘•‡†–‡’‘”ƒ”‹Ž›™‹–Š Žƒ’•ǤŠ‡‡™—„‹Ž‹ ƒŽ’‘•‹–‹‘‹•ƒ”‡†ƒ†‹ ‹•‡†ǡƒ† –Š‡—„‹Ž‹ ƒŽ•–ƒŽ‹•’—ŽŽ‡†–Š”‘—‰Šƒ†•—–—”‡†‹’Žƒ ‡Ǥ‡ –—•’Ž‹ ƒ–‹‘‹•’‡”ˆ‘”‡† ‹’ƒ–‹‡–•™Š‘Šƒ˜‡ƒ•‹‰‹ˆ‹ ƒ–”‡ –—•†‹ƒ•–ƒ•‹•™‹–Šƒ„†‘‹ƒŽ„—Ž‰‹‰ ’”‡‘’‡”ƒ–‹˜‡Ž›ȋ‹†‹ ƒ–‡†‹ˆ–Š‡”‡ –—•†‹ƒ•–ƒ•‹•‹•‘”‡–Šƒ•‡˜‡ ‡–‹‡–‡”•’‡” ‘”™‡‰‹ƒ‰—‹†‡Ž‹‡•ȋͺʹȌȌǤŠ‡ƒ„†‘‹ƒŽ†‡ˆ‡ –‹• Ž‘•‡†–Š‡•ƒ‡–Š”‡‡ǦŽƒ›‡”‡†™ƒ›

15 15 ƒ•†—”‹‰–Š‡ ˆŽƒ’’”‘ ‡†—”‡Ǥ™‘ Ž‘•‡†Ǧ•›•–‡•— –‹‘†”ƒ‹•ȋͳͺ ”‡ ŠȌƒ”‡ ’Žƒ ‡†—†‡”–Š‡—†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’Ǥ‘’”‘‰”‡••‹˜‡–‡•‹‘•—–—”‡•ƒ”‡—•‡†Ǥ ‘’”‡••‹‘‰ƒ”‡–•ƒ”‡™‘”ˆ‘”ˆ‘—”Ǧ•‹š™‡‡•’‘•–‘’‡”ƒ–‹˜‡Ž›Ǥ  

16 16 2 Aims

The overall aim of our studies was to assess the donor-site morbidity in DIEAP flap breast reconstructions – both objectively and subjectively. The problem statements (italic) and aims (bold) were as follows:  To close the DIEAP flap defect, the abdominal skin cranial to the flap has to be extensively undermined and mobilized. This process includes ligation of perforators and high-tension closure which could lead to ischemia and tissue necrosis. Laser Doppler perfusion imaging (LDPI) offers a microcirculatory tool which could provide a greater understanding of the perfusion dynamics in the undermined abdominal flap before, during, and after DIEAP flap surgery. Aim 1 Perform a LDPI study of the undermined abdominal flap to obtain more knowledge on perfusion dynamics and thereby predict areas susceptible to necrosis (paper I).

A growing body of literature has documented the decreased risk of secondary rectus muscle atrophy in DIEAP flap surgery compared with other abdominal flaps, however, only one study had used computed tomography (CT).(49) This study compared cross-sectional areas of the rectus muscles at the level of the umbilicus. Previous research from our Department has shown that iatrogenic muscle atrophy is greater both cranially and caudally to the donor-site.(83) A comparison of pre- and postoperative CT scans covering several abdominal zones would be beneficial determining rectus muscle morbidity. Aim 2 Use CT to compare pre- and postoperative rectus muscle measurements in zones covering different parts of the abdominal wall to determine rectus muscle morbidity (paper II).

Diastasis recti abdominis (DRA) is important for the abdominal contour and appearance. No previous studies have assessed changes to the DRA after DIEAP flap breast reconstruction. Aim 3 Use CT to compare pre- and postoperative DRA (paper II).  Varying degrees of hernia, abdominal bulging, seroma, and hematoma have been reported after DIEAP flap surgery.(47, 51, 84) CT enables the scrupulous evaluation of the abdominal wall for such postoperative changes. 

17 17 Aim 4 Use CT to assess the degree of hernia, abdominal bulging, seroma, and hematoma postoperatively (paper II).

The postoperative appearance of the donor-site is of major importance to the DIEAP flap patients. One study reported that having a simultaneous abdominoplasty (AP) is the main reason of choosing DIEAP flap breast reconstruction for many patients.(52) There is, however, a paucity of studies documenting patient-reported abdominoplasty outcomes and satisfaction after DIEAP flap surgery. Aim 5 Perform a questionnaire-based study to assess patient-reported abdominoplasty outcomes and satisfaction after DIEAP flap surgery (paper III).  The DIEAP flap abdominoplasty is designed to give an end result resembling an AP. The latter can be seen as the gold standard in terms of the donor-site closure. There are, however, several steps of an AP that are not routinely performed in DIEAP flap surgery. Recent studies suggest modifications of the DIEAP flap procedure to greater mimic an AP and thereby improve the abdominoplasty outcomes.(85-87) A comparison of patient- reported abdominoplasty outcomes could give an indication of the necessity of such modifications.  Aim 6 Compare patient-reported abdominoplasty outcomes of DIEAP flap and AP patients to determine the need to modify the DIEAP flap procedure (paper III).  DIEAP flap and AP patients represent two rather different patient groups. To better understand the results provided by completing aim 6, it is instrumental to compare general patient-reported outcome measures (PROM) and satisfaction. Aim 7 Compare general PROMs and satisfaction of DIEAP flap and AP patients (paper III).

18 18 3 Material and methods

Study design (paper I-III) Š‹•–Š‡•‹•‹•„ƒ•‡†‘–™‘’”‘•’‡ –‹˜‡ Ž‹‹ ƒŽ•–—†‹‡•ȋ’ƒ’‡” ƒ† Ȍǡƒ†‘‡ ”‡–”‘•’‡ –‹˜‡“—‡•–‹‘ƒ‹”‡Ǧ„ƒ•‡†•–—†›ȋ’ƒ’‡” ȌǤŽŽ•–—†‹‡•™‡”‡”‡‰‹•–‡”‡†ƒ† ’—„Ž‹•Š‡†‹–Š‡Ž‹‹ ƒŽ”‹ƒŽ•Ǥ‰‘˜†ƒ–ƒ„ƒ•‡ǣͲʹͶͺͳʹͺͶȋ’ƒ’‡” ȌǡͲʹͷ͸͵ͻ͹͹ ȋ’ƒ’‡” Ȍǡƒ†Ͳ͵ʹͲͻͳ͸͹ȋ’ƒ’‡” ȌǤ  Approvals (paper I-III) Š‡”‡•‡ƒ” Š’”‘–‘ ‘Ž‘ˆ’ƒ’‡” ™ƒ•ƒ’’”‘˜‡†„›–Š‡Ž‘ ƒŽ–Š‹ ƒŽ‘‹––‡‡ȋޔǢ ”‡ˆǤ‘ǤǦͲ͹Ͳ͹ͳƒȌƒ†‘”™‡‰‹ƒ‘ ‹ƒŽ ‹‡ ‡ƒ–ƒ‡”˜‹ ‡•ȋ‡“—ƒŽ•ƒ–ƒ”‘–‡ –‹‘ ˆˆ‹ ‹‡”ǢDz‡”•‘˜‡”‘„—†dzȌȋ”‡ˆǤ‘Ǥͳ͸ʹͷͺȀȌǤŠ‡”‡•‡ƒ” Š’”‘–‘ ‘Ž‘ˆ’ƒ’‡” ™ƒ• ƒ’’”‘˜‡†„›–Š‡Ž‘ ƒŽ–Š‹ ƒŽ‘‹––‡‡ȋ”‡ˆǤ‘ǤʹͲͳͶȀͳʹͲͺȀ•Þ”Ǧޕ–ȌǤ ’’Ž‹ ƒ–‹‘–‘Ž‘ ƒŽ–Š‹ ƒŽ‘‹––‡‡™ƒ•‘–•—„‹––‡†ˆ‘”’ƒ’‡” Ǥƒ–ƒ”‘–‡ –‹‘ ˆˆ‹ ‡”™ƒ•‘– ‘–ƒ –‡†ˆ‘”’ƒ’‡” ƒ† ǡ™Š‹ Š‹•†‹• —••‡†—†‡”Dz–Š‹ ƒŽ ‘•‹†‡”ƒ–‹‘•dzǤ  Power and sample size calculations (paper I-III) ’”‹‘”‹’‘™‡”ƒ†•ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•™‡”‡’‡”ˆ‘”‡†ˆ‘”’ƒ’‡” ǤŠ‡‡–Š‘†• ƒ†”‡•—Ž–•ƒ”‡†‡• ”‹„‡†‹Dz‡–Š‘†‘Ž‘‰‹ ƒŽ ‘•‹†‡”ƒ–‹‘•dzˆ‘”’ƒ’‡” ǤŽ‡ƒ•‡ƒŽ•‘•‡‡ Dz‘•–ǦŠ‘ ’‘™‡”ƒ†•ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•dzˆ‘”ƒ††‹–‹‘ƒŽ ƒŽ —Žƒ–‹‘•ƒ† †‹• —••‹‘•”‡‰ƒ”†‹‰–Š‹•’ƒ’‡”Ǥ  ’”‹‘”‹ƒ†•ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•™‡”‡‘–’‡”ˆ‘”‡†ˆ‘”’ƒ’‡” ƒ† Ǥ Ž‡ƒ•‡•‡‡Dz‘•–ǦŠ‘ ’‘™‡”ƒ†•ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•dzˆ‘” ƒŽ —Žƒ–‹‘•ƒ† †‹• —••‹‘•Ǥ  Patients (paper I-III) ƒ’‡” ‹ Ž—†‡†ʹͲ ˆŽƒ’’ƒ–‹‡–•‘’‡”ƒ–‡†‹ʹͲͲͺƒ†ʹͲͲͻǤ ƒ’‡” ‹ Ž—†‡†ͳͶ ˆŽƒ’’ƒ–‹‡–•‘’‡”ƒ–‡†‹ʹͲͳ͵ƒ†ʹͲͳͶǤ ƒ’‡” ‹ Ž—†‡†–™‘‰”‘—’•‘ˆ’ƒ–‹‡–•ǣͳȌDz ‰”‘—’dzǣ͵Ͷ•‡ ‘†ƒ”› ˆŽƒ’ „”‡ƒ•–”‡ ‘•–”— –‡†’ƒ–‹‡–•ǡƒ†ʹȌDz„†‘‹‘’Žƒ•–›‰”‘—’dzȋ‰”‘—’Ȍǣ͵Ͳ ’ƒ–‹‡–•ǤŠ‡ ˆŽƒ’’ƒ–‹‡–•™‡”‡‘’‡”ƒ–‡†‹–Š‡’‡”‹‘†ʹͲͲͲǦʹͲͲͶǡ™Š‹Ž‡–Š‡ ’ƒ–‹‡–•™‡”‡‘’‡”ƒ–‡†‹ʹͲͲʹƒ†ʹͲͲ͵ǤͺͷΨ’‡” ‡–ƒ‰‡ȋʹͻȀ͵ͶȌ‘ˆ–Š‡ ‰”‘—’ ƒ†͸͸ΨȋʹͲȀ͵ͲȌ‘ˆ–Š‡‰”‘—’ƒ•™‡”‡†–Š‡“—‡•–‹‘ƒ‹”‡•Ǥ ŽŽ ˆŽƒ’’ƒ–‹‡–•Šƒ†—†‡”‰‘‡ƒ•–‡ –‘›ƒ•ƒ”‡•—Ž–‘ˆ ƒ ‡”ƒ†—†‡”™‡– •‡ ‘†ƒ”›—‹Žƒ–‡”ƒŽ„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ‹Žƒ–‡”ƒŽ„”‡ƒ•–”‡ ‘•–”— –‹‘•ƒ†  ˆŽƒ’•—•‡†‹‘Ǧ„”‡ƒ•–”‡ ‘•–”— –‹‘•™‡”‡‡š Ž—†‡†ǤŽŽ•‘‡”••–‘’’‡†•‘‹‰ ˆ‘—”™‡‡•’”‹‘”–‘•—”‰‡”›Ǥ‘‡‘ˆ–Š‡ ˆŽƒ’’ƒ–‹‡–•‹’ƒ’‡” Šƒ†Ž‹’‘•— –‹‘ ’‡”ˆ‘”‡†Ǥ

19 19 ŽŽ’ƒ–‹‡–•Šƒ†ƒŽ‹’‘ —–ƒ‡‘—•‘˜‡”Šƒ‰‘ˆ–Š‡ƒ„†‘‡™‹–Šƒ‹‹—‘ˆ–™‘ ‡–‹‡–‡”•Ǥ”ƒ•’‘•‹–‹‘‘ˆ–Š‡—„‹Ž‹ —•™ƒ•’‡”ˆ‘”‡†‹ƒŽŽ’ƒ–‹‡–•Ǥ͹ͷΨȋͳͷȀʹͲȌ Šƒ†Ž‹’‘•— –‹‘ǡƒ†ͳͲΨȋʹȀʹͲȌŠƒ†”‡ –—•’Ž‹ ƒ–‹‘’‡”ˆ‘”‡†Ǥ  Statistical methods (paper I-III) –ƒ–‹•–‹ ƒŽƒƒŽ›•‹•ˆ‘”’ƒ’‡” ƒ† ™‡”‡’‡”ˆ‘”‡†—•‹‰ –ƒ–‹•–‹ •ʹͳǤͲ ȋ ǡ”‘ǡȌǡ™Š‹Ž‡•–ƒ–‹•–‹ ƒŽƒƒŽ›•‹•ˆ‘”’ƒ’‡” ™‡”‡’‡”ˆ‘”‡†—•‹‰  –ƒ–‹•–‹ •ʹͷǤͲȋ ǡ”‘ǡȌǤ‡ Š‘•‡ƒͷΨ•‹‰‹ˆ‹ ƒ ‡Ž‡˜‡ŽǤ ’ƒ’‡” ǡ PǦ˜ƒŽ—‡•„‡–™‡‡ͷΨƒ†ͳͲΨ™‡”‡‹–‡”’”‡–‡†ƒ•–”‡†•Ǥ ƒ–‡‰‘”‹ ƒŽ†ƒ–ƒ™‡”‡’”‡•‡–‡†ƒ•—„‡”ȋ’‡” ‡–ƒ‰‡•Ȍǡƒ† ‘–‹—‘—•†ƒ–ƒ™‡”‡ ’”‡•‡–‡†ƒ•‡ƒ•ȋ•–ƒ†ƒ”††‡˜‹ƒ–‹‘Ȍȋ‹ǦƒšȌ‹ˆ‘–‘–Š‡”™‹•‡•–ƒ–‡†Ǥ’‡ ‹ˆ‹  •–ƒ–‹•–‹ ƒŽ‡–Š‘†•‹–Š‡–Š”‡‡•–—†‹‡•™‡”‡ƒ•ˆ‘ŽŽ‘™•ǣ Paper I ‡ ƒ—•‡‘ˆ”‡’‡ƒ–‡†ƒ† Ž—•–‡”‡†‡ƒ•—”‡‡–•ǡŽ‹‡ƒ”‹š‡†‘†‡Ž•™‹–Šƒ”ƒ†‘ ‹–‡” ‡’–™‡”‡—•‡†Ǥ‡’ƒ”ƒ–‡•–ƒ–‹•–‹ ƒŽ‘†‡Ž•ˆ‘”‡ƒ Š‘ˆ–Š‡ˆ‘—”œ‘‡•™‡”‡ ‘†— –‡†ƒ†–Š‡•‡˜‡‘„•‡”˜ƒ–‹‘–‹‡•™‡”‡ƒ••‡••‡†ƒ•ƒˆ‹š‡†ˆƒ –‘”Ǥ‘”‡‘˜‡”ǡ •‡’ƒ”ƒ–‡•–ƒ–‹•–‹ ƒŽ‘†‡Ž•ˆ‘”‡ƒ Š‘ˆ–Š‡•‡˜‡‘„•‡”˜ƒ–‹‘–‹‡•™‡”‡ ‘†— –‡†ǡƒ† –Š‡ˆ‘—”œ‘‡•™‡”‡–Š‡ƒ••‡••‡†ƒ•ƒˆ‹š‡†ˆƒ –‘”Ǥ‘ˆ‡””‘‹ ‘””‡ –‹‘™ƒ•—•‡†‹ƒŽŽ ’ƒ‹”™‹•‡ ‘’ƒ”‹•‘•Ǥ Paper II ‡Žƒ–‡†•ƒ’Ž‡•™‡”‡ ‘’ƒ”‡†™‹–Š‘Ǧ’ƒ”ƒ‡–”‹ ‹Ž ‘š‘‹‰ƒ–‡•–Ǥ †‡’‡†‡–•ƒ’Ž‡•™‡”‡ ‘’ƒ”‡†™‹–ŠƒǦŠ‹–‡›U-–‡•–Ǥ‡ƒ”•‘ǯ• ‘””‡Žƒ–‹‘ –‡•–•™‡”‡ ‘†— –‡†–‘ ƒŽ —Žƒ–‡–Š‡ƒ••‘ ‹ƒ–‹‘„‡–™‡‡ǣȋͳȌ Šƒ‰‡•ƒ†”‡ –—• —• Ž‡ Šƒ‰‡•ǡƒ†ʹȌ Šƒ‰‡•ƒ† Ȁƒ‰‡Ǥ‘†›ƒ••‹†‡šȋ Ȍ‹•†‡ˆ‹‡†ƒ• „‘†›ƒ••ȋ‰Ȍ†‹˜‹†‡†„›–Š‡•“—ƒ”‡‘ˆ–Š‡„‘†›Š‡‹‰Š–ȋȌǤ Paper III ”†‹ƒŽ‡•–ȋ ƒƒȌ™ƒ•—•‡†ˆ‘” ‘’ƒ”‹•‘‘ˆ‘”†‹ƒŽ†ƒ–ƒǤ”‘••Ǧ–ƒ„—Žƒ–‹‘™ƒ• ’‡”ˆ‘”‡†–‘ ‘†— – ‹•Š‡”ǯ•‡šƒ ––‡•–ȋ™‹–Š ”‡‡ƒǦ ƒŽ–‘‡š–‡•‹‘Ȍƒ• ƒ’’”‘’”‹ƒ–‡Ǥ‹ Š‘–‘‘—•†ƒ–ƒ™‡”‡ƒƒŽ›œ‡†—•‹‰ƒǦŠ‹–‡›U-–‡•–Ǥ—‡”‹ ƒŽ †ƒ–ƒ™‡”‡ƒŽ•‘’”‹ƒ”‹Ž›ƒƒŽ›œ‡†—•‹‰ƒǦŠ‹–‡›UǦ–‡•–†—‡–‘Ž‘™•ƒ’Ž‡•‹œ‡ ƒ†Žƒ ‘ˆ‘”ƒŽ‹–›Ǥ—‡”‹ ƒŽ†ƒ–ƒ„‡‹‰‘”ƒŽŽ›†‹•–”‹„—–‡†™‡”‡ ‘’ƒ”‡†—•‹‰ ‹†‡’‡†‡–t-–‡•–Ǥ  Microcirculation (paper I) Š‡˜ƒ• —Žƒ”•›•–‡‹• ‘’‘•‡†‘ˆ–Š‡‹ ”‘ ‹” —Žƒ–‹‘ƒ†ƒ ”‘ ‹” —Žƒ–‹‘ǤŠ‡ ‹ ”‘ ‹” —Žƒ–‹‘ ‘•‹•–•‘ˆƒ”–‡”‹‘Ž‡•ȋ•ƒŽŽƒ”–‡”‹‡•Ȍǡ ƒ’‹ŽŽƒ”‹‡•ǡ˜‡—Ž‡•ȋ•ƒŽŽ˜‡‹•Ȍǡ ƒ†ƒ”–‡”‹‘˜‡‘—•ƒƒ•–‘‘•‡•ȋ•Š—–‹‰˜‡••‡Ž•Ȍȋ ‹‰Ǥ͹ȌǤŠ‡ƒ ”‘ ‹” —Žƒ–‹‘ ”‡’”‡•‡–•ƒŽŽ–Š‡Žƒ”‰‡”˜‡••‡Ž•ȋƒ”–‡”‹‡•ƒ†˜‡‹•ȌǤȋͺͺȌ–—†›‹‰–Š‡”‘Ž‡•‘ˆ–Š‡ ‹ ”‘ ‹” —Žƒ–‘”›•›•–‡ǡ–Š‡ ƒ’‹ŽŽƒ”‹‡•„”‹‰—–”‹–‹˜‡„Ž‘‘†–‘–Š‡–‹••—‡•ǡ™Š‡”‡ƒ•–Š‡ ƒ”–‡”‹‘Ž‡•ǡ˜‡—Ž‡•ǡƒ†ƒ”–‡”‹‘˜‡‘—•ƒƒ•–‘‘•‡•’Žƒ›ƒ‹’‘”–ƒ–”‘Ž‡‹ –Š‡”‘”‡‰—Žƒ–‹‘Ǥ

20 20  Fig. 7 Microcirculation. Blood travels through the arterioles (red), then capillaries, before draining into venules (blue). Used with kind permission from Perimed AB (Järfälla, Sweden)  Skin and cutaneous vasculature (paper I) —”•‹ ‘•‹•–•‘ˆ–™‘Žƒ›‡”•ǣͳȌ‡’‹†‡”‹•ȋͲǤͲ͸ǦͲǤ͸–Š‹ Ȍƒ†ʹȌ†‡”‹•ȋͳǦͶ –Š‹ ȌǤȋͺͻȌ’‹†‡”‹•‹•ƒƒ˜ƒ• —Žƒ”Žƒ›‡”ƒ‹Ž› ‘’‘•‡†‘ˆ‡”ƒ–‹‘ ›–‡•ǡ™Š‹Ž‡ †‡”‹•‹•ƒ˜ƒ• —Žƒ”Žƒ›‡”‘ˆ ‘‡ –‹˜‡–‹••—‡ ‘–ƒ‹‹‰˜‡••‡Ž•ǡ‡”˜‡•ǡŽ›’Šƒ–‹ •ǡ ƒ†ƒ†‡šƒŽ•–”— –—”‡•Ǥ ‘”’”ƒ –‹ ƒŽ’—”’‘•‡•ǡ–Š‡ —–ƒ‡‘—•˜ƒ• —Žƒ–—”‡™‹–Š‹‘—” •‹Šƒ•„‡‡†‹˜‹†‡†‹–‘ƒ•—’‡”ˆ‹ ‹ƒŽȋDz•—„’ƒ’‹ŽŽƒ”dzȌƒ†ƒ†‡‡’ȋDz•—„†‡”ƒŽdzȌ ’Ž‡š—•ǤȋͻͲȌŠ‡ˆ‘”‡”‹•’‘•‹–‹‘‡†‹–Š‡Š‹‰Š†‡”‹•ȂŒ—•–„‡Ž‘™–Š‡’ƒ’‹ŽŽƒ”› †‡”‹•ǤŠ‡Žƒ––‡”‹•’‘•‹–‹‘‡†‹–Š‡Ž‘™†‡”‹•ȂŒ—•–ƒ„‘˜‡–Š‡•—„ —–ƒ‡‘—•–‹••—‡•Ǥ ’‘”–ƒ–Ž›ǡ‡ƒ Š‘ˆ–Š‡ —–ƒ‡‘—•’Ž‡š—•‡•ƒ”‡‹–‡” ‘‡ –‡†„›˜‡”–‹ ƒŽŽ›‘”‹‡–‡† ˜‡••‡Ž•ƒ†Šƒ˜‡„›–Šƒ–ƒ•–”‘‰‡ˆˆ‡ –‘‡ƒ Š‘–Š‡”Ǥ  Laser Doppler perfusion imaging (LDPI) (paper I) ƒ’‡” ™ƒ•„ƒ•‡†‘–Š‡—•‡‘ˆ ǤŠ‹•‹•–”—‡–‹•ƒ†‡˜‡Ž‘’‡–‘ˆŽƒ•‡”‘’’Ž‡” ˆŽ‘™‡–”›ȋ ȌǤŠ‹Ž‡ Šƒ•ƒ’”‘„‡ƒˆˆ‹š‡†–‘–Š‡•‹ƒ†•–—†‹‡•„Ž‘‘†ˆŽ‘™ƒ–‘‡ •‹‰Ž‡•‹–‡ǡ ‹•’‘•‹–‹‘‡†ƒ–ƒ†‹•–ƒ ‡ƒ†•–—†‹‡•„Ž‘‘†ˆŽ‘™ƒ–—Ž–‹’Ž‡•‹–‡•ǤŠ‹• ‹•ƒ†‡’‘••‹„Ž‡„›ƒ‹–‡”ƒŽ‹””‘”–Šƒ–ƒ—–‘ƒ–‹ ƒŽŽ›‘˜‡•–Š‡Žƒ•‡”‹ƒ•–‡’™‹•‡ ˆƒ•Š‹‘ˆ”‘‘‡•‹–‡–‘ƒ‘–Š‡”ǤŠ‡–‡ Š‹“—‡Šƒ•„‡‡‡•–ƒ„Ž‹•Š‡†ƒ•ƒˆ‡ƒ•‹„Ž‡ƒ†

21 21 ”‡’”‘†— ‹„Ž‡‡–Š‘†ˆ‘”ƒ••‡••‡–‘ˆ —–ƒ‡‘—•’‡”ˆ—•‹‘™‹–ŠŽ‘™‹–”ƒǦƒ†‹–‡”Ǧ ‘„•‡”˜‡”˜ƒ”‹ƒ„‹Ž‹–›ǤȋͻͳǡͻʹȌŠ‡ ‘””‡Žƒ–‹‘ ‘‡ˆˆ‹ ‹‡–„‡–™‡‡ƒ –—ƒŽƒ†‡ƒ•—”‡† ’‡”ˆ—•‹‘Šƒ•„‡‡‹’”‡••‹˜‡Ž›Š‹‰ŠȋR αͲǤͻͻ͸Ȍ ‘ˆ‹”‹‰ƒŽ‹‡ƒ””‡Žƒ–‹‘•Š‹’Ǥȋͻ͵Ȍ  ‘–Š ƒ† ƒ”‡‘Ǧ‹˜ƒ•‹˜‡ƒ†„ƒ•‡†‘–Š‡‘’’Ž‡”‡ˆˆ‡ –ǣŠ‡Žƒ•‡” „‡ƒ‡‹––‡†‹•• ƒ––‡”‡†ƒ†’ƒ”–Ž›ƒ„•‘”„‡†„›–Š‡–‹••—‡•Ǥ‹‰Š–Š‹––‹‰‘˜‹‰„Ž‘‘† ‡ŽŽ•—†‡”‰‘‡•ƒ‘’’Ž‡”•Š‹ˆ–ȋ Šƒ‰‡‘ˆˆ”‡“—‡ ›Ȍǡ™Š‹Ž‡Ž‹‰Š–Š‹––‹‰•–ƒ–‹ ‘„Œ‡ –•‹• — Šƒ‰‡†Ǥ‡ˆŽ‡ –‡†Ž‹‰Š–‹•’‹ ‡†—’„›ƒ†‡–‡ –‘”ǡ ‘˜‡”–‡†‹–‘‡Ž‡ –”‘‹ •‹‰ƒŽ•ǡ ‘””‡ –‡†ȋ‡Ǥ‰Ǥ•›•–‡‘‹•‡ƒ†Žƒ•‡”ƒ‰Ž‡Ȍǡƒ†’”‘ ‡••‡†–‘ ”‡ƒ–‡ƒ ‘Ž‘”Ǧ ‘†‡† ’‡”ˆ—•‹‘ƒ’ǤȋͻͶǡͻͷȌ••— Šǡ–Š‡•’ƒ–‹ƒŽŠ‡–‡”‘‰‡‡‹–›‘ˆ–Š‡–‹••—‡’‡”ˆ—•‹‘‹• •Š‘™Ǥ  ‹‡’‹š‡Ž•‘ˆƒ’Š‘–‘‰”ƒ’Šǡ–Š‡ ‘Ž‘”Ǧ ‘†‡†’‡”ˆ—•‹‘ƒ’‹•ƒ†‡—’„› —Ž–‹’Ž‡‹†‹˜‹†—ƒŽ‡ƒ•—”‡‡–•”‡ˆŽ‡ –‹‰–Š‡•–‡’™‹•‡‘˜‡‡–‘ˆ–Š‡Žƒ•‡”Ǥƒ Š •–‡’ȋƒ’’”‘š‹ƒ–‡Ž›͵‹™‹†–ŠȌ ƒŽ —Žƒ–‡•–Š‡’‡”ˆ—•‹‘ƒ–‹–••’‡ ‹ˆ‹ •‹–‡Ǥȋͻ͸ȌŠ‡ †‡‰”‡‡‘ˆ‘’’Ž‡”Ǧ•Š‹ˆ–‡†’Š‘–‘•”‡ˆŽ‡ –•–Š‡„Ž‘‘† ‘ ‡–”ƒ–‹‘ƒ†–Š‡ƒ‰‹–—†‡‘ˆ –Š‡‘’’Ž‡”•Š‹ˆ––Š‡ˆŽ‘™˜‡Ž‘ ‹–›Ǥȋͻͳǡͻ͹ȌŠ‹•‹•—•‡†„›–Š‡ ‘’—–‡”–‘ ƒŽ —Žƒ–‡ „Ž‘‘†’‡”ˆ—•‹‘™Š‹ Š‹•‰‹˜‡ƒ•ƒ—„‡”‘ˆDz’‡”ˆ—•‹‘—‹–•dzȋȌǤŠ‹•‹•ƒ ƒ”„‹–”ƒ”›—‹–™Š‹ Š ƒ‘–„‡–”ƒ•Žƒ–‡†‹–‘ƒƒ„•‘Ž—–‡’‡”ˆ—•‹‘˜ƒŽ—‡ȋ‡Ǥ‰Ǥ Ȁ‹ȀͳͲͲ‰”ƒ–‹••—‡ȌǤŠ‡”‡‹•ǡŠ‘™‡˜‡”ǡƒ†‘ —‡–‡†Ž‹‡ƒ”‹–›„‡–™‡‡• ‡ƒ•—”‡†ƒ†–”—‡„Ž‘‘†’‡”ˆ—•‹‘ǤȋͻͺȌ  Š‡‡ƒ•—”‡‡–†‡’–Š‘ˆ–Š‡ •›•–‡‹•Ž‹‹–‡†–‘–Š‡•‹‘Ž›ǤŠ‡ ‹•–”—‡–—•‡†‹‘—”•–—†›Šƒ•ƒ• ƒ†‡’–Š‘ˆͲǤͷǦͳǤȋͻ͹ǡͻͺȌŠ‡•’”‘˜‹†‡† †‘ǡ‹‘–Š‡”™‘”†•ǡ”‡’”‡•‡––Š‡„Ž‘‘†’‡”ˆ—•‹‘‹–Š‡‹ ”‘˜ƒ• —Žƒ”•›•–‡ȋ‘––Š‡ •—„ —–ƒ‡‘—•ƒ ”‘˜ƒ• —Žƒ”•›•–‡ȌǤȋͻ͹Ȍ ˆƒ –ǡ„ƒ•‡†‘–Š‡• ƒ†‡’–Šǡ‹–‹•–Š‡ •—’‡”ˆ‹ ‹ƒŽȋDz•—„’ƒ’‹ŽŽƒ”dzȌ’Ž‡š—•’‡”ˆ—•‹‘™Š‹ Š‹•ƒ‹Ž›•–—†‹‡†ǤŠ‡• ƒ†‡’–Š‹• †‡’‡†‡–‘•‡˜‡”ƒŽ–‹••—‡’”‘’‡”–‹‡•Ȃ•— Šƒ••‹–Š‹ ‡••ǡ ƒ’‹ŽŽƒ”›„‡††‡•‹–›ǡ ƒ†„Ž‘‘†‘š›‰‡•ƒ–—”ƒ–‹‘Ǥȋͻ͹ǡͻͺȌ   LDPI measurements and calculations (paper I) ŽŽ‡ƒ•—”‡‡–•™‡”‡’‡”ˆ‘”‡†™‹–Š–Š‡•ƒ‡ ‹•–”—‡–ȋ ͵ǡ‡”‹‡†ǡ ¡”ˆ¡ŽŽƒǡ™‡†‡ȌǤŠ‡‹•–”—‡– ‘–ƒ‹•ƒŽ‘™’‘™‡”Žƒ•‡”ȋ Žƒ••ʹȌ–Šƒ–‡•—”‡•–Šƒ– ‘ƒ††‹–‹‘ƒŽ•ƒˆ‡–›’”‡ ƒ—–‹‘•ƒ”‡‡ ‡••ƒ”›ǤŠ‡Žƒ•‡”„‡ƒ ƒ—•‡•‘’ƒ–‹‡– †‹• ‘ˆ‘”–Ǥ  ‘—”•–—†›ǡ–Š‡†‹•–ƒ ‡ˆ”‘–Š‡Žƒ•‡”Š‡ƒ†–‘–Š‡•‹™ƒ••‡–ƒ–͵ͷ ‡–‹‡–‡”•ǡƒ†–Š‡”‡•‘Ž—–‹‘™ƒ•’Žƒ ‡†ƒ–ƒŽ‘™”ƒ‰‡ǤŽ‘™”ƒ‰‡”‡•‘Ž—–‹‘‡ƒ• –Šƒ––Š‡‡ƒ•—”‡‡–™‹†–Šȋ’‡”•–‡’Ȍ‹•ƒ’’”‘š‹ƒ–‡Ž›͵ǤŠ‡„”‘ƒ†‡”–Š‡ ‡ƒ•—”‡‡–™‹†–Šǡ–Š‡Ž‘™‡”–Š‡”‡•‘Ž—–‹‘ǤȋͻͺȌ

22 22  –‡”•‘ˆ‡š’‡”‹‡–ƒŽ ‘†‹–‹‘•ǡ–Š‡—†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’™ƒ•Ž‡ˆ– —†‹•–—”„‡†ƒ–Ž‡ƒ•––‡‹—–‡•„‡ˆ‘”‡‡ƒ Š• ƒǡƒ†‡ˆˆ‘”–™ƒ•ƒ†‡–‘‡‡’Ž‹‰Š–ƒ† –‡’‡”ƒ–—”‡ȋʹʹιȌ ‘†‹–‹‘• ‘•–ƒ–Ǥ  ‡˜‡• ƒ•™‡”‡’‡”ˆ‘”‡†ˆ‘”‡ƒ Š’ƒ–‹‡–ǣͳȌ”‡‘’‡”ƒ–‹˜‡ǡʹȌˆ–‡””ƒ‹•‹‰ –Š‡ˆŽƒ’ǡ͵Ȍˆ–‡”—†‡”‹‹‰ǡͶȌˆ–‡”ƒ„†‘‹ƒŽ Ž‘•—”‡ǡͷȌ‘•–‘’‡”ƒ–‹˜‡†ƒ›ͳǡ͸Ȍ ‘•–‘’‡”ƒ–‹˜‡†ƒ›͵ǡƒ†͹Ȍ‘•–‘’‡”ƒ–‹˜‡†ƒ›͹ǤƒŽ‹„”ƒ–‹‘™ƒ•’‡”ˆ‘”‡†ƒˆ–‡”‡ƒ Š ‡ƒ•—”‡‡–Ǥ  ƒ–ƒƒ “—‹•‹–‹‘ƒ† ƒŽ —Žƒ–‹‘•™‡”‡’‡”ˆ‘”‡†—•‹‰–Š‡•‘ˆ–™ƒ”‡ ™‹ ͵Ǥͳȋ‡”‹‡†ǡ ¡”ˆ¡ŽŽƒǡ™‡†‡ȌǤŠ‡•–ƒ†ƒ”†‹œ‡†œ‘‡•†‡• ”‹„‡†„‡Ž‘™™‡”‡ ƒ’’Ž‹‡†‹–Š‡•‘ˆ–™ƒ”‡Ǥƒ”ƒ‡–‡”••— Šƒ•–Š‡—„‡”‘ˆ‡ƒ•—”‡‡–’‘‹–•ƒ† ‡ƒ•™‡”‡–Š‡ ƒŽ —Žƒ–‡†ǤŠ‡•ƒŽŽ‡•–—„‡”‘ˆ‡ƒ•—”‡‡–’‘‹–•™‹–Š‹ƒ œ‘‡™ƒ•͸ͳȋœ‘‡ͳ‹‘‡’ƒ–‹‡–ȌǤ  Standardized zones (paper I) ‡™ƒ–‡†–‘‘‹–‘”•’ƒ–‹ƒŽƒ†–‡’‘”ƒŽ‹ ”‘ ‹” —Žƒ–‘”› Šƒ‰‡•‹–Š‡ —†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’„‡ˆ‘”‡ǡ†—”‹‰ǡƒ†ƒˆ–‡”–Š‡ ˆŽƒ’’”‘ ‡†—”‡Ǥ ‘—” œ‘‡•ȋœ‘‡•ͳǦͶǢ ”ƒ‹ƒŽ–‘ ƒ—†ƒŽȌ™‡”‡•–ƒ†ƒ”†‹œ‡†‹–Š‡ •‘ˆ–™ƒ”‡—•‹‰ˆ‘—” ”‡ˆ‡”‡ ‡Ž‹‡•ǣͳȌǣƒ˜‡”–‹ ƒŽŽ‹‡ˆ”‘–Š‡š‹’Š‘‹†’”‘ ‡••–‘–Š‡ ƒ—†ƒŽ„‘”†‡”‘ˆ–Š‡ —†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’ǡʹȌǣƒŠ‘”‹œ‘–ƒŽŽ‹‡†‹˜‹†‹‰‹–™‘ŠƒŽ˜‡•ǡ͵Ȍǣƒ ˜‡”–‹ ƒŽŽ‹‡–Š”‘—‰Š–Š‡‹–‡”•‡ –‹‘‘ˆŽ‹‡ƒ†–Š‡ ‘•–ƒŽƒ”‰‹ǡƒ†ͶȌǣƒ Š‘”‹œ‘–ƒŽŽ‹‡’ƒ”ƒŽŽ‡Ž–‘–Š‡ ƒ—†ƒŽ„‘”†‡”‘ˆ–Š‡ƒ„†‘‹ƒŽˆŽƒ’Ǥ‡‡ ‹‰—”‡•ͺƒ†ͻǤ

Fig. 8 The standardized zones 1-4. “Intensity” showing the four standardized zones and reference lines made in the LDPI software (on a grayscale clinical photograph). “Perfusion” showing the four zones superimposed upon the corresponding, color-coded perfusion map.

 ŽŽˆ‘—”œ‘‡•™‡”‡•‹–—ƒ–‡†ƒ”‘—†–Š‡ƒ„†‘‹ƒŽ‹†Ž‹‡ƒ††‹†‘–‹ Ž—†‡ –Š‡‘•–Žƒ–‡”ƒŽƒ”‡ƒ•‘ˆ–Š‡—†‡”‹‡†•‹Ǥ••— Šǡ–Š‡•–ƒ†ƒ”†‹œ‡†œ‘‡• ‘˜‡”‡† Dzœ‘‡ͳdz‘ˆ–Š‡˜ƒ• —Žƒ”–‡””‹–‘”‹‡•‘ˆ–Š‡ƒ„†‘‡†‡• ”‹„‡†„› —‰‡”ǤȋͻͻȌŠ‹•™ƒ• †‘‡†‡Ž‹„‡”ƒ–‡Ž›–‘‹ Ž—†‡‡ƒ•—”‡‡–•™Š‡”‡–Š‡Žƒ•‡”„‡ƒ‹–‡”•‡ –•–Š‡•‹ •—”ˆƒ ‡‘”‡‘”Ž‡••’‡”’‡†‹ —Žƒ”Ž›Ǥ˜‡†ƒ‡–ƒŽǤŠƒ˜‡’”‡˜‹‘—•Ž›†‡‘•–”ƒ–‡†–Šƒ–  ˜ƒŽ—‡••–ƒ›ƒŽ‘•–‡“—‹˜ƒŽ‡–—–‹Ž–Š‡ƒ‰Ž‡‘ˆ‹ Ž‹ƒ–‹‘ȋ•Ž‘’‡‘ˆ–Š‡•‹

23 23 •—”ˆƒ ‡Ȍ‡š ‡‡†•͵ͺιǤ‡›‘†–Š‹•‹ Ž‹ƒ–‹‘ǡ‹–‹•‹ ”‡ƒ•‹‰Ž›†‹ˆˆ‹ —Ž––‘‘„–ƒ‹˜ƒŽ‹† ‡ƒ•—”‡‡–•ǤȋͻʹȌ 

Fig. 9 LDPI set-up: Intraoperative photo illustrating the LDPI machine situated 35 cm above the abdomen, and the four standardized zones marked directly on the patient (which was done for illustrative purposes). Photo: Dr. Tyge Tind Tindholdt

Standardized zones (paper II) ‡™ƒ–‡†–‘ ‘’ƒ”‡–Š‡’”‡‘’‡”ƒ–‹˜‡ƒ†’‘•–‘’‡”ƒ–‹˜‡ƒ„†‘‹ƒŽ™ƒŽŽ‹•‡˜‡”ƒŽ œ‘‡•Ȃ‹ Ž—†‹‰œ‘‡• ”ƒ‹ƒŽŽ›ƒ† ƒ—†ƒŽŽ›–‘–Š‡†‘‘”Ǧ•‹–‡Ǥ ‘—”œ‘‡•ȋ–”ƒ•˜‡”•‡ •‡ –‹‘•Ȍǡƒ‡†œ‘‡•Ǧǡ™‡”‡•–ƒ†ƒ”†‹œ‡†ǣͳȌ‘‡ǣͷ  ”ƒ‹ƒŽ–‘–Š‡—„‹Ž‹ —•ǡ ʹȌ‘‡ǣ—„‹Ž‹ ƒŽœ‘‡ǡ͵Ȍ‘‡ǣ ‡–”ƒŽœ‘‡ȋ‹†™ƒ›„‡–™‡‡œ‘‡•ƒ†Ȍǡƒ† ͶȌ‘‡ǣͷ  ”ƒ‹ƒŽ–‘–Š‡’—„‹ •›’Š›•‹•Ǥ ‹‰—”‡ͳͲ‹ŽŽ—•–”ƒ–‡•–Š‡Ž‘ ƒ–‹‘‘ˆ‡ƒ Š œ‘‡Ǥ

24 24 Fig. 10 The standardized zones A-D. Illustration: Dr. Christoffer Aam Ingvaldsen

Computed tomography (CT) (paper II) –—†› ™ƒ•„ƒ•‡†‘„‘–Š”‘—–‹‡ǡ’”‡‘’‡”ƒ–‹˜‡ ‘’—–‡†–‘‘‰”ƒ’Š›ƒ‰‹‘‰”ƒ’Š› ȋȌƒ†•–—†›Ǧ•’‡ ‹ˆ‹ ǡ’‘•–‘’‡”ƒ–‹˜‡Ǥ ‘•–’”‡˜‹‘—•ƒƒ–‘‹ ƒŽ•–—†‹‡•‘†‘‘”Ǧ•‹–‡‘”„‹†‹–›‹ˆ”‡‡ƒ„†‘‹ƒŽˆŽƒ’• Šƒ˜‡„‡‡’‡”ˆ‘”‡†—•‹‰—Ž–”ƒ•‘‘‰”ƒ’Š›ǤȋͶͺǡͺ͵ǡͳͲͲȌ‘’ƒ”‡†™‹–Š —Ž–”ƒ•‘‘‰”ƒ’Š›ǡ‡ƒ„Ž‡•ƒ‘”‡†‡–ƒ‹Ž‡†‡˜ƒŽ—ƒ–‹‘‘ˆ•–”— –—”ƒŽ ‘’‘‡–• ȋ†‹”‡ –Ž›ƒ†‹†‹”‡ –Ž›Ȍƒˆˆ‡ –‡†‹ˆŽƒ’Šƒ”˜‡•–‹‰Ǥ‹•ƒŽ•‘ƒ“—‹ ‡”ƒ†‘”‡ ƒ —”ƒ–‡‘†ƒŽ‹–›™Š‡ƒ••‡••‹‰–Š‡ƒ„†‘‹ƒŽ™ƒŽŽˆ‘”Š‡”‹ƒƒ†ƒ„†‘‹ƒŽ„—Ž‰‹‰ Ȃ‡•’‡ ‹ƒŽŽ›‹‘„‡•‡’ƒ–‹‡–•ǤȋͳͲͳȌ  Š‡’”‡‘’‡”ƒ–‹˜‡• ƒ•ǡ—•‡†–‘†‡Ž‹‡ƒ–‡–Š‡–‘’‘‰”ƒ’Š›‘ˆ–Š‡’‡”ˆ‘”ƒ–‘”•ǡ ‘˜‡”‡†–Š‡ƒ„†‘‹ƒŽ™ƒŽŽˆ”‘–Š‡•‡ ‘†Ž—„ƒ”˜‡”–‡„”ƒ–‘–Š‡’—„‹ •›’Š›•‹•Ǥ

25 25 Š‡›™‡”‡’‡”ˆ‘”‡†‹•—’‹‡’‘•‹–‹‘ǡƒ†–Š‡’ƒ–‹‡–•™‡”‡‹•–”— –‡†‘––‘ ‘–”ƒ ––Š‡ƒ„†‘‹ƒŽ—• Ž‡•ǤŠ‡’”‡‘’‡”ƒ–‹˜‡• ƒ•™‡”‡ ‘–”ƒ•–‡Šƒ ‡†Ǥ  Š‡’‘•–‘’‡”ƒ–‹˜‡• ƒ•™‡”‡’‡”ˆ‘”‡†ƒ’’”‘š‹ƒ–‡Ž›–™‘›‡ƒ”•ƒˆ–‡”–Š‡ „”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ‡ƒˆ‘ŽŽ‘™Ǧ—’–‹‡™ƒ•ʹ͵Ǥͷ‘–Š•ȋ‹ǦƒšǣͳͻǦʹ͸ȌǤŠ‡•‡ • ƒ•™‡”‡‡š–‡†‡† ”ƒ‹ƒŽŽ›Ȃ•–ƒ”–‹‰ˆ”‘–Š‡š‹’Š‘‹†’”‘ ‡••–‘–Š‡’—„‹  •›’Š›•‹•ǤŠ‡’ƒ–‹‡–•™‡”‡‰‹˜‡•‹‹Žƒ”‹•–”— –‹‘•ƒ•–Š‡’”‡‘’‡”ƒ–‹˜‡• ƒ•ǤŠ‡ ’‘•–‘’‡”ƒ–‹˜‡• ƒ•™‡”‡‘Ǧ ‘–”ƒ•–‡Šƒ ‡†ƒ†ƒ “—‹”‡†™‹–Š–Š‡•ƒ‡‹ƒ‰‡ ’ƒ”ƒ‡–‡”•–‘ƒ Š‹‡˜‡ƒ•‹†‡–‹ ƒŽ‹ƒ‰‡•‡–•ƒ•’‘••‹„Ž‡Ǥ  ŽŽ• ƒ•™‡”‡’‡”ˆ‘”‡†‘—Ž–‹†‡–‡ –‘”•›•–‡•Ǥ™‘†‹ˆˆ‡”‡–ƒ Š‹‡•ǡ ‘‡͸ͶǦ”‘™•›•–‡ƒ†‘‡͵ʹͲǦ”‘™•›•–‡ǡ™‡”‡—•‡†Ǥ

Radiological assessment (paper II) ŽŽ‡ƒ•—”‡‡–•™‡”‡”‡ ‘”†‡†•‡’ƒ”ƒ–‡Ž›„›–™‘ ‘•—Ž–‹‰”ƒ†‹‘Ž‘‰‹•–•ǤŠ‡›™‡”‡ „Ž‹†‡†–‘–Š‡—„‡”•”‡ ‘”†‡†„›–Š‡‹” ‘ŽŽ‡ƒ‰—‡ƒ†–Š‡•‹†‡‘ˆ•—”‰‡”›Ǥ  Š‡ˆ‘ŽŽ‘™‹‰–Š”‡‡ƒƒ–‘‹ ƒŽˆ‡ƒ–—”‡•™‡”‡‡ƒ•—”‡†„‹Žƒ–‡”ƒŽŽ›ƒ ‘”†‹‰–‘ –Š‡ˆ‘—”•–ƒ†ƒ”†‹œ‡†œ‘‡•†‹• —••‡†ƒ„‘˜‡ǣͳȌ–‡”‘’‘•–‡”‹‘”†‹ƒ‡–‡”ȋȌ‘ˆ–Š‡ ”‡ –—•—• Ž‡ǡʹȌ”ƒ•˜‡”•‡†‹ƒ‡–‡”ȋȌ‘ˆ–Š‡”‡ –—•—• Ž‡ǡƒ†͵Ȍ ƒ–Žƒ›‡” –Š‹ ‡••ȋŽƒ”‰‡•–ƒ–‡”‘’‘•–‡”‹‘”†‹•–ƒ ‡ȌǤ‹ƒ•–ƒ•‹•”‡ –‹ƒ„†‘‹‹•ȋȌ™ƒ• ‡ƒ•—”‡†‹–Š‡‹†Ž‹‡‹‡ƒ Š‘ˆ–Š‡ˆ‘—”œ‘‡•Ǥ  ƒ††‹–‹‘ǡ–Š‡ƒ„†‘‹ƒŽ™ƒŽŽ•™‡”‡• ”‡‡‡†ˆ‘”‘–Š‡”•‹‰•‘ˆ†‘‘”Ǧ•‹–‡ ‘”„‹†‹–›ȋ•— Šƒ•Š‡”‹ƒ•ǡ„—Ž‰‹‰ǡ•‡”‘ƒ•ǡƒ†Š‡ƒ–‘ƒ•ȌǤ

Questionnaires (paper III) ƒ’‡” ™ƒ•„ƒ•‡†‘–™‘•–—†›Ǧ•’‡ ‹ˆ‹ “—‡•–‹‘ƒ‹”‡•™Š‹ Š ‘˜‡”‡†ƒ„†‘‹ƒŽƒ† ‰‡‡”ƒŽ•Ǥ‘–ŠŠƒ†“—‡•–‹‘•™‹–Š†‹ Š‘–‘‘—•ȋDz›‡•dz‘”Dz‘dzȌǡ‘”†‹ƒŽȋ‡Ǥ‰Ǥ DzŽ‡••dzǡDz— Šƒ‰‡†dzǡDz‘”‡dzȌǡƒ†—‡”‹ ƒŽȋ‡Ǥ‰ǤͳǦͳͲȌƒ•™‡”ƒŽ–‡”ƒ–‹˜‡•Ǥ   Š‡“—‡•–‹‘ƒ‹”‡•™‡”‡’‹Ž‘–‡†‹ˆ‹˜‡’ƒ–‹‡–•ǤŠ‹•ƒ –‡†ƒ•ƒ ‘–”‘Ž‡ƒ•—”‡ ˆ‘”Žƒ‰—ƒ‰‡ǡ—†‡”•–ƒ†‹‰ǡƒ††‹ˆˆ‹ —Ž–›‹ƒ•™‡”‹‰–Š‡˜ƒ”‹‘—•“—‡•–‹‘•Ǥƒ–‹‡–• †‹†‘–”‡’‘”–ƒ›‹•—†‡”•–ƒ†‹‰Ǥ

26 26 4 Results

•—ƒ”›‘ˆ–Š‡ƒ‹”‡•—Ž–•‹••›•–‡‹œ‡†ƒ ‘”†‹‰–‘–Š‡ƒ‹•’”‡˜‹‘—•Ž›‘—–Ž‹‡†Ǥ

Aim 1 Perform a LDPI study of the undermined abdominal flap to obtain more knowledge on perfusion dynamics and thereby predict areas susceptible to necrosis (paper I). Results: Š‡ˆ‘ŽŽ‘™‹‰ ”‡•—Ž–•ƒ”‡†‹˜‹†‡†‹–‘’”‡‘’‡”ƒ–‹˜‡ǡ‹–”ƒ‘’‡”ƒ–‹˜‡ǡƒ† ’‘•–‘’‡”ƒ–‹˜‡ǤŠ‡’‡”ˆ—•‹‘†›ƒ‹ •ƒ”‡†‡’‹ –‡†‹ ‹‰ǤͳͳǤ Preoperative: ‡ƒ’‡”ˆ—•‹‘‹ ”‡ƒ•‡†•— ‡••‹˜‡Ž›‹ƒ ”ƒ‹ƒŽ–‘ ƒ—†ƒŽˆƒ•Š‹‘ȋœ‘‡ ͳδœ‘‡ʹδœ‘‡͵δœ‘‡ͶȌǤ‘‡•͵ƒ†ͶǡŽ‘ ƒ–‡† Ž‘•‡–‘–Š‡—„‹Ž‹ —•ǡŠƒ† •‹‰‹ˆ‹ ƒ–Ž›Š‹‰Š‡”’‡”ˆ—•‹‘ ‘’ƒ”‡†™‹–Šœ‘‡ͳǤ Intraoperative: ›”ƒ‹•‹‰–Š‡ˆŽƒ’ǡ–Š‡•‹’‡”ˆ—•‹‘‘ˆ–Š‡ƒ„†‘‹ƒŽˆŽƒ’ȋœ‘‡•ͳǦͶȌ ‹ ”‡ƒ•‡†•Ž‹‰Š–Ž›ǤŠ‹•™ƒ•ǡŠ‘™‡˜‡”ǡƒ‹•‹‰‹ˆ‹ ƒ–‹ ”‡ƒ•‡ ‘’ƒ”‡†™‹–Š ’”‡‘’‡”ƒ–‹˜‡˜ƒŽ—‡•Ǥ––Š‹•’‘‹–‘ˆ–Š‡’”‘ ‡†—”‡ǡ–Š‡ƒ„†‘‹ƒŽˆŽƒ’•‡‡‡†–‘„‡ —‹ˆ‘”Ž›’‡”ˆ—•‡†ƒ†‘•‹‰‹ˆ‹ ƒ–ǡ•’ƒ–‹ƒŽ†‹ˆˆ‡”‡ ‡•™‡”‡ˆ‘—†Ǥ  Š‡•—„•‡“—‡–—†‡”‹‹‰†‹†ǡ‘–Š‡‘–Š‡”Šƒ†ǡ ƒ—•‡†”ƒƒ–‹  Šƒ‰‡•–‘ –Š‡•‹’‡”ˆ—•‹‘ǣ‘‡•ͳǦ͵‹ ”‡ƒ•‡†•‹‰‹ˆ‹ ƒ–Ž›ǡ™Š‹Ž‡œ‘‡Ͷ†‡ ”‡ƒ•‡† ‹•‹‰‹ˆ‹ ƒ–Ž›ǤŠ‡”‡™‡”‡ƒ”‡†•’ƒ–‹ƒŽ†‹ˆˆ‡”‡ ‡•ƒ†œ‘‡ͳŠƒ†•‹‰‹ˆ‹ ƒ–Ž› Š‹‰Š‡”’‡”ˆ—•‹‘–Šƒ”‡ƒ‹‹‰œ‘‡•Ǥ•— ‡••‹˜‡†‡ ”‡ƒ•‡‘ˆ’‡”ˆ—•‹‘™ƒ••‡‡ ˆ”‘œ‘‡ͳ–‘œ‘‡Ͷȋœ‘‡ͳεœ‘‡ʹεœ‘‡͵εœ‘‡ͶȌǤŠ‡‡ƒ’‡”ˆ—•‹‘ ‡ƒ•—”‡†‹œ‘‡ͳƒˆ–‡”—†‡”‹‹‰™ƒ•–Š‡Š‹‰Š‡•––Š”‘—‰Š‘—––Š‡•–—†›Ǥ  ˆ–‡”–Š‡—†‡”‹‹‰Šƒ†„‡‡ ‘’Ž‡–‡†ƒ†–Š‡ ˆŽƒ’†‡ˆ‡ –™ƒ• Ž‘•‡†ǡ –Š‡”‡™ƒ•ƒƒ”‡††”‘’‘ˆ‡ƒ’‡”ˆ—•‹‘‹œ‘‡•ͳǦͶǤŠ‹•‹•™‡ŽŽ‹ŽŽ—•–”ƒ–‡†‹ ‹‰Ǥ ͳͳǤˆ–‡”ƒ„†‘‹ƒŽ Ž‘•—”‡ǡœ‘‡Ͷ”‡ƒ Š‡†‹–•Ž‘™‡•–‡ƒ’‡”ˆ—•‹‘ƒ†™ƒ• •‹‰‹ˆ‹ ƒ–Ž›Ž‘™‡” ‘’ƒ”‡†™‹–Šœ‘‡ͳǤ‘‡ͳǦ͵ǡŠ‘™‡˜‡”ǡŠƒ†–Š‡‹”Ž‘™‡•–‡ƒ ’‡”ˆ—•‹‘’”‡‘’‡”ƒ–‹˜‡Ž›Ǥ‘‡Ͷǯ•‡ƒ’‡”ˆ—•‹‘ƒˆ–‡”ƒ„†‘‹ƒŽ Ž‘•—”‡™ƒ•‘– •‹‰‹ˆ‹ ƒ–Ž›Ž‘™‡”–Šƒ‹–•’”‡‘’‡”ƒ–‹˜‡‡ƒ’‡”ˆ—•‹‘Ǥ Postoperative: ˜‡”ƒŽŽǡ–Š‡’‘•–‘’‡”ƒ–‹˜‡’‡”ˆ—•‹‘‘ˆ‡ƒ Šœ‘‡•–ƒ„‹Ž‹œ‡†ƒ–ƒ •‹‰‹ˆ‹ ƒ–Ž›Š‹‰Š‡”Ž‡˜‡Ž ‘’ƒ”‡†™‹–Š’”‡‘’‡”ƒ–‹˜‡˜ƒŽ—‡•Ǥ‘‡Ͷ†‹†ǡŠ‘™‡˜‡”ǡ ‘–‹—‡–‘„‡•‹‰‹ˆ‹ ƒ–Ž›Ž‘™‡”–Šƒœ‘‡ͳ‘’‘•–‘’‡”ƒ–‹˜‡†ƒ›ͳǤ’‘•–‘’‡”ƒ–‹˜‡ †ƒ›͵ƒ†͹ƒŽŽ•— Š•’ƒ–‹ƒŽ†‹ˆˆ‡”‡ ‡•™‡”‡‰‘‡Ǥ ‘–‹••—‡‡ ”‘•‹•™ƒ•‘„•‡”˜‡†‹ƒ›‘ˆ–Š‡’ƒ–‹‡–•Ǥ

27 27  Fig. 11 Perfusion dynamics. Graph illustrating mean perfusion units for each zone at times indicated above. POD = postoperative day

Aim 2 Use CT to compare pre- and postoperative rectus muscle measurements in zones covering different parts of the abdominal wall to determine rectus muscle morbidity (paper II). Results: Š‡ ‘’ƒ”‹•‘‘ˆƒ„†‘‹ƒŽ• ƒ••Š‘™‡†–Š‡ˆ‘ŽŽ‘™‹‰”‡ –—•—• Ž‡ Šƒ‰‡•‹ƒ–‡”‘’‘•–‡”‹‘”†‹ƒ‡–‡”ȋȌƒ†–”ƒ•˜‡”•‡†‹ƒ‡–‡”ȋȌƒ ‘”†‹‰–‘ –Š‡ˆ‘—”•–ƒ†ƒ”†‹œ‡†œ‘‡•ȋœ‘‡•ǦǢ ”ƒ‹ƒŽ–‘ ƒ—†ƒŽȌǣ

28 28 ͳȌ Š‡‘’‡”ƒ–‡†”‡ –—•—• Ž‡Šƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž›‹ ”‡ƒ•‡†‹œ‘‡•ƒ† ƒ††‡ ”‡ƒ•‡†‹œ‘‡ ‘’ƒ”‡†™‹–Š’”‡‘’‡”ƒ–‹˜‡‡ƒ•—”‡‡–•‘ˆ–Š‡ •ƒ‡”‡ –—•—• Ž‡ ʹȌ ‘•‹‰‹ˆ‹ ƒ– Šƒ‰‡•™‡”‡ˆ‘—† ‘’ƒ”‹‰’”‡Ǧƒ†’‘•–‘’‡”ƒ–‹˜‡• ƒ•‘ˆ–Š‡ ‘Ǧ‘’‡”ƒ–‡†”‡ –—•—• Ž‡• ͵Ȍ ‘’ƒ”‹‰–Š‡‘’‡”ƒ–‡†ƒ†–Š‡‘Ǧ‘’‡”ƒ–‡†”‡ –—•—• Ž‡•ǡ–Š‡ˆ‘”‡”Šƒ†ƒ •‹‰‹ˆ‹ ƒ–Ž›†‡ ”‡ƒ•‡†‹œ‘‡ ͶȌ ‘•‹‰‹ˆ‹ ƒ–”‡•—Ž–•™‡”‡ˆ‘—† ‘’ƒ”‹‰ƒ† Šƒ‰‡•‹ˆŽƒ’•„ƒ•‡† ‘‡‹–Š‡”ǣͳȌ‡’‡”ˆ‘”ƒ–‘”˜‡”•—•–™‘’‡”ˆ‘”ƒ–‘”•ǡ‘”ʹȌ‡†‹ƒŽ”‘™’‡”ˆ‘”ƒ–‘” ˜‡”•—•Žƒ–‡”ƒŽ”‘™’‡”ˆ‘”ƒ–‘”Ǥ

Aim 3 Use CT to compare pre- and postoperative DRA (paper II). Results: Š‡ ‘’ƒ”‹•‘‘ˆƒ„†‘‹ƒŽ• ƒ••Š‘™‡†–Š‡ˆ‘ŽŽ‘™‹‰ Šƒ‰‡• ƒ ‘”†‹‰–‘–Š‡ˆ‘—”•–ƒ†ƒ”†‹œ‡†œ‘‡•ȋœ‘‡•ǦǢ ”ƒ‹ƒŽ–‘ ƒ—†ƒŽȌ—•‡†ǣ ͳǤ —’”ƒ—„‹Ž‹ ƒŽȋœ‘‡Ȍ™ƒ••‹‰‹ˆ‹ ƒ–Ž›†‡ ”‡ƒ•‡†’‘•–‘’‡”ƒ–‹˜‡Ž› ʹǤ ˆ”ƒ—„‹Ž‹ ƒŽȋœ‘‡•ƒ†Ȍ™ƒ••‹‰‹ˆ‹ ƒ–Ž›‹ ”‡ƒ•‡†’‘•–‘’‡”ƒ–‹˜‡Ž› ͵Ǥ Š‡”‡™‡”‡‘•–ƒ–‹•–‹ ƒŽŽ›•‹‰‹ˆ‹ ƒ– ‘””‡Žƒ–‹‘•„‡–™‡‡ǣͳȌƒ†”‡ –—• —• Ž‡ Šƒ‰‡•ǡ‘”ʹȌ Šƒ‰‡•ƒ† Ȁƒ‰‡Ǥ

Aim 4 Use CT to assess the degree of hernia, abdominal bulging, seroma, and hematoma postoperatively (paper II). Results: ‘‡™Š‡”‹ƒ•ǡƒ„†‘‹ƒŽ„—Ž‰‹‰ǡ‘”Š‡ƒ–‘ƒ•™‡”‡ˆ‘—†Ǥ™‘’ƒ–‹‡–• ȋͳͶΨȌŠƒ†•‡”‘ƒˆ‘”ƒ–‹‘‹–Š‡ƒ„†‘‹ƒŽ™ƒŽŽǤŠ‡•‡”‘ƒ•†‹†‘–”‡“—‹”‡ƒ› ˆ—”–Š‡”•—”‰‹ ƒŽƒƒ‰‡‡–Ǥ 

Aim 5 Perform a questionnaire-based study to assess patient-reported abdominoplasty outcomes and satisfaction after DIEAP flap surgery (paper III). Results: ͷͻΨ‘ˆ–Š‡ ˆŽƒ’’ƒ–‹‡–•™‡”‡‘”‡•ƒ–‹•ˆ‹‡†™‹–Š–Š‡‹”ƒ„†‘‡ƒˆ–‡” •—”‰‡”›ǤͳͶΨ™‡”‡‘”‡†‹••ƒ–‹•ˆ‹‡†ǡƒ†ʹ͹Ψ™‡”‡‡‹–Š‡”‘”‡•ƒ–‹•ˆ‹‡†‘” †‹••ƒ–‹•ˆ‹‡†Ǥ

ƒ• ƒŽ‡ˆ”‘Ͳ–‘ͳͲǡ–Š‡ˆ‘ŽŽ‘™‹‰”‡•—Ž–•™‡”‡”‡’‘”–‡†ȋ‡ƒάȌǣ ͳȌ ƒ–‹•ˆƒ –‹‘™‹–Šƒ’’‡ƒ”ƒ ‡‘ˆ–Š‡ƒ„†‘‡ǣ͹Ǥ͹άʹǤͷ ȋͲα˜‡”›†‹••ƒ–‹•ˆ‹‡†ǡͳͲα˜‡”›•ƒ–‹•ˆ‹‡†Ȍ ʹȌ ƒ–‹•ˆƒ –‹‘™‹–Šƒ’’‡ƒ”ƒ ‡‘ˆ–Š‡—„‹Ž‹ —•ǣ͹Ǥ͸άʹǤͷ ȋͲα˜‡”›†‹••ƒ–‹•ˆ‹‡†ǡͳͲα˜‡”›•ƒ–‹•ˆ‹‡†Ȍ

29 29 ͵Ȍ „†‘‹ƒŽ™ƒŽŽ—• Ž‡ˆ— –‹‘ǣ͵ǤʹάʹǤͻ ȋͲᐑ”‡†— ‡†—• Ž‡ˆ— –‹‘ǡͳͲα ‘’Ž‡–‡Ž›Ž‘•–—• Ž‡ˆ— –‹‘Ȍ ͶȌ „†‘‹ƒŽ™ƒŽŽ’ƒ‹ǣʹǤͲάͳǤͶ ȋͲᐑ’ƒ‹ǡͳͲᕇ˜‡”‡’ƒ‹Ȍ ͷȌ ‘™„Ž‡‹•Š‹‰‹•–Š‡• ƒ””‹‰ǣͶǤͲά͵Ǥ͵ ȋͲᐑ–„Ž‡‹•Š‹‰ǡͳͲα˜‡”›„Ž‡‹•Š‹‰Ȍ –‡”•‘ˆƒ‘—–‘ˆ• ƒ””‹‰ǡͳ͹Ψ”‡’‘”–‡†DzŽ‡••–Šƒ‡š’‡ –‡†dzǡͷͻΨDzƒ•‡š’‡ –‡†dzǡ ƒ†ʹͶΨDz‘”‡–Šƒ‡š’‡ –‡†dzǤ –‡”•‘ˆ˜‹•‹„‹Ž‹–›‘ˆ• ƒ””‹‰ǡʹͶΨ”‡’‘”–‡†DzŽ‡••–Šƒ‡š’‡ –‡†dzǡͶͺΨDzƒ•‡š’‡ –‡†dzǡ ƒ†ʹͺΨDz‘”‡–Šƒ‡š’‡ –‡†dzǤ –‡”•‘ˆ Šƒ‰‡‘ˆƒ„†‘‹ƒŽ ‘–‘—”ǡ͸ʹΨ”‡’‘”–‡†Dz‘‡dzǡ͵ͺΨ”‡’‘”–‡† Dz„—Ž‰‹‰dzǡƒ†ͲΨ”‡’‘”–‡†DzŠ‡”‹ƒdzǤ

Aim 6 Compare patient-reported abdominoplasty outcomes of DIEAP flap and AP patients to determine the need to modify the DIEAP flap procedure (paper III). Results:ƒ• ƒŽ‡ˆ”‘ͲǦͳͲǡ–Š‡”‡™ƒ•ƒ–”‡†‘ˆ ˆŽƒ’’ƒ–‹‡–•„‡‹‰‘”‡ •ƒ–‹•ˆ‹‡†™‹–Š–Š‡ƒ’’‡ƒ”ƒ ‡‘ˆ–Š‡ƒ„†‘‡ ‘’ƒ”‡†–‘’ƒ–‹‡–•ȋPαͲǤͲͺͷȌǤ  –Š‡ ‘–”ƒ”›ǡ™Š‡ Š‘‘•‹‰„‡–™‡‡–Š‡‘”†‹ƒŽƒ•™‡”ƒŽ–‡”ƒ–‹˜‡•Dz›‡•dzǡ Dz‡‹–Š‡”›‡•‘”‘dzǡƒ†Dz‘dz‹ƒ•™‡”‹‰™Š‡–Š‡”–Š‡›™‡”‡‘”‡•ƒ–‹•ˆ‹‡†™‹–Š–Š‡ ƒ’’‡ƒ”ƒ ‡‘ˆƒ„†‘‡ƒˆ–‡”•—”‰‡”›ǡ•‹‰‹ˆ‹ ƒ ‡™ƒ•‘–”‡ƒ Š‡†ȋPαͲǤͷͳȌǤͷͻΨ‘ˆ –Š‡ ‰”‘—’™‡”‡‘”‡•ƒ–‹•ˆ‹‡† ‘’ƒ”‡†–‘ͷͲΨ‘ˆ–Š‡‰”‘—’ǤͳͶΨ‘ˆ–Š‡  ‰”‘—’™‡”‡‘–‘”‡•ƒ–‹•ˆ‹‡† ‘’ƒ”‡†–‘ʹͲΨ‘ˆ–Š‡‰”‘—’ǤŠ‡”‡ƒ‹‹‰ ’ƒ–‹‡–•ƒ•™‡”‡†Dz‡‹–Š‡”›‡•‘”‘dzǤ  ‘’ƒ”‹•‘•‘ˆ–Š‡‰”‘—’•›‹‡Ž†‡†‹•‹‰‹ˆ‹ ƒ–PǦ˜ƒŽ—‡• ‘ ‡”‹‰–Š‡ ƒ’’‡ƒ”ƒ ‡‘ˆ–Š‡—„‹Ž‹ —•ǡƒ„†‘‹ƒŽ™ƒŽŽ—• Ž‡ˆ— –‹‘ǡƒ„†‘‹ƒŽ™ƒŽŽ’ƒ‹ǡ • ƒ””‹‰ȋƒ‘—–ƒ†˜‹•‹„‹Ž‹–›Ȍǡƒ†ƒ„†‘‹ƒŽ ‘–‘—” Šƒ‰‡•Ǥ 

Aim 7 Compare general PROMs and satisfaction of DIEAP flap and AP patients (paper III). Results: –Š‡ ‘’ƒ”‹•‘•‘ˆ‰‡‡”ƒŽ•ǡ ˆŽƒ’’ƒ–‹‡–•™‡”‡•‹‰‹ˆ‹ ƒ–Ž› ‘”‡•ƒ–‹•ˆ‹‡†™‹–Š–Š‡‹”„‘†‹‡•™Š‡†”‡••‡†–Šƒ’ƒ–‹‡–•ȋPαͲǤͲͲͻȌǤͺ͸Ψ‘ˆ–Š‡  ‰”‘—’ƒ†ͷͷΨ‘ˆ–Š‡‰”‘—’ƒ•™‡”‡†–Šƒ––Š‡›ˆ‡Ž–•ƒ–‹•ˆ‹‡†Ǥ–Š‡‘–Š‡” Šƒ†ǡ–Š‡ ‰”‘—’™ƒ••‹‰‹ˆ‹ ƒ–Ž›‘”‡™‘””‹‡†ƒ„‘—––Š‡‹”Š‡ƒŽ–Š–Šƒ–Š‡ ‰”‘—’’‘•–‘’‡”ƒ–‹˜‡Ž›ȋPαͲǤͲ͵ͳȌǤ  ’ƒ–‹‡–•Šƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž›‘”‡ƒŽ–‡”‡†„‘†›‹ƒ‰‡–Šƒ ˆŽƒ’’ƒ–‹‡–• ȋPαͲǤͲͳ͸ȌǤ’ƒ–‹‡–•ƒŽ•‘• ‘”‡†Š‹‰Š‡”‹–‡”•‘ˆ•‡š—ƒŽ†‡•‹”‡ Šƒ‰‡•–Šƒ  ˆŽƒ’’ƒ–‹‡–•ȋPαͲǤͲͲ͵ȌǤ ˆƒ –ǡͶͲΨ‘ˆ’ƒ–‹‡–•”‡’‘”–‡†ƒDz‹’”‘˜‡†dz•‡š—ƒŽ †‡•‹”‡ ‘’ƒ”‡†–‘‘Ž›ͳͶΨ‘ˆ–Š‡ ˆŽƒ’’ƒ–‹‡–•Ǥ‘”‡‘˜‡”ǡͳ͹Ψ‘ˆ–Š‡  ‰”‘—’”‡’‘”–‡†ƒDz™‘”•‡dz•‡š—ƒŽ†‡•‹”‡ ‘’ƒ”‡†–‘ͲΨ‘ˆ–Š‡’ƒ–‹‡–•Ǥ  Š‡”‡™‡”‡‘•‹‰‹ˆ‹ ƒ–†‹ˆˆ‡”‡ ‡•”‡‰ƒ”†‹‰ Šƒ‰‡•‹•‡ŽˆǦ‹ƒ‰‡ǡ•‘ ‹ƒŽ

30 30 ”‡Žƒ–‹‘•Š‹’•ǡ„‡‹‰ƒ‡†™‹–Š’ƒ”–‡”ǡƒ†‘˜‡”ƒŽŽ•ƒ–‹•ˆƒ –‹‘Ǥ –‡”•‘ˆ–Š‡Žƒ––‡”ǡ ͻ͹Ψ‘ˆ ˆŽƒ’’ƒ–‹‡–•ƒ†ͳͲͲΨ‘ˆ’ƒ–‹‡–•™‘—Ž†Šƒ˜‡‰‘‡–Š”‘—‰Š–Š‡ •ƒ‡‘’‡”ƒ–‹‘ƒ‰ƒ‹ǡͻ͹Ψ‘ˆ ˆŽƒ’’ƒ–‹‡–•ƒ†ͺͷΨ‘ˆ’ƒ–‹‡–•™‡”‡‘˜‡”ƒŽŽ •ƒ–‹•ˆ‹‡†™‹–Š–Š‡‘’‡”ƒ–‹‘ǡƒ†ͻ͵Ψ‘ˆ ˆŽƒ’’ƒ–‹‡–•ƒ†ͻͷΨ‘ˆ’ƒ–‹‡–• ™‘—Ž†”‡ ‘‡†–Š‡‘’‡”ƒ–‹‘–‘‘–Š‡”’ƒ–‹‡–•Ǥ  ͻͲΨ‘ˆ–Š‡ ‰”‘—’ƒ†͹ͲΨ‘ˆ–Š‡‰”‘—’™‡”‡•ƒ–‹•ˆ‹‡†™‹–Š–Š‡ ’”‡‘’‡”ƒ–‹˜‡ ‘—•‡ŽŽ‹‰ǡ™Š‹ Š™‡”‡„› ‘’ƒ”‹•‘‹•‹‰‹ˆ‹ ƒ–Ž›†‹ˆˆ‡”‡–ȋPαͲǤ͵ͳȌǤ  

31 31 5 Discussion of main findings

Š‡ƒˆ‘”‡‡–‹‘‡†”‡•—Ž–•ƒ”‡‹–Š‡ˆ‘ŽŽ‘™‹‰–‡š––”ƒ•Žƒ–‡†‹–‘ƒ‹ˆ‹†‹‰•ǤŠ‡•‡ ˆ‹†‹‰•”‡ˆŽ‡ –™Šƒ–™‡„‡Ž‹‡˜‡ ‘—Ž†Šƒ˜‡ƒ‹’ƒ –‘ˆ—–—”‡ ˆŽƒ’•—”‰‡”›ƒ† ’ƒ–‹‡– ƒ”‡ǤŠ‡ˆ‹†‹‰•ƒ”‡†‹• —••‡†‹”‡Žƒ–‹‘–‘’—„Ž‹•Š‡†Ž‹–‡”ƒ–—”‡Ǥ  Paper I “The periumbilical skin is well perfused”.Š‡•‹‰‹ˆ‹ ƒ–Ž›Š‹‰Š‡”’”‡‘’‡”ƒ–‹˜‡ ’‡”ˆ—•‹‘‹œ‘‡•͵ƒ†Ͷȋ ‘’ƒ”‡†™‹–Šœ‘‡ͳȌ ‘ˆ‹”•–Š‡’”‡•‡ ‡‘ˆ†‘‹ƒ– ’‡”ˆ‘”ƒ–‘”•’‡”‹—„‹Ž‹ ƒŽŽ›ǤȋͶ͵ǡͳͲʹǡͳͲ͵ȌŠ‹•‹•ƒŽ•‘‹ŽŽ—•–”ƒ–‡†‹ ‹‰—”‡ͳʹ™Š‡”‡ †‘‹ƒ–ȋ‡†‹ƒŽȌ’‡”ˆ‘”ƒ–‘”•‘ˆ‡ƒ ŠŠ‡‹ƒ„†‘‡Šƒ˜‡„‡‡ƒ”‡†Ǥ  ›’‡”ˆ‘”‹‰ƒƒ–‘‹ ƒŽ†‹••‡ –‹‘•ǡ ‡‹–ƒ‡–ƒŽǤˆ‘—†–Šƒ––Š‡ƒŒ‘”‹–›‘ˆ †‘‹ƒ–’‡”ˆ‘”ƒ–‘”•ƒ”‡Ž‘ ƒ–‡†™‹–Š‹ƒ†‹•–ƒ ‡‘ˆ–™‘ ‡–‹‡–‡”•ˆ”‘–Š‡ —„‹Ž‹ —•ǤȋͶ͵Ȍ‘”‡‘˜‡”ǡ„›”‡˜‹‡™‹‰ͳͷͲŠ‡‹ƒ„†‘‡•‘ƒ‰‹‘‰”ƒ’Š›ƒ† ‡˜ƒŽ—ƒ–‹‰ƒŽŽ’‡”ˆ‘”ƒ–‘”•Žƒ”‰‡”–ŠƒʹǤͲǡƒƒ†‡–ƒŽǤ†‡‘•–”ƒ–‡†–Šƒ––Š‡Žƒ”‰‡•– ’‡”ˆ‘”ƒ–‘”ƒ”‘•‡ƒ–‘”„‡Ž‘™–Š‡—„‹Ž‹ —•‹͸ͻΨ‘ˆ–Š‡ ƒ•‡•™Š‹Ž‡–Š‡”‡ƒ‹‹‰͵ͳ Ψƒ”‘•‡ƒ„‘˜‡–Š‡—„‹Ž‹ —•ǤȋͳͲ͵ȌͻΨ™‡”‡‹ˆƒ –Ž‘ ƒ–‡†‘”‡–Šƒ–™‘ ‡–‹‡–‡”• ”ƒ‹ƒŽ–‘–Š‡—„‹Ž‹ —•Ȃ Ž‘•‡–‘–Š‡„‘”†‡”‘ˆœ‘‡•͵ƒ†Ͷ‹‘—”•–—†›ǤŠ‹•‹• ‹–‡”‡•–‹‰ƒ•–Š‡ ”ƒ‹ƒŽˆŽƒ’‹ ‹•‹‘‘”ƒŽŽ›‹•’Žƒ ‡†ƒ––Š‡˜‡”›—’’‡”„‘”†‡”‘ˆ–Š‡ —„‹Ž‹ —•ȋ‹ Ž—†‹‰Ž‹––Ž‡•—’”ƒ—„‹Ž‹ ƒŽ–‹••—‡ȌǤ ‘–Š‡”™‘”†•ǡ‡•’‡ ‹ƒŽŽ›„ƒ•‡†‘–Š‡ †ƒ–ƒ‘ˆƒƒ†‡–ƒŽǤǡ–Š‡•–ƒ†ƒ”† ˆŽƒ’‹ ‹•‹‘™‹ŽŽ’Žƒ ‡–Š‡Žƒ”‰‡•–’‡”ˆ‘”ƒ–‘”ƒ– –Š‡‡†‰‡‘ˆ‘”‘—–•‹†‡–Š‡ˆŽƒ’‹‘‡–Š‹”†‘ˆ–Š‡’ƒ–‹‡–•Ǥ•–ƒ†ƒ”† ˆŽƒ’†‡•‹‰ ‹–Š‡•‡’ƒ–‹‡–•‹‰Š–‹ ”‡ƒ•‡–Š‡”‹•‘ˆˆŽƒ’ ‘’Ž‹ ƒ–‹‘•ǤŠ‹••—„•‡–‘ˆ’ƒ–‹‡–• ‘—Ž†ǡ–Š‡”‡ˆ‘”‡ǡ„‡‡ˆ‹–ˆ”‘ƒ ”ƒ‹ƒŽŽ›•Š‹ˆ–‡† ˆŽƒ’†‡•‹‰Ǥ ˆ–Š‡DzŠ‹‰Š  ˆŽƒ’dz‹• Š‘•‡ǡ–Š‡•—’”ƒ—„‹Ž‹ ƒŽ•‹„”‹†‰‡•Š‘—Ž†’”‡•—ƒ„Ž›„‡’”‡•‡”˜‡†ȋ‘– •’Ž‹–ȌǤŽ‡ƒ•‡•‡‡DzŽ‹‹ ƒŽ‹’Ž‹ ƒ–‹‘•ƒ†ˆ—–—”‡”‡•‡ƒ” Šdzˆ‘”‘”‡–Š‘—‰Š–•‘–Š‹• ƒ––‡”Ǥ 

32 32

Fig. 12 Dominant medial perforator location. Graphical representation of dominant medial perforator location. The red dots indicate the individual perforator locations and the black dots represent the average perforator locations. Used with kind permission from Prof. M. Saint-Cyr (Divison of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, USA)

“Undermining can cause both an increase of perfusion (reactive hyperemia) and decrease of perfusion”.’‘•–Ǧ—†‡”‹‹‰”‡ƒ –‹˜‡Š›’‡”‡‹ƒŠƒ•’”‡˜‹‘—•Ž›„‡‡ ”‡’‘”–‡†„›ƒ”•‡–ƒŽǤȋ”ƒ–‘†‡ŽȌǡ›†‹ƒ†ƒ˜‹Ž‹ȋ”ƒ„„‹–‘†‡ŽȌǡƒ†ސ•‡–Šƒ† ‘Žƒ†ȋ’‘” ‹‡‘†‡ŽȌǤȋͳͲͶǦͳͲ͸Ȍ‡–ǡ‘—”•–—†›™ƒ•–Š‡ˆ‹”•––‘†‘ —‡––Š‹• Š›’‡”‡‹ ”‡•’‘•‡‹”‡‰ƒ”†•–‘ ˆŽƒ’•—”‰‡”›„›–Š‡—•‡‘ˆ Ǥ –™ƒ• •—’’‘”–‡†„›ˆ‹†‹‰•‹ƒ ˆŽƒ’”‡•‡ƒ” Šƒ”–‹ Ž‡„›‡”‰¤”†‡–ƒŽǤ’—„Ž‹•Š‡†‘‡ ›‡ƒ”ƒˆ–‡”ǤȋͳͲ͹Ȍ  Š‡‘„•‡”˜‡†’‘•–Ǧ—†‡”‹‹‰”‡ƒ –‹˜‡Š›’‡”‡‹ƒ”‡•‡„Ž‡•ǡ‹’ƒ”–ǡ–Š‡™‡ŽŽǦ ‘™’Š‡‘‡‘‘ˆ’‘•–Ǧ‘ Ž—•‹˜‡”‡ƒ –‹˜‡Š›’‡”‡‹ƒȋ ȌǤŠ‹•–‡””‡ˆ‡”•–‘ –Š‡‹ ”‡ƒ•‡‹ —–ƒ‡‘—•„Ž‘‘†ˆŽ‘™ƒ„‘˜‡„ƒ•‡Ž‹‡Ž‡˜‡Ž•ˆ‘ŽŽ‘™‹‰–Š‡”‡Ž‡ƒ•‡‘ˆƒ „”‹‡ˆƒ”–‡”‹ƒŽ‘ Ž—•‹‘ǤȋͳͲͺȌ  ǡƒ ‘’Ž‡š‹–‡”’Žƒ›‘ˆ—Ž–‹’Ž‡ˆƒ –‘”•ȋ•‡•‘”› ‡”˜‡•ǡ›‘‰‡‹ ”‡•’‘•‡•ǡ‡–ƒ„‘Ž‹ ƒ†‡†‘–Š‡Ž‹ƒŽ˜ƒ•‘†‹Žƒ–‘”•ȌŠƒ•„‡‡ ’”‘’‘•‡†ǤȋͳͲͺȌ  Š‡†‹Žƒ–‹‘‘ˆ•‘Ǧ ƒŽŽ‡†Dz Š‘‡dz‘”Dz‹†‹”‡ –dz˜‡••‡Ž• ‘—Ž† ‘–”‹„—–‡‹•— Š Š›’‡”‡‹ ”‡•’‘•‡•’”‡˜‡–‹‰’‘–‡–‹ƒŽ–‹••—‡‡ ”‘•‹•ǤȋͳͲͷǡͳͲͻǡͳͳͲȌŠ‡•‡ƒ”‡ ƒƒ•–‘‘–‹ ˜‡••‡Ž•™‹–Š”‡†— ‡† ƒŽ‹„‡”•‹œ‡ȋ ‘’ƒ”‡†–‘Dz–”—‡dz‘”Dz†‹”‡ –dz˜‡••‡Ž•Ȍ ™Š‹ Šƒ”‡ƒ„Ž‡–‘†‹Žƒ–‡ƒ†–Š‡”‡„›‹ ”‡ƒ•‡„Ž‘‘†ˆŽ‘™‹ˆ‡‡†‡†ǤŠ‡› ‘’‘•‡ƒ ƒ†ƒ’–ƒ„Ž‡˜ƒ• —Žƒ”‡–™‘”™Š‹ Š”‘ˆ‡••‘” ƒƒ›Ž‘”†‡• ”‹„‡†–Š‡ˆ‘ŽŽ‘™‹‰™ƒ›ǣ Dzƒ•–‘‘–‹ ˜‡••‡Ž•ƒ”‡‘–Œ—•– ‘†—‹–•ǡ–Š‡›ƒ”‡ˆ— –‹‘ƒŽƒ† ‘–”‘ŽˆŽ‘™‹‡‹–Š‡”

33 33 †‹”‡ –‹‘„‡–™‡‡˜ƒ• —Žƒ”–‡””‹–‘”‹‡•ǤdzȋͳͲͻȌƒƒ•–‘‘–‹ ˜‡••‡ŽȋDzŽ‹‹‰˜‡••‡ŽdzȌ „‡–™‡‡‡†‹ƒŽƒ†Žƒ–‡”ƒŽ”‘™‹•’‹ –—”‡†‹ ‹‰—”‡ͳ͵Ǥ

 Fig. 13 The DIEA perforators and anastomoses. A 3D volume-rendered reconstruction from an axial slice CTA showing DIEA perforators and a true anastomotic vessel linking the medial and lateral rows. Used with kind permission from Prof. W Rozen (Department of Surgery, Monash University, Victoria, Australia) Š‡”‡ƒ –‹˜‡Š›’‡”‡‹ƒ‘„•‡”˜‡†‹‘—”•–—†›‹•‹†‡‡†ƒ‹–‡”‡•–‹‰ˆ‹†‹‰ ‘ ‡”‹‰–Š‡‹ ”‘ ‹” —Žƒ–‘”›‹’ƒ –‘ˆ ˆŽƒ’•—”‰‡”›ǡ„—–ǡ’‡”Šƒ’•‘”‡ ‹’‘”–ƒ–Ž›ǡ‹–ƒ –•ƒ•ƒ‘†‡Žˆ‘”•‹‹Žƒ”ǡŽƒ”‰‡Ǧ• ƒŽ‡—†‡”‹‹‰‡Ž•‡™Š‡”‡‘–Š‡ „‘†›ǤŠ‡†ƒ–ƒ‰‹˜‡••—”‰‡‘•ƒ‰”‡ƒ–‡”—†‡”•–ƒ†‹‰‘ˆ–Š‡”ƒ’‹†Ž› Šƒ‰‹‰ǡ ‹ ”‘ ‹” —Žƒ–‘”›†›ƒ‹ •‹—†‡”‹‡†–‹••—‡•Ǥ  Š‡ˆƒ ––Šƒ–„Ž‘‘†’‡”ˆ—•‹‘‹œ‘‡•ͳǦ͵‹ ”‡ƒ•‡†•‹‰‹ˆ‹ ƒ–Ž›ǡ™Š‹Ž‡‹– †‡ ”‡ƒ•‡†‹œ‘‡Ͷǡ‹†‹ ƒ–‡–Šƒ––Š‡”‡ƒ –‹˜‡Š›’‡”‡‹ƒ‹•†‡’‡†‡–‘†‹•–ƒ ‡ˆ”‘ ‘Ǧ—†‡”‹‡†–‹••—‡Ǣƒ–ƒ ‡”–ƒ‹†‹•–ƒ ‡ǡ–Š‡†‹Žƒ–‹‘‘ˆDz Š‘‡dz˜‡••‡Ž•‹•‘–ƒ„Ž‡ –‘•— ‡••ˆ—ŽŽ› ‘’‡•ƒ–‡ˆ‘”–Š‡•‡˜‡”‡†’‡”ˆ‘”ƒ–‘”•Ǥ‡™‡”‡‘–ƒ„Ž‡–‘‰‹˜‡ƒ •’‡ ‹ˆ‹  —–Ǧ‘ˆˆ‹–‡”•‘ˆ—†‡”‹‹‰Ž‡‰–Š„ƒ•‡†‘‘—”•–—†›ǤŠ‹•Ž‡‰–Š†‘‡• ’”‡•—ƒ„Ž›˜ƒ”›ƒ ‘”†‹‰–‘ƒƒ–‘‹ ƒŽ”‡‰‹‘ƒ†ˆƒ –‘”••— Šƒ•–Š‡’ƒ–‹‡–ǯ•ƒ‰‡ ƒ†Š‡ƒŽ–Šǡ†”—‰—•‡ǡ‹ ‘–‹‡‡š’‘•—”‡ǡ–‡’‡”ƒ–—”‡ǡƒ†Ž‡˜‡Ž‘ˆ—†‡”‹‹‰Ǥ

“Tension reduces perfusion”.•—„•–ƒ–‹ƒŽ†‡ ”‡ƒ•‡‘ˆ„Ž‘‘†’‡”ˆ—•‹‘™ƒ•‘„•‡”˜‡† ‹œ‘‡•ͳǦͶƒˆ–‡”ƒ„†‘‹ƒŽ Ž‘•—”‡ǤŠ‹•‹•‹ ‘ ‡”–™‹–Š’”‡˜‹‘—••–—†‹‡••Š‘™‹‰ –Šƒ––‡•‹‘”‡†— ‡•’‡”ˆ—•‹‘ǤȋͳͲ͸ǡͳͳͳǦͳͳͶȌ ˆƒ –ǡƒ”Š‹ŽŽ‡–ƒŽǤ—•‡†ƒ•‹Ǧ •–”‡– Š‹‰†‡˜‹ ‡‘–Š‡ˆ‘”‡ƒ”‘ˆ’ƒ–‹‡–•ƒ††‹”‡ –Ž›‘„•‡”˜‡†ƒ ‘ŽŽƒ’•‡‘ˆ •—’‡”ˆ‹ ‹ƒŽ†‡”ƒŽ‹ ”‘˜ƒ• —Žƒ–—”‡ƒ–”‡Žƒ–‹˜‡Ž›Ž‘™ƒ‰‹–—†‡•ǤȋͳͳͳȌŠ‡ ‘ŽŽƒ’•‡‘ˆ ˜‡••‡Ž• ƒ—•‡†„›–Š‡—‹ƒš‹ƒŽ–‡•‹‘”‡•—Ž–‡†‹‘„Ž‹–‡”ƒ–‹‘‘ˆ„Ž‘‘†ˆŽ‘™Ǥ  ‘—”•–—†›ǡ‹–‹•‹’‘••‹„Ž‡–‘ ‘ Ž—†‡™Š‡–Š‡”‹–‹•–‡•‹‘ƒŽ‘‡‘”–‡•‹‘ ‘„‹‡†™‹–Š—†‡”‹‹‰–Šƒ– ƒ—•‡†–Š‡†”ƒƒ–‹ †‡ ”‡ƒ•‡‘ˆ„Ž‘‘†’‡”ˆ—•‹‘Ǥ‘ ƒ•™‡”–Š‹•“—‡•–‹‘ǡ™‡ ‘—Ž†Šƒ˜‡ ‘’ƒ”‡†–Š”‡‡†‹ˆˆ‡”‡– ˆŽƒ’†‡ˆ‡ – Ž‘•—”‡•Ǣ‘‡™‹–Š•–ƒ†ƒ”†‹œ‡†—†‡”‹‹‰ǡ‘‡™‹–ŠŽ‹‹–‡†—†‡”‹‹‰ǡƒ†‘‡ ™‹–Š‘—–—†‡”‹‹‰Ǥ•–Š‡—†‡”‹‹‰‹•˜‹–ƒŽ‹ƒ –—ƒŽŽ›ƒ Š‹‡˜‹‰†‡ˆ‡ – Ž‘•—”‡ǡ –Š‹•‹•‘–’”ƒ –‹ ƒ„Ž‡Ǥ ƒ’‘” ‹‡•–—†›ǡŠ‘™‡˜‡”ǡ‡Ž‹•‡–ƒŽǤ‘„•‡”˜‡†–Šƒ–„‘–ŠŽƒ•‡”

34 34 ‘’’Ž‡”ˆŽ‘™‡–”›•‹‰ƒŽ•ƒ†–”ƒ• —–ƒ‡‘—•‘š‹‡–”›˜ƒŽ—‡•†‡ ”‡ƒ•‡†‹•–”‡– Š‡† •‹™Š‡–Š‡”‘”‘–‹–™ƒ•—†‡”‹‡†ǤȋͳͳͶȌŠ‹•‹†‹ ƒ–‡–Šƒ––‡•‹‘ƒŽ‘‡”‡†— ‡• ’‡”ˆ—•‹‘Ǥ  “The most distal part of the undermined abdominal flap has the highest susceptibility of tissue necrosis – especially after the abdominal closure”.Š‹•‹• –Š‡ˆ‹”•–•–—†›–Šƒ–ƒ••‡••‡•’‡”ˆ—•‹‘†›ƒ‹ •‹–Š‡—†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’‹  ˆŽƒ’•—”‰‡”›Ǥ –‹•ǡ–Š‡”‡ˆ‘”‡ǡ–Š‡ˆ‹”•–†ƒ–ƒ†‘ —‡–‹‰–Š‡•‹‰‹ˆ‹ ƒ–Ž›Ž‘™‡” ’‡”ˆ—•‹‘˜ƒŽ—‡•‹–Š‡‘•–†‹•–ƒŽœ‘‡ƒˆ–‡” ˆŽƒ’ƒ„†‘‹ƒŽ Ž‘•—”‡Ǥ•‹‹Žƒ” †‡ ”‡ƒ•‡‘ˆ„Ž‘‘†’‡”ˆ—•‹‘Šƒ•ǡŠ‘™‡˜‡”ǡ„‡‡†‘ —‡–‡†‹ƒ„†‘‹‘’Žƒ•–›’ƒ–‹‡–• „›—•‹‰Žƒ•‡”ˆŽ—‘”‡• ‡ ‡‹ƒ‰‹‰ǤȋͳͳͷǦͳͳ͹Ȍ  Š‡‘„•‡”˜‡†’‡”ˆ—•‹‘†”‘’†‹•–ƒŽŽ› ‘—Ž†‡š’Žƒ‹–Š‡†‹•–ƒŽˆŽƒ’‡ ”‘•‹•ƒ†Ȁ‘” ™‘—†„”‡ƒ†‘™‘ ƒ•‹‘ƒŽŽ›•‡‡‹ƒ„†‘‹ƒŽˆŽƒ’•—”‰‡”›Ǥ ‘”‡šƒ’Ž‡ǡ ‹”œƒ„‡‹‰‹‡–ƒŽǤ”‡ ‘”†‡†ƒ”ƒ–‡‘ˆͳ͵Ǥ͹Ψ‘ˆ†‡Žƒ›‡†ƒ„†‘‹ƒŽ™‘—†Š‡ƒŽ‹‰ƒˆ–‡” ˆ”‡‡ƒ„†‘‹ƒŽˆŽƒ’•—•‡†‹„”‡ƒ•–”‡ ‘•–”— –‹‘ǤȋͳͳͺȌŠ‡›†‡ˆ‹‡††‡Žƒ›‡†Š‡ƒŽ‹‰ ƒ•ƒ‘’‡ƒ„†‘‹ƒŽ™‘—†–Šƒ–’‡”•‹•–‡†ˆ‘”‰”‡ƒ–‡”–Šƒ‘‡‘–Š’‘•–‘’‡”ƒ–‹˜‡Ž›Ǥ — Š™‘—† ‘’Ž‹ ƒ–‹‘• ƒ”‡•—Ž–‹ Š”‘‹ ƒ„†‘‹ƒŽ™‘—†•”‡“—‹”‹‰Ž‘‰Ǧ–‡” ‘•‡”˜ƒ–‹˜‡™‘—† ƒ”‡ƒ†Ȁ‘”•—”‰‹ ƒŽ‹–‡”˜‡–‹‘ǤȋͳͳͺȌ  —”•–—†›†‘‡•‘–ƒ††”‡••–Š‡ ƒ—•‡•‘ˆ†‹•–ƒŽ ‹” —Žƒ–‘”›‹•–ƒ„‹Ž‹–›Ǥ• †‹• —••‡†‡ƒ”Ž‹‡”‹–Š‹••‡ –‹‘ǡ„‘–Š—†‡”‹‹‰ƒ†Ȁ‘”—‹ƒš‹ƒŽ–‡•‹‘ƒ”‡’‘••‹„Ž‡ ‡š’Žƒƒ–‹‘•ǤŠ‹•‹•ƒ‡–Š‘†‘Ž‘‰‹ ƒŽ•Š‘”– ‘‹‰‘ˆ–Š‡•–—†›Ǥ  ‡˜‡”ƒŽ‡š’‡”‹‡–ƒŽ•–—†‹‡•Šƒ˜‡–”‹‡†–‘— ‘˜‡”‹–”‹•‹ ǡ’ƒ–Š‘’Š›•‹‘Ž‘‰‹ ƒŽ ‡ Šƒ‹•• ‘–”‹„—–‹‰‹†‹•–ƒŽˆŽƒ’‡ ”‘•‹•Ǥƒ›Š›’‘–Š‡•‡•Šƒ˜‡„‡‡•Šƒ”‡†ǡ •— Šƒ•ǣͳȌDz•–‡ƒŽ‡ˆˆ‡ –dz™Š‡”‡–Š‡’”‘š‹ƒŽˆŽƒ’•–‡ƒŽ•„Ž‘‘†ˆ”‘–Š‡†‹•–ƒŽˆŽƒ’ȋͳͲͷȌ ƒ†ʹȌ˜ƒ•‘ ‘•–”‹ –‹‘ ƒ—•‡†„›ƒDzŠ›’‡”ƒ†”‡‡”‰‹ •–ƒ–‡dzȋ–”‹‰‰‡”‡†„›–Š‡”‡Ž‡ƒ•‡ ‘ˆ‘”‡’‹‡’Š”‹‡ƒˆ–‡”–”ƒ•‡ –‹‘‘ˆ•›’ƒ–Š‡–‹ ‡”˜‡•ƒ ‘’ƒ›‹‰–Š‡˜ƒ• —Žƒ” •—’’Ž›–‘–Š‡ˆŽƒ’ȌȋͳͳͻȌǤ”‡˜‹‡™‘ˆ–Š‹•Ž‹–‡”ƒ–—”‡‹•„‡›‘†–Š‡ˆ”ƒ‡™‘”‘ˆ–Š‹• –Š‡•‹•Ǥ  “The undermined abdominal flap needs less than one day to successfully implement compensatory mechanisms preventing tissue ischemia and potentially necrosis”.‡”ˆ‘”ƒ–‘”•ƒ”‡•‡˜‡”‡††—”‹‰–Š‡ ˆŽƒ’Šƒ”˜‡•–‹‰ƒ†ƒ„†‘‹ƒŽˆŽƒ’ —†‡”‹‹‰ǤŠ‹•‡•—‡•‹ƒ•‹‹Žƒ”ˆƒ•Š‹‘†—”‹‰ƒǤ‘‘—”‘™Ž‡†‰‡ǡ’ƒ’‡”  ‘—Ž†„‡–Š‡ˆ‹”•–•–—†›–Šƒ–Šƒ• ‘’Ž‡–‡†’‘•–‘’‡”ƒ–‹˜‡‡ƒ•—”‡‡–•‘ˆ–Š‡ —†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’ƒ•–Š‡–Š”‡‡”‡ˆ‡””‡†•–—†‹‡• ‘’Ž‡–‡†–Š‡‹” ‡ƒ•—”‡‡–•‹–”ƒ‘’‡”ƒ–‹˜‡Ž›ȋƒˆ–‡”–Š‡ƒ„†‘‹ƒŽ Ž‘•—”‡ȌǤȋͳͳͷǦͳͳ͹Ȍ—” ’‘•–‘’‡”ƒ–‹˜‡‡ƒ•—”‡‡–•’”‘˜‹†‡†‹–‡”‡•–‹‰‘„•‡”˜ƒ–‹‘•‹ŽŽ—•–”ƒ–‹‰”ƒ’‹†ǡ ‘’‡•ƒ–‘”›”‡•’‘•‡•–Šƒ–‹ ”‡ƒ•‡†„Ž‘‘†’‡”ˆ—•‹‘ǤŠ‡•‡”‡•’‘•‡•™‡”‡ ‘„•‡”˜‡†ƒ•‡ƒ”Ž›ƒ•’‘•–‘’‡”ƒ–‹˜‡†ƒ›ͳǤ ”‘–Š‹•†ƒ›ǡƒŽŽœ‘‡•Šƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž› Š‹‰Š‡”’‡”ˆ—•‹‘ ‘’ƒ”‡†™‹–Š’”‡‘’‡”ƒ–‹˜‡˜ƒŽ—‡•ǤŠ‡œ‘ƒŽ‡ƒ•—”‡‡–•™‡”‡ ƒ††‹–‹‘ƒŽŽ›Š‘‘‰‡‹œ‡†™‹–Š–‹‡Ȃ†‡‘•–”ƒ–‹‰ƒ”ƒ–Š‡”—‹ˆ‘”Ž›’‡”ˆ—•‡† ƒ„†‘‹ƒŽˆŽƒ’Ǥ  Š‡ ‡–Š‘††‘‡•ǡ—ˆ‘”–—ƒ–‡Ž›ǡ‘–‰‹˜‡ƒ›Š‹–‘ˆ–Š‡—†‡”Ž›‹‰ ‡ Šƒ‹••‘ˆ–Š‹•’‡”ˆ—•‹‘‹ ”‡ƒ•‡Ǥ‡„‡Ž‹‡˜‡–Š‡”‡ƒ”‡ƒ —–‡ǡ•Š‘”–ǦŽƒ•–‹‰ƒ† †‡Žƒ›‡†ǡŽ‘‰ǦŽƒ•–‹‰‡ Šƒ‹••‹—†‡”‹‡†–‹••—‡•–Šƒ–’”‡˜‡–‹• Š‡‹ƒƒ†

35 35 ’‘–‡–‹ƒŽŽ›‡ ”‘•‹•Ǥ•†‹• —••‡†‡ƒ”Ž‹‡”–Š‡”‡‹•ƒƒ —–‡’‘•–Ǧ—†‡”‹‹‰”‡ƒ –‹˜‡ Š›’‡”‡‹ƒ•‡‡‹–‹••—‡••‡’ƒ”ƒ–‡†ˆ”‘‹–•’‡”ˆ‘”ƒ–‘”•ǤŠ‹•Š›’‡”‡‹ ”‡•’‘•‡ ‘—Ž†„‡ƒ Š‹‡˜‡†–Š”‘—‰Š†‹Žƒ–‹‘‘ˆ–Š‡ƒˆ‘”‡‡–‹‘‡†Dz Š‘‡dz˜‡••‡Ž•ǡ™Š‹ Š‹• •—’’‘”–‡†„›ƒ†‡Žƒ›ˆŽƒ’•–—†›ȋƒ‹ƒŽ‘†‡ŽȌ’‡”ˆ‘”‡†„›Šƒ”ƒ†ƒ›Ž‘”ǤȋͳʹͲȌ Š‡›•Š‘™‡†–Šƒ–Dz Š‘‡dz˜‡••‡Ž•—†‡”™‡–’”‘‰”‡••‹˜‡•‡“—‡–‹ƒŽ†‹Žƒ–‹‘ǡ‘•– †”ƒƒ–‹ ƒŽŽ›„‡–™‡‡’‘•–‘’‡”ƒ–‹˜‡†ƒ›ʹƒ†͵Ǥ••— Šǡ™‡Š›’‘–Š‡•‹œ‡–Šƒ– ƒŽ‹„‡” Šƒ‰‡•‘ˆDz Š‘‡dzƒƒ•–‘‘–‹ ˜‡••‡Ž•ƒ”‡ƒƒŒ‘”ˆƒ –‘”‹–Š‡‹ ”‡ƒ•‡†’‡”ˆ—•‹‘ •‡‡ˆ”‘’‘•–‘’‡”ƒ–‹˜‡†ƒ›Ͳ–‘͵ǤŠ‡„Ž‘‘†ˆŽ‘™‹‰–Š”‘—‰Š–Š‡•‡ƒƒ•–‘‘–‹  ˜‡••‡Ž•‘•–’”‘„ƒ„Ž›‘”‹‰‹ƒ–‡ˆ”‘‹–‡” ‘•–ƒŽ˜‡••‡Ž•Žƒ–‡”ƒŽŽ›ȋͻͻȌƒ†•—’‡”‹‘” ‡’‹‰ƒ•–”‹ ˜‡••‡Ž• ”ƒ‹ƒŽŽ›ȋͳͲ͹ȌǤ

“The significantly increased and homogenized blood perfusion seen the first postoperative week might be a result of persistently dilated “choke” vessels and/or regeneration of vascular networks”. –‡”•‘ˆ†‡Žƒ›‡†ǡŽ‘‰ǦŽƒ•–‹‰ ‡ Šƒ‹••ǡ™‡–Š‡‘”‹œ‡–Šƒ––Š‡ ‘•‹•–‡–Ž›Š‹‰Š‡ƒ•—”‡‡–••‡‡‹–Š‡ —†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’™‹–Š‹–Š‡ˆ‹”•–’‘•–‘’‡”ƒ–‹˜‡™‡‡ ‘—Ž†‹†‹ ƒ–‡ǣͳȌ ‡”•‹•–‡–Ž›†‹Žƒ–‡†Dz Š‘‡dz˜‡••‡Ž•ǡƒ†Ȁ‘”ʹȌ‡‰‡‡”ƒ–‹‘‘ˆ˜ƒ• —Žƒ”‡–™‘”•ǤŠ‹• ‹•†‹• —••‡†‹–Š‡ˆ‘ŽŽ‘™‹‰–‡š–ǣ  ͳȌ‡”•‹•–‡–Ž›†‹Žƒ–‡†Dz Š‘‡dz˜‡••‡Ž•ǣŠ‡ƒˆ‘”‡‡–‹‘‡†’—„Ž‹ ƒ–‹‘„›Šƒ” ƒ†ƒ›Ž‘”•–—†‹‡††‡Žƒ›‡†ˆŽƒ’•—’–‘‘‡›‡ƒ”’‘•–‘’‡”ƒ–‹˜‡Ž›ǤȋͳʹͲȌ ‡”‡ǡ–Š‡Dz Š‘‡dz ˜‡••‡Ž• ‘–‹—‡†–‘‰”ƒ†—ƒŽŽ›†‹Žƒ–‡–Š‡ˆ‹”•–’‘•–‘’‡”ƒ–‹˜‡™‡‡ǤŠ‹• ‘—Ž†‡š’Žƒ‹–Š‡ Š‹‰Š’‡”ˆ—•‹‘ˆ‘—†–Š”‘—‰Š‘—––Š‡’‘•–‘’‡”ƒ–‹˜‡’Šƒ•‡‘ˆ‘—”•–—†›Ǥ —”–Š‡”‘”‡ǡ–Š‡ †‹Žƒ–‹‘™ƒ•ƒŽ•‘ƒ••‘ ‹ƒ–‡†™‹–ŠŠ›’‡”’Žƒ•‹ƒƒ†Š›’‡”–”‘’Š›‘ˆ–Š‡ ‡ŽŽ•‹–Š‡˜‡••‡Ž ™ƒŽŽǡ‹†‡‡†‹†‹ ƒ–‹‰‘”’Š‘Ž‘‰‹ ƒŽ Šƒ‰‡•‡ƒ––‘Žƒ•–ǤŠ‹•™ƒ• ‘ˆ‹”‡†‘‡ ›‡ƒ”’‘•–‘’‡”ƒ–‹˜‡Ž›™Š‡”‡–Š‡›ˆ‘—†ƒ’‡”ƒ‡–Ž›‹ ”‡ƒ•‡†˜‡••‡Ž†‹ƒ‡–‡”ǡ™Š‹ Š ™ƒ•ǡ‹ˆƒ –ǡ‹””‡˜‡”•‹„Ž‡ȋƒˆ–‡””‡Ǧƒƒ•–‘‘•‹•ȌǤŠ‡ƒ—–Š‘”•’”‘’‘•‡†–Šƒ––Š‡†‹Žƒ–‡† Dz Š‘‡dz˜‡••‡Ž•†‘‘–”‡–—”–‘–Š‡‹”‘”‹‰‹ƒŽ•‹œ‡Ǥ  ʹȌ‡‰‡‡”ƒ–‹‘‘ˆ˜ƒ• —Žƒ”‡–™‘”•ǣƒ„•–‡–ƒŽǤ’‡”ˆ‘”‡†ƒ‹–‡”‡•–‹‰•–—†› ‹˜‡•–‹‰ƒ–‹‰–Š‡‡‘Ǧ˜ƒ• —Žƒ”‹œƒ–‹‘‘ˆ—”‹‡ˆ”‡‡ˆŽƒ’•ǤȋͳʹͳȌŠ‡›”‡’‘”–‡† •‹‰‹ˆ‹ ƒ– Šƒ‰‡•‹–Š‡†‡˜‡Ž‘’‡–‘ˆ–Š‡˜ƒ• —Žƒ”•›•–‡™‹–Š‹–Š‡ˆ‹”•–ͳʹ†ƒ›• ƒˆ–‡”•—”‰‡”›ǣŠ‡‹”ˆŽƒ’•Šƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž›‹ ”‡ƒ•‡†‹ ”‘˜‡••‡Ž•‹œ‡–Š”‡‡ƒ†•‡˜‡ †ƒ›•’‘•–‘’‡”ƒ–‹˜‡Ž›ǡƒ†‹ ”‡ƒ•‡†‹ ”‘˜‡••‡Ž†‡•‹–›•‡˜‡ƒ†ͳʹ†ƒ›• ’‘•–‘’‡”ƒ–‹˜‡Ž›Ǥ‘”‡‘˜‡”ǡג‡œ‡–ƒŽǤ—•‡†‹—‘Š‹•–‘ Š‡‹ ƒŽƒ”‡”•‹ƒ”ƒ„„‹– ‘†‡Ž–‘†‡‘•–”ƒ–‡ˆ‘”ƒ–‹‘‘ˆ‡™˜‡••‡Ž•‹†‡Žƒ›‡†ˆŽƒ’•ǤȋͳʹʹȌŠ‡›ˆ‘—†ƒ ‹ ”‡ƒ•‹‰—„‡”‘ˆ ƒ’‹ŽŽƒ”‹‡•ˆ”‘’‘•–‘’‡”ƒ–‹˜‡†ƒ›–™‘–‘•‡˜‡ǤŽ–Š‘—‰Šƒ„•–‡– ƒŽǤƒ†ג‡œ‡–ƒŽǤ—•‡†ƒ‹ƒŽ‘†‡Ž•ǡ–Š‡”‡•—Ž–••—‰‰‡•––Šƒ––Š‡˜ƒ• —Žƒ”„—‹Ž†Ǧ—’‹ —†‡”‹‡†–‹••—‡•ƒ†ˆŽƒ’•ƒ–‡”‹ƒŽ‹œ‡•ƒŽ”‡ƒ†›–Š‡˜‡”›ˆ‹”•–’‘•–‘’‡”ƒ–‹˜‡™‡‡Ǥ   Paper II “DIEAP flap harvesting causes significant morphological changes to the rectus muscle at and inferiorly to the intramuscular perforator dissection”.—”•‹‰‹ˆ‹ ƒ– †ƒ–ƒˆ”‘œ‘‡•ǡǡƒ† ‘—Ž†‹†‹ ƒ–‡–Šƒ–‘”’Š‘Ž‘‰‹ ƒŽ—• Ž‡ Šƒ‰‡•ƒ‹Ž› †‡˜‡Ž‘’ƒ–ƒ†‹ˆ‡”‹‘”Ž›–‘–Š‡‹–”ƒ—• —Žƒ”’‡”ˆ‘”ƒ–‘”†‹••‡ –‹‘Ǥ—”ˆ‹†‹‰•ƒ”‡‹

36 36 ‡‡’‹‰™‹–Š’”‡˜‹‘—••–—†‹‡•ȋͶͻǡͺ͵ǡͳͲͲȌǡƒ† ‘—Ž†„‡‡š’Žƒ‹‡†„›–Š‡ ƒ—†ƒŽ ’”‘‰”‡••‹‘‘ˆ’‡†‹ Ž‡†‹••‡ –‹‘ƒ†Ȁ‘”–Š‡‡†‹ƒŽǦ‹ˆ‡”‹‘”†‹”‡ –‹‘‘ˆ‡”˜‡•ȋ ‹‰ǤͳͶȌ ’‘••‹„Ž›„‡‹‰†ƒƒ‰‡†Ǥ

 Fig. 14 Iatrogenic nerve injury after intramuscular perforator dissection. Figure showing the segmental motor nerves innervating the abdominal region and their medial-inferior direction. A myotomy has been made on the left side severing two of the nerves. Illustration: Øystein Horgmo, University of Oslo   –Š‡ ‘–”ƒ”›ǡƒƒƒ†‹ƒ”‡•‡ƒ” Š‰”‘—’”‡’‘”–‡†‘•‹‰‹ˆ‹ ƒ– Šƒ‰‡‘ˆ —• Ž‡•‹œ‡ƒˆ–‡”ƒƒŽ›œ‹‰ʹ͸’ƒ‹”‡†”‡ –—•—• Ž‡•„‡ˆ‘”‡ƒ†ƒˆ–‡” ˆŽƒ’

37 37 •—”‰‡”›Ǥȋͳʹ͵ȌŠ‡‹”•–—†›ǡ’—„Ž‹•Š‡†ƒ›‡ƒ”ƒˆ–‡”ǡ ‘’ƒ”‡†•ǡ•ǡƒ† ”‘••Ǧ •‡ –‹‘ƒŽƒ”‡ƒ•Ǥ‘–Š’”‡‘’‡”ƒ–‹˜‡˜‡”•—•’‘•–‘’‡”ƒ–‹˜‡‡ƒ•—”‡‡–•‘ˆ–Š‡•ƒ‡ ”‡ –—•„‡ŽŽ›ǡƒ†’‘•–‘’‡”ƒ–‹˜‡‡ƒ•—”‡‡–•‘ˆ‘’‡”ƒ–‡†˜‡”•—•‘Ǧ‘’‡”ƒ–‡†”‡ –—• „‡ŽŽ›ǡ™‡”‡ ‘’ƒ”‡†Ȃ•‹‹Žƒ”Ž›–‘‘—”‡–Š‘†Ǥ‡ƒˆ‘ŽŽ‘™Ǧ—’–‹‡–‘’‘•–‘’‡”ƒ–‹˜‡ ‹ƒ‰‹‰™ƒ•ͳǤ͸ͺ›‡ƒ”•ȋ”ƒ‰‡ǡͲǤͻͻ–‘͵Ǥͷ͸›‡ƒ”•ȌǤˆ‘”–—ƒ–‡Ž›ǡ–Š‡ƒƒ–‘‹ ƒŽŽ‡˜‡Ž —•‡†–‘ ‘’Ž‡–‡–Š‡‡ƒ•—”‡‡–•™ƒ•‘–’”‘˜‹†‡†„›–Š‡ƒ—–Š‘”•‹–Š‡‘”‹‰‹ƒŽ ƒ”–‹ Ž‡Ǥ –™ƒ•ǡŠ‘™‡˜‡”ǡ•’‡ ‹ˆ‹ ƒŽŽ›”‡“—‡•–‡†‹ƒŽ‡––‡”–‘–Š‡ƒ—–Š‘”•ˆ”‘’Žƒ•–‹  •—”‰‡‘•„ƒ•‡†‹‡‹Œ‹‰ǤȋͳʹͶȌŠ‡›”‡ˆ‡””‡†–‘‘—”•–—†›ƒ†ƒ•‡†–Š‡ƒƒ†‹ƒ ”‡•‡ƒ” Š‡”–‘ƒ†‘’–ƒƒƒŽ‘‰‘—•ˆ‘—”Ǧœ‘‡Ǧ‡–Š‘†–‘‹’”‘˜‡–Š‡ ”‡†‹„‹Ž‹–›ƒ† ‡ˆˆ‡ –‹˜‡‡••‘ˆ–Š‡‹”•–—†›Ǥƒ ƒ†ƒǡ–Š‡•‡‹‘”ƒ—–Š‘”‘ˆ–Š‡ƒƒ†‹ƒ•–—†›ǡ”‡’Ž‹‡† Žƒ–‡”–Šƒ––Š‡‡ƒ•—”‡‡–•™‡”‡•–ƒ†ƒ”†‹œ‡†–‘ƒ’‘‹–͵Ͳ„‡Ž‘™–Š‡ ‡–‡”‘ˆ –Š‡—„‹Ž‹ —•ǤȋͳʹͷȌŠ‡›˜‹‡™‡†–Š‹•Ž‡˜‡Žƒ•–Š‡‘•–Ž‹‡Ž›ƒ”‡ƒ–‘†‡˜‡Ž‘’ Šƒ‰‡• †—‡–‘–Š‡†‘‹ƒ–’‡”ˆ‘”ƒ–‘”•–Šƒ–ƒ”‡Ž‘ ƒ–‡†Š‡”‡Ǥ††‹–‹‘ƒŽŽ›ǡ–Š‡›™ƒ–‡†–‘Ž‹‹– –Š‡’‘•–‘’‡”ƒ–‹˜‡™‹†‘™–‘”‡†— ‡”ƒ†‹ƒ–‹‘‡š’‘•—”‡Ǥ͵Ͳ„‡Ž‘™–Š‡—„‹Ž‹ —• ‹•’”‘„ƒ„Ž›•‘‡™Šƒ–‹„‡–™‡‡‘—”œ‘‡ȋDz—„‹Ž‹ ƒŽœ‘‡dzȌƒ†œ‘‡ȋDz ‡–”ƒŽ œ‘‡dzȌǤ  ƒ•‡†‘†ƒ–ƒˆ”‘Ž‘†‡‡Ž‡–ƒŽǤȋͶͻȌǡ–Š‡ƒƒ†‹ƒ”‡•‡ƒ” Š‡”•ȋͳʹ͵Ȍǡƒ† ‘—”•‡Ž˜‡•ǡ™‡„‡Ž‹‡˜‡–Šƒ–‘”’Š‘Ž‘‰‹ ƒŽ”‡ –—•—• Ž‡ Šƒ‰‡•–Š‹• Ž‘•‡–‘–Š‡ —„‹Ž‹ —•ƒ”‡• ƒ” ‡Ǥ‘‘‹‰ƒ–‘—”†ƒ–ƒǡˆ‘—”‘—–‘ˆˆ‹˜‡•‹‰‹ˆ‹ ƒ– ‘’ƒ”‹•‘•™‡”‡ ‹ˆƒ –Ž‘ ƒ–‡†‘”‡ ƒ—†ƒŽŽ›ȋœ‘‡•ƒ†ȌǤ‡Š›’‘–Š‡•‹œ‡ǡ–Š‡”‡ˆ‘”‡ǡ–Šƒ–‘•–‘ˆ –Š‡”‡ –—•—• Ž‡‘”„‹†‹–›‹•ƒ–ƒ†‹ˆ‡”‹‘”–‘–Š‡ƒ–‡”‹‘””‡ –—••Š‡ƒ–Š‹ ‹•‹‘ǡƒ† •—‰‰‡•––Šƒ–•–—†‹‡•‡˜ƒŽ—ƒ–‹‰”‡ –—•—• Ž‡‘”„‹†‹–›•Š‘—Ž†‹ Ž—†‡ƒƒ–‘‹ ƒŽ Ž‡˜‡Ž• ƒ—†ƒŽȋƒ†‹†‡ƒŽŽ› ”ƒ‹ƒŽȌ–‘–Š‡ Š‘•‡’‡”ˆ‘”ƒ–‘”ȋ•ȌǤ  “The number and row of perforators do not significantly affect the extent of rectus muscle morbidity”. –‡”•‘ˆ’‡”ˆ‘”ƒ–‘”—„‡”•ƒ†”‘™ǡ™‡†‹†‘–ˆ‹†ƒ› •‹‰‹ˆ‹ ƒ–†ƒ–ƒ ‘’ƒ”‹‰ǣͳȌ‡’‡”ˆ‘”ƒ–‘”˜‡”•—•–™‘’‡”ˆ‘”ƒ–‘”•ǡƒ†ʹȌ‡†‹ƒŽ”‘™ ’‡”ˆ‘”ƒ–‘”˜‡”•—•Žƒ–‡”ƒŽ’‡”ˆ‘”ƒ–‘”Ǥ—”•–—†›™ƒ•ǡŠ‘™‡˜‡”ǡ—†‡”’‘™‡”‡†ȋ‘Ž›‹‡ ˆŽƒ’•™‹–Š‘‡’‡”ˆ‘”ƒ–‘”ƒ†ˆ‹˜‡ˆŽƒ’•™‹–Š–™‘’‡”ˆ‘”ƒ–‘”•ȌǤŠ‡‘„•‡”˜ƒ–‹‘•ƒ”‡ǡ‘ –Š‡‘–Š‡”Šƒ†ǡ‹ƒ ‘”†ƒ ‡™‹–Šƒ‡š–‡•‹˜‡ǡͳͲǦ›‡ƒ””‡–”‘•’‡ –‹˜‡ƒƒŽ›•‹• ’‡”ˆ‘”‡†„› ƒ”˜‡›‡–ƒŽǤȋͳʹ͸ȌŠ‡›‹ Ž—†‡†ʹͲͶ͵ ‘•‡ —–‹˜‡ƒ„†‘‹ƒŽˆ”‡‡ˆŽƒ’• ƒ††‹†‘–ˆ‹†ƒ›•‹‰‹ˆ‹ ƒ–ƒ••‘ ‹ƒ–‹‘„‡–™‡‡ǣͳȌ—„‡”‘ˆ’‡”ˆ‘”ƒ–‘”•ƒ†”ƒ–‡ ‘ˆƒ„†‘‹ƒŽ„—Ž‰‡ȀŠ‡”‹ƒǡƒ†ʹȌ•‡‘ˆ‡†‹ƒŽ˜‡”•—•Žƒ–‡”ƒŽ’‡”ˆ‘”ƒ–‘”•ƒ†”ƒ–‡‘ˆ ƒ„†‘‹ƒŽ„—Ž‰‡ȀŠ‡”‹ƒǤ‘”‡‘˜‡”ǡ–Š‡”‡™‡”‡‘ƒ••‘ ‹ƒ–‹‘•„‡–™‡‡’‡”ˆ‘”ƒ–‘” —„‡”•‘””‘™•ǡƒ†ƒ„†‘‹ƒŽ™‡ƒ‡••ǡ‹ƒˆ— –‹‘ƒŽ•–—†›„›‡‡‡–ƒŽǤȋͳʹ͹Ȍ  Š‡†ƒ–ƒ‘ˆ ƒ”˜‡›‡–ƒŽǤǡ‡‡‡–ƒŽǤǡƒ†‘—”•‡Ž˜‡•†‘‘–•—’’‘”––Š‡ƒ†˜‹ ‡‘ˆ —•‹‰‡†‹ƒŽ”‘™’‡”ˆ‘”ƒ–‘”•ƒ•’”‘’‘•‡†„›™‡ŽŽǦ‘™”‡•‡ƒ” Š‡”••— Šƒ•‘œ‡ ƒ†ƒ›Ž‘”ǤȋͳʹͺȌŠ‡‹”ƒ†˜‹ ‡‹•„ƒ•‡†‘ƒ ƒ†ƒ˜‡”‹ •–—†›†‘ —‡–‹‰–Š‡’”‘š‹‹–› ‘ˆŽƒ–‡”ƒŽ”‘™’‡”ˆ‘”ƒ–‘”•ƒ†‡”˜‡•ǤŠ‡‹””‡•—Ž–•ƒ”‡ ‘””‘„‘”ƒ–‡†ƒ†„‘Ž•–‡”‡†„› —–Ž‡”‡–ƒŽǤ™Š‘”‡–”‘•’‡ –‹˜‡Ž›•Š‘™‡†ƒ‹ ”‡ƒ•‡†”‹•‘ˆ„—Ž‰‡ȀŠ‡”‹ƒ—•‹‰–™‘‘” ‘”‡’‡”ˆ‘”ƒ–‘”•ƒ†Žƒ–‡”ƒŽ”‘™’‡”ˆ‘”ƒ–‘”•ǤȋͳʹͻȌ‡„ƒ–‡ ‘–‹—‡•™Š‡–Š‡”–Š‹•‹•–Š‡ ƒ•‡‘ˆ‘–Ǥ  Ž–Š‘—‰Š”‡•‡ƒ” Š‡”•Šƒ˜‡†‘ —‡–‡†˜ƒ”›‹‰†‘‘”Ǧ•‹–‡‘”„‹†‹–›”‡‰ƒ”†‹‰ ’‡”ˆ‘”ƒ–‘”—„‡”•ƒ†”‘™•ǡ‹–‹•‹’‘”–ƒ––‘ƒ ‘™Ž‡†‰‡–Šƒ––Š‡•‡ƒ”‡‘Ž›–™‘‘ˆ ƒ›ˆƒ –‘”•†‡–‡”‹‹‰–Š‡‡š–‡–‘ˆ‹ƒ–”‘‰‡‹ —• Ž‡†ƒƒ‰‡Ǥ ƒ –‘”••— Šƒ•–Š‡

38 38 †‹•–ƒ ‡„‡–™‡‡’‡”ˆ‘”ƒ–‘”•‹ ‘”’‘”ƒ–‡†ǡ–”ƒ•˜‡”•‡—• Ž‡‹ ‹•‹‘•ǡ—• Ž‡ƒ† ˆƒ• ‹ƒŠƒ”˜‡•–ǡƒ†‡•Š—•‡ƒ”‡•‹‹Žƒ”Ž›‹’‘”–ƒ–Ǥ ‡‡”ƒŽŽ›•’‡ƒ‹‰ǡŠ‘™‡˜‡”ǡ™‡ „‡Ž‹‡˜‡–Šƒ–‘‡•Š‘—Ž†–”›–‘—•‡ƒ•ˆ‡™’‡”ˆ‘”ƒ–‘”•ƒ•’‘••‹„Ž‡ƒ†’”‹ƒ”‹Ž›Ž‘‘ˆ‘” ƒ†‡“—ƒ–‡’‡”ˆ‘”ƒ–‘”•‹–Š‡‡†‹ƒŽ”‘™ǤŠ‡•‡Šƒ˜‡‘•– ‘‘Ž›–Š‡Žƒ”‰‡•– ƒŽ‹„‡”Ȃ „‘–Š‹–‡”•‘ˆƒ”–‡”›ƒ†ƒ••‘ ‹ƒ–‡†˜‡ƒ‡ ‘‹–ƒ–‡•Ǥȋͳ͵ͲȌ  “The increased APD of the operated muscle might be permanent”. œ‘‡ǡ‡ƒ ‹ ”‡ƒ•‡†ˆ”‘ͻǤ͵–‘ͳͲǤͲȋͲǤ͹†‹ˆˆ‡”‡ ‡ǡPαͲǤͲͶͶȌǤ œ‘‡ǡ‡ƒ ‹ ”‡ƒ•‡†ˆ”‘ͳͲǤʹ–‘ͳͳǤʹȋͳ†‹ˆˆ‡”‡ ‡ǡPαͲǤͲ͵ͺȌǤ‘–Šœ‘ƒŽ ‹ ”‡ƒ•‡• ‘•–‹–—–‡ƒ͹Ψ‹ ”‡ƒ•‡ǡ™Š‹ Š™‡™‘—Ž†•ƒ›‹•”ƒ–Š‡”Ž‹‹–‡†ƒ†ƒ› ‘–”‡’”‡•‡–ƒ›•—„•–ƒ–‹ƒŽ—• Ž‡†ƒƒ‰‡Ǥ‡–ǡƒ‡“—‹˜ƒŽ‡–‹ ”‡ƒ•‡‘ˆ™ƒ• ƒŽ•‘†‡‘•–”ƒ–‡†„›‡‡‡–ƒŽǤ‘‡‘–Š’‘•–‘’‡”ƒ–‹˜‡Ž›ǤȋͳͲͲȌŠ‡•‡”‡•—Ž–• ‘—Ž†‹ ‘ ‡”–‹†‹ ƒ–‡ƒ–”—‡ƒ–‡”‘’‘•–‡”‹‘”–Š‹ ‡‹‰‘ˆ–Š‡‘’‡”ƒ–‡†—• Ž‡„‡ŽŽ›Ǥ–Š‡ ‘–”ƒ”›ǡ–Š‡‹”‹ ”‡ƒ•‡†ƒ–‘‡‘–Š™ƒ•”‡•‘Ž˜‡†ƒˆ–‡”‘‡›‡ƒ”ǤŠ‡ƒ—–Š‘”• ƒ––”‹„—–‡†–Š‡‹ ”‡ƒ•‡†—• Ž‡–Š‹ ‡••–‘ƒ’‘•–‘’‡”ƒ–‹˜‡‡†‡ƒ–Šƒ–”‡•‘Ž˜‡•™‹–Š –‹‡Ǥ‡ƒŽ•‘„‡Ž‹‡˜‡–Šƒ––Š‹• ‘—Ž†„‡–Š‡ ƒ•‡™Š‡”‡ƒ ‘„‹ƒ–‹‘‘ˆ‹’ƒ‹”‡† ˜‡‘—•ƒ†Ž›’Šƒ–‹ †”ƒ‹ƒ‰‡ ƒ—•‡—• Ž‡‡†‡ƒǤ   Š‡ƒ‰ƒ‹ǡ–Š‡‹ ”‡ƒ•‡†‹œ‘‡•ƒ†–Šƒ–™‡”‡ˆ‘—†–™‘›‡ƒ”• ’‘•–‘’‡”ƒ–‹˜‡Ž›‹‘—”•–—†›•—‰‰‡•–‘”‡’‡”ƒ‡– Šƒ‰‡•Ǥˆ‘”–—ƒ–‡Ž›ǡ™‡†‘‘– Šƒ˜‡”‡’‡ƒ–‡†’‘•–‘’‡”ƒ–‹˜‡‡ƒ•—”‡‡–•–‘Ž‘‘ˆ‘” Šƒ‰‡•‘˜‡”–‹‡Ǥ•‘—” ‡ƒ•—”‡‡–•™‡”‡’‡”ˆ‘”‡†–™‘›‡ƒ”•’‘•–‘’‡”ƒ–‹˜‡Ž›ǡƒ†‘–ƒ–‘‡‘–Šƒ† ‘‡›‡ƒ”ȋ•‹‹Žƒ”Ž›–‘–Š‡ƒˆ‘”‡‡–‹‘‡†•–—†›Ȍǡƒ†‹”‡ – ‘’ƒ”‹•‘‘ˆ–Š‡†ƒ–ƒ‹•ƒŽ•‘ ‹ˆ‡ƒ•‹„Ž‡Ǥ  Š‡—•‡††‘‡•‘–‰‹˜‡ƒƒ†‡“—ƒ–‡ƒ•™‡”–‘™Š‡–Š‡”‘—”‹ ”‡ƒ•‡†• ”‡’”‡•‡– Š”‘‹ —• Ž‡‡†‡ƒ‘”‘–Ǥ—• Ž‡‡†‡ƒ‹•†‡ˆ‹‡†ƒ•ƒ‹ ”‡ƒ•‡‘ˆˆ”‡‡ ™ƒ–‡”™Š‹ Š‹•™‡ŽŽǦ†‡ˆ‹‡†‘ƒ‰‡–‹ ”‡•‘ƒ ‡‹ƒ‰‹‰ȋ ȌǤȋͳ͵ͳȌ – ƒ‘ —” ˆ”‘ƒ™‹†‡˜ƒ”‹‡–›‘ˆ ƒ—•‡•Ǥ –‡”•‘ˆ‹ƒ–”‘‰‡‹ ‡†‡ƒǡƒ••—•’‡ –‡†Š‡”‡ǡ–Š‡ ‹ ”‡ƒ•‡†—• —Žƒ”™ƒ–‡” ‘–‡–•’‡”•‹•–ƒ‹Ž›‹–Š‡•—„ƒ —–‡’Šƒ•‡ȋ‘‡Ǧ•‹š ‘–Š•ȌǤˆ–‡”–Š‹•ǡƒ†‹–‘–Š‡ Š”‘‹ ’Šƒ•‡ȋε•‹š‘–Š•ȌǡŽ‡••™ƒ–‡”‹••‡‡‹–Š‡ —• Ž‡Ǥ •–‡ƒ†ǡ’”‘‰”‡••‹˜‡—• Ž‡ƒ–”‘’Š›ƒ†”‡’Žƒ ‡‡–™‹–Šˆƒ–ƒ”‡ ‘„•‡”˜‡†Ǥȋͳ͵ͳȌ  •—ƒ”›ǡ–Š‡”‡‹•‘ Ž‡ƒ” ƒ—•‡‘ˆ–Š‡’‡”ƒ‡–Ž›‹ ”‡ƒ•‡†ǤŠ”‘‹  —• Ž‡‡†‡ƒ†—‡–‘‹’ƒ‹”‡†˜‡‘—•ȀŽ›’Šƒ–‹ †”ƒ‹ƒ‰‡‹•’Žƒ—•‹„Ž‡ǡŠ‘™‡˜‡”ǡƒˆ–‡” ”‡˜‹‡™‹‰‘”‡Ž‹–‡”ƒ–—”‡™‡„‡Ž‹‡˜‡–Šƒ–‘–Š‡”‡š’Žƒƒ–‹‘••— Šƒ•‹ ”‡ƒ•‡†ˆƒ– ™‹–Š‹–Š‡—• Ž‡„‡ŽŽ›ƒ†• ƒ”–‹••—‡ˆ‘”ƒ–‹‘ƒ”‡‘”‡Ž‹‡Ž›Ǥ‘‡–Š‡Ž‡••ǡŽ‹––Ž‡ ‘„Œ‡ –‹˜‡”‡•‡ƒ” Š‡š‹•–•–‘•—„•–ƒ–‹ƒ–‡–Š‹•Ǥ ƒŽ•‡’‘•‹–‹˜‡ƒ••‘ ‹ƒ–‹‘•ȋ–›’‡ ‡””‘”•Ȍ ƒ”‡ƒ‘–Š‡”’Žƒ—•‹„Ž‡‡š’Žƒƒ–‹‘†—‡–‘–Š‡Ž‘™•ƒ’Ž‡•‹œ‡ƒ†—Ž–‹’Ž‡ ‘’ƒ”‹•‘• ˆ‘—†‹‘—”•–—†›Ǥ  ƒ•–Ž›ǡ–Š‡”‡ƒ”‡”ƒ†‹‘Ž‘‰‹ ƒŽ‘†ƒŽ‹–‹‡•ƒ†‘”‡‡–Š‘†‘Ž‘‰‹ ƒŽŽ›•‘—† ƒ’’”‘ƒ Š‡•–Šƒ– ‘—Ž†’‘••‹„Ž›‰‹˜‡—•ƒ„‡––‡”ƒ†‘”‡ ‘””‡ –—†‡”•–ƒ†‹‰‘ˆ —• Ž‡‘”„‹†‹–›ǤŽ‡ƒ•‡•‡‡DzŽ‹‹ ƒŽ‹’Ž‹ ƒ–‹‘•ƒ†ˆ—–—”‡”‡•‡ƒ” Šdzˆ‘”‘”‡ –Š‘—‰Š–•‘–Š‹•ƒ––‡”Ǥ

“The decreased TD of the operated muscle could represent localized atrophy”.ŽŽ •‹œ‘‡•Ǧ†‡ ”‡ƒ•‡†ǡ„—–‘Ž›œ‘‡•ƒ† Šƒ‰‡•™‡”‡”‡•’‡ –‹˜‡Ž›„‘”†‡”Ǧ

39 39 •‹‰‹ˆ‹ ƒ–ƒ†•‹‰‹ˆ‹ ƒ–ǤŠ‡†‡ ”‡ƒ•‡†‹–Š‡–™‘‘•– ƒ—†ƒŽœ‘‡• ‘—Ž†„‡ƒ ‹†‹ ƒ–‹‘‘ˆŽ‘ ƒŽ‹œ‡†—• Ž‡ƒ–”‘’Š›‘ˆ‹ƒ–”‘‰‡‹ ‘”‹‰‹Ǥ•†‡• ”‹„‡†ƒ„‘˜‡ǡ™‡ „‡Ž‹‡˜‡–Šƒ–‘•–”‡ –—•—• Ž‡‘”„‹†‹–›†‡˜‡Ž‘’•ƒ–ƒ†‹ˆ‡”‹‘”Ž›–‘–Š‡ ‹–”ƒ—• —Žƒ”’‡”ˆ‘”ƒ–‘”†‹••‡ –‹‘Ǥ ‡”‡ǡ„‘–Š–Š‡’‡”ˆ‘”ƒ–‘”•ƒ†‹–•ƒ”–‡”‹ƒŽ„”ƒ Š‡• ƒ”‡•‡’ƒ”ƒ–‡†ˆ”‘–Š‡—• Ž‡ǤŠ‹•”‡†— ‡•–Š‡—• —Žƒ”„Ž‘‘†•—’’Ž›’‘••‹„Ž› ƒ—•‹‰ ƒ–”‘’Š›Ǥ ƒ††‹–‹‘ǡ–Š‡—• Ž‡ƒŽ•‘•—ˆˆ‡”•ˆ”‘‹ƒ–”‘‰‡‹ †‡‡”˜ƒ–‹‘Ǥ—• Ž‡ ‘”’Š‘Ž‘‰› Šƒ‰‡•ƒ”‡‡š’‡ –‡†–‘‘ —”™Š‡„‘–Šƒ”–‡”‹ƒŽ„Ž‘‘†•—’’Ž›ƒ†‡”˜‡• ƒ”‡•‡’ƒ”ƒ–‡†ˆ”‘–Š‡—• Ž‡„‡ŽŽ›Ǥ  ‘—”•–—†›ǡ–Š‡‡ƒ‘ˆ–Š‡‘’‡”ƒ–‡†—• Ž‡•†‡ ”‡ƒ•‡†ˆ”‘͸ͺǤ͸–‘ ͸ͷǤ͹ȋʹǤͻ†‹ˆˆ‡”‡ ‡ǡPαͲǤͲ͸ͶȌ‹œ‘‡ƒ†ˆ”‘Ͷ͹Ǥͻ–‘ͶͶǤͷȋ͵ǤͶ †‹ˆˆ‡”‡ ‡ǡPαͲǤͲ͵ͷȌ‹œ‘‡Ǥ‘’ƒ”‹‰–Š‡‡ƒ‹œ‘‡„‡–™‡‡‘’‡”ƒ–‡† ˜‡”•—•‘Ǧ‘’‡”ƒ–‡†”‡ –—•—• Ž‡•ǡ–Š‡ˆ‘”‡”™ƒ•ͶǤ͹•ƒŽŽ‡”ȋPαͲǤͲͶͺȌǤƒ‹† †‹ˆˆ‡”‡–Ž›ǡ–Š‡™‹†–Š‘ˆ‘’‡”ƒ–‡†”‡ –—•—• Ž‡‹•͹ΨŽ‡••–Šƒ–Š‡‘Ǧ‘’‡”ƒ–‡†”‡ –—• —• Ž‡ǤŽ–Š‘—‰Š–Š‡•‡†‹ˆˆ‡”‡ ‡•ƒ”‡•ƒŽŽƒ†„‘”†‡”Ǧ•‹‰‹ˆ‹ ƒ–ǡ–Š‡›”ƒ‹•‡ ‹–‡”‡•–‹‰“—‡•–‹‘•‹‡‡†‘ˆ„‡‹‰†‹• —••‡†ǣ •–Š‡ƒ””‘™‹‰‘ˆ–Š‡‘’‡”ƒ–‡†”‡ –—• —• Ž‡”‡ƒŽǫ ˆ›‡•ǡ†‘‡•‹–‹ˆŽ—‡ ‡—• Ž‡ˆ— –‹‘ǫ  ‹‹Žƒ”–‘–Š‡”‡•—Ž–•ǡ–Š‡”‡•—Ž–•Šƒ˜‡–‘„‡‹–‡”’”‡–‡†™‹–Š ƒ—–‹‘†—‡ –‘–Š‡Ž‘™•ƒ’Ž‡•‹œ‡ƒ†—Ž–‹’Ž‡ ‘’ƒ”‹•‘•Ǥ‡ ƒǯ– ‘ Ž—†‡‘™Š‡–Š‡”‘”‘– –Š‡”‡‹•ƒ–”—‡ƒ””‘™‹‰‘ˆ–Š‡‹ˆ”ƒ—„‹Ž‹ ƒŽ•‡‰‡–•‘ˆ–Š‡‘’‡”ƒ–‡†—• Ž‡„‡ŽŽ› „ƒ•‡†‘‘—”†ƒ–ƒǤ‘”‡‘˜‡”ǡ–Š‡‡ƒ•—”‡‡–‹•”ƒ–Š‡”—–”ƒ†‹–‹‘ƒŽƒ•Šƒ• Š‹•–‘”‹ ƒŽŽ›„‡‡–Š‡ Š‘•‡‡ƒ•—”‡‡–•–—†›‹‰”‡ –—•—• Ž‡‘”„‹†‹–›‹  ˆŽƒ’’ƒ–‹‡–•ǤȋͶͺǡͺ͵ǡͳͲͲȌŠ‹•‹‰Š–„‡–Š‡ˆ‹”•–•–—†›–Šƒ–Šƒ•‡˜ƒŽ—ƒ–‡†’‘•–‘’‡”ƒ–‹˜‡  Šƒ‰‡•‘ˆ–Š‡”‡ –—•„‡ŽŽ›ǡƒ†–Š‡”‡‹• ‘•‡“—‡–Ž›‘Ž‹–‡”ƒ–—”‡–Šƒ–•—’’‘”–•‘” —†‡”‹‡•‘—”‘„•‡”˜ƒ–‹‘•Ǥ–‹ŽŽǡ™‡„‡Ž‹‡˜‡–Šƒ–—• Ž‡ƒ–”‘’Š›‹•ƒŽ‹‡Ž› ‘•‡“—‡ ‡‘ˆ ˆŽƒ’Šƒ”˜‡•–‹‰Ȃ‡•’‡ ‹ƒŽŽ›•‹ ‡‹–™ƒ•‘Ž›†‡‘•–”ƒ–‡†‘ ‘‡•‹†‡Ǣƒ‡Ž›–Š‡‘’‡”ƒ–‡†‘‡Ǥ  “Volume calculations are a better way of investigating rectus muscle morbidity” ”‡ˆ‡””‡†Ž‹–‡”ƒ–—”‡ƒ†’ƒ’‡” ǡ–™‘Ǧ†‹‡•‹‘ƒŽ‡ƒ•—”‡‡–•ƒ† ”‘••Ǧ•‡ –‹‘ƒŽ ƒ”‡ƒ•Šƒ˜‡„‡‡—•‡†–‘‹˜‡•–‹‰ƒ–‡”‡ –—•—• Ž‡‘”„‹†‹–›Ǥ‹–Š–Š‡”ƒ’‹†Ž›ƒ†˜ƒ ‹‰ ‹ƒ‰‹‰–‡ Š‹“—‡•ƒ†•‘ˆ–™ƒ”‡ˆ‘—†‹”ƒ†‹‘Ž‘‰›ǡ˜‘Ž—‡ ƒŽ —Žƒ–‹‘•‘ˆˆ‡”ƒ„‡––‡” ™ƒ›‘ˆƒ••‡••‹‰‘”’Š‘Ž‘‰‹ ƒŽ—• Ž‡ Šƒ‰‡•Ǥ ‡”‡ǡƒŽƒ”‰‡—„‡”‘ˆ ”‘••Ǧ•‡ –‹‘ƒŽ ƒ”‡ƒ•ƒ”‡ ‘•‘Ž‹†ƒ–‡†–‘ ƒŽ —Žƒ–‡—• Ž‡˜‘Ž—‡•ǡƒ†˜‘Ž—‡”‡†‡”‹‰ ƒ„‡—•‡† ƒ•ƒƒ†Œ— ––‘‹ŽŽ—•–”ƒ–‡–Š‡—• Ž‡„‡ŽŽ‹‡•Ǥ ‹‰—”‡ͳͷƒ†‹ŽŽ—•–”ƒ–‡•— Š˜‘Ž—‡ ”‡†‡”‹‰™Š‹ Š™‡Šƒ˜‡’‡”ˆ‘”‡†‘• ƒ•ˆ”‘–Š‡•–—†›†‹• —••‡†Ǥ ǡ˜‘Ž—‡ ƒŽ —Žƒ–‹‘•Šƒ˜‡„‡‡ƒ††‡†Ǥ 

40 40 

 Fig. 15 Volume rendering by using CT scans. A (above): Volume rending. B (below): Volume rendering with volume calculations of each rectus belly. Illustrations: Dr. Gerhard Bosse (Department of Radiology, Rikshospitalet, Oslo University Hospital)

41 41  ʹͲͳͺǡ™‡™‡”‡‡š ‹–‡†–‘•‡‡–Šƒ–ƒ‰”‘—’‘ˆ‘—–Š‘”‡ƒ’Žƒ•–‹ •—”‰‡‘• ’—„Ž‹•Š‡†ƒƒ”–‹ Ž‡™Š‡”‡–Š‡›Šƒ†‹ˆƒ –ƒ••‡••‡†”‡ –—•—• Ž‡˜‘Ž—‡•Ǥȋͳ͵ʹȌ‘–Š ’”‡‘’‡”ƒ–‹˜‡˜‡”•—•’‘•–‘’‡”ƒ–‹˜‡—• Ž‡˜‘Ž—‡•ǡƒ†‘’‡”ƒ–‡†˜‡”•—•‘Ǧ‘’‡”ƒ–‡† —• Ž‡˜‘Ž—‡•ǡ™‡”‡ ‘’ƒ”‡†‹ʹͷ’ƒ–‹‡–•Ǥ•‹‰ǡ˜‘Ž—‡‡ƒ•—”‡‡–•™‡”‡ ’‡”ˆ‘”‡†ˆ”‘–Š‡—„‹Ž‹ —•–‘–Š‡DzŽ‘™‡”ƒ”‰‹dzǤŠ‡DzŽ‘™‡”ƒ”‰‹dz‹•‘– •’‡ ‹ˆ‹‡†ǡŠ‘™‡˜‡”™‡„‡Ž‹‡˜‡–Š‡›”‡ˆ‡”–‘–Š‡ ƒ—†ƒŽ„‘”†‡”‘ˆ–Š‡—†‡”‹‡† ƒ„†‘‹ƒŽˆŽƒ’Ǥ –Š‡‹”•–—†›ǡ–Š‡‡ƒˆ‘ŽŽ‘™Ǧ—’–‹‡„‡–™‡‡”‡ ‘•–”— –‹˜‡•—”‰‡”› ƒ†ƒ„†‘‹ƒŽ™ƒ•Ͷ͹Ǥ͵‘–Š•Ȃƒ’’”‘š‹ƒ–‡Ž›–Š‡†‘—„Ž‡†‘ˆ‘—”•ǤŠ‡ƒ—–Š‘”• ‘–‡†ƒ˜‘Ž—‡†‡ ”‡ƒ•‡‘ˆͳͻǤͷͶ ͵‘–Š‡‘’‡”ƒ–‡†•‹†‡ȋPδͲǤͲͲͳȌǤ–Š‡ ‘–”ƒŽƒ–‡”ƒŽǡ‘Ǧ‘’‡”ƒ–‡†•‹†‡ƒ†‡ ”‡ƒ•‡‘ˆͳʹǤ͵ͻ ͵™ƒ•ƒŽ•‘ˆ‘—†ȋPδͲǤͲͲͳȌǤ Š‡•‡ Šƒ‰‡• ‘—Ž†’‘‹–‹ƒ†‹”‡ –‹‘‘ˆ‹ƒ–”‘‰‡‹ —• Ž‡ƒ–”‘’Š›Ǥ‡–ǡ’‘•–‘’‡”ƒ–‹˜‡ †‡ ‘†‹–‹‘‹‰‹‰Š–„‡‡˜‡‘”‡”‡ƒ•‘ƒ„Ž‡ƒ•„‘–Š•‹†‡•ǯ˜‘Ž—‡•†‡ ”‡ƒ•‡† •‹‰‹ˆ‹ ƒ–Ž›ǤŠ‡ ‘’ƒ”‹•‘‘ˆ‘’‡”ƒ–‡†˜‡”•—•‘Ǧ‘’‡”ƒ–‡†—• Ž‡˜‘Ž—‡••Š‘™‡† ‘Ž›ƒͻΨ†‹ˆˆ‡”‡ ‡™Š‹ Š™ƒ•‹•‹‰‹ˆ‹ ƒ–ȋPαͲǤͳͲȌǤ  ‘†ƒ–‡ǡ™‡„‡Ž‹‡˜‡–Šƒ––Š‹•’—„Ž‹ ƒ–‹‘”‡’”‡•‡–•–Š‡„‡•–‡–Š‘†—•‡†‹ ‹˜‡•–‹‰ƒ–‹‰”‡ –—•—• Ž‡‘”„‹†‹–›Ǥ ƒ ‘”†ƒ ‡™‹–Š‘—””‡•—Ž–•ǡ–Š‡› †‡‘•–”ƒ–‡†”‡ –—•—• Ž‡ Šƒ‰‡•ȂƒŽ–Š‘—‰Š‘–„‡‹‰•‹‰‹ˆ‹ ƒ–Ž›†‹ˆˆ‡”‡– ‘’ƒ”‹‰–Š‡‘’‡”ƒ–‡†ƒ†–Š‡‘Ǧ‘’‡”ƒ–‡†”‡ –—••‹†‡Ǥ  ‡•’‹–‡Šƒ˜‹‰ƒ‹’”‘˜‡†”ƒ†‹‘Ž‘‰‹ ‡–Š‘†‘Ž‘‰›ǡ–Š‡‹”•–—†›†‘‡•‘–•ƒ› ƒ›–Š‹‰ƒ„‘—–”‡ –—•—• Ž‡•–”‡‰–Šƒ†ˆ— –‹‘ƒŽ‹–›Ǥ

“Rectus muscle strength and functionality are prime endpoints in evaluating muscle morbidity”. —””‡•‡ƒ” Š‰”‘—’„‡Ž‹‡˜‡•–Šƒ–ƒ –—ƒŽ—• Ž‡ˆ— –‹‘ Šƒ‰‡• ƒ”‡‘”‡‹’‘”–ƒ––‘‹˜‡•–‹‰ƒ–‡–Šƒ‘”’Š‘Ž‘‰‹ ƒŽ—• Ž‡ Šƒ‰‡•‘„•‡”˜‡†‘ ”ƒ†‹‘Ž‘‰‹ ƒŽ‹˜‡•–‹‰ƒ–‹‘•ǤŠ‡”‡ƒ”‡ǡˆ‘”–—ƒ–‡Ž›ǡ•–—†‹‡•–Šƒ–Šƒ˜‡ˆ‘ —•‡†‘”‡‘ •–”‡‰–Šƒ†ˆ— –‹‘ƒŽ‹–›‹–Š‡ ˆŽƒ’ƒ„†‘‡Ǥ‘‡‘ˆ–Š‡•‡•–—†‹‡•Šƒ˜‡ˆ‘—† Ž‹‹–‡†‡˜‹†‡ ‡‘ˆƒ„†‘‹ƒŽ™ƒŽŽ™‡ƒ‡‹‰ƒˆ–‡” ˆŽƒ’•—”‰‡”›ǡ•— Šƒ•ǣͳȌ Ž‘†‡‡Ž‡–ƒŽǤ”‡’‘”–‡†ƒŽ‹‹–‡††‡ ”‡ƒ•‡‘ˆ–”—ˆŽ‡š‹‰•–”‡‰–Šǡ›‡––Š‡ƒ –‹˜‹–‹‡•‘ˆ †ƒ‹Ž›Ž‹˜‹‰™‡”‡—ƒˆˆ‡ –‡†‹ƒŽŽ’ƒ–‹‡–•ȋͶͻȌǡʹȌ —––‡”‡–ƒŽǤ—•‡†‹•‘‹‡–‹  †›ƒ‘‡–‡”ƒ†•Š‘™‡†‘•‹‰‹ˆ‹ ƒ–†‹ˆˆ‡”‡ ‡• ‘’ƒ”‹‰ ˆŽƒ’’ƒ–‹‡–• ™‹–ŠŠ‡ƒŽ–Š› ‘–”‘Ž•ȋͳ͵͵Ȍǡ͵Ȍ¡••ƒ‡–ƒŽǤ•Š‘™‡†ƒŽ‘•–‹†‡–‹ ƒŽ ›‘•‘‘‰”ƒ’Š‹ ”‡•—Ž–• ‘’ƒ”‹‰‘’‡”ƒ–‡†ƒ†‘Ǧ‘’‡”ƒ–‡†—• Ž‡„‡ŽŽ‹‡•–™‘ ‘–Š•’‘•–‘’‡”ƒ–‹˜‡Ž›ȋͳ͵ͶȌǡͶȌ‘†‡‡–ƒŽǤŠƒ†‘•‹‰‹ˆ‹ ƒ–”‡†— –‹‘‹—• Ž‡ •–”‡‰–Šˆ‘”„‘–Š ‘ ‡–”‹ ƒ†‹•‘‡–”‹ —• Ž‡–‡•–‹‰ȋͳ͵ͷȌǡƒ†ͷȌ†ƒ‡–ƒŽǤ ”‡’‘”–‡†ƒ‹•‹‰‹ˆ‹ ƒ–†‡ ”‡ƒ•‡‘ˆ–”—ˆŽ‡š‘”•–”‡‰–Š‹„‘–Š•‹‰Ž‡Ǧƒ††‘—„Ž‡Ǧ ’‡†‹ Ž‡† ˆŽƒ’•—•‹‰‹•‘‹‡–‹ †›ƒ‘‡–‡”ȋͳ͵͸ȌǤ–Š‡ ‘–”ƒ”›ǡ‘–Š‡” •–—†‹‡•Šƒ˜‡ˆ‘—†‡˜‹†‡ ‡‘ˆƒ•—„•–ƒ–‹ƒŽ—• Ž‡ƒ –‹˜‹–›Ȁ•–”‡‰–Š”‡†— –‹‘ǡ•— Šƒ•ǣ ͳȌ‘––‡”‘‡–ƒŽǤ’‡”ˆ‘”‡†‡Ž‡ –”‘›‘‰”ƒ’Š‹ ‡šƒ‹ƒ–‹‘•ƒ††‡‘•–”ƒ–‡†–Šƒ––Š‡ ‘’‡”ƒ–‡†—• Ž‡„‡ŽŽ›ƒ –‹˜‹–›™ƒ•͹ͲΨ‘ˆ‘Ǧ‘’‡”ƒ–‡†—• Ž‡„‡ŽŽ›ƒ –‹˜‹–›ƒ–ͳͷ ‘–Š•ȋͳ͵͹ȌǡʹȌ‡Ž„‡”‡–ƒŽǤ—•‡†•–ƒ†ƒ”†‹œ‡†ƒ„†‘‹ƒŽ—• Ž‡–‡•–•ƒ†•Š‘™‡†ƒ •‹‰‹ˆ‹ ƒ–Ž›”‡†— ‡†•–”‡‰–ŠȀˆ— –‹‘‹–Š‡Ž‘™‡”ƒ„†‘‡ƒ–‘‡›‡ƒ” ’‘•–‘’‡”ƒ–‹˜‡Ž›ȋͳ͵ͺȌǡƒ†͵Ȍ‡‡‡–ƒŽǤ†‡–‡ –‡†ˆ— –‹‘ƒŽ™‡ƒ‡••‹ͳ͹Ψ‘ˆ–Š‡‹” ’ƒ–‹‡–•ƒ–‘‡›‡ƒ”’‘•–‘’‡”ƒ–‹˜‡Ž›—•‹‰—’’‡”ƒ†Ž‘™‡”ƒ„†‘‹ƒŽ—• Ž‡ˆ— –‹‘ –‡•–•ȋͳʹ͹ȌǤ  Ž–Š‘—‰Š–Š‡•‡”‡•—Ž–•ƒ”‡‘–ˆ—ŽŽ› ‘‰”—‡–ǡ‘—”ƒ””ƒ–‹˜‡”‡˜‹‡™‘ˆ”‡Ž‡˜ƒ–

42 42 Ž‹–‡”ƒ–—”‡’ƒ‹–•ƒ’‹ –—”‡‘ˆ”ƒ–Š‡”Ž‹‹–‡†ǡ„—–•‘‡–‹‡••–ƒ–‹•–‹ ƒŽŽ›•‹‰‹ˆ‹ ƒ–ǡ †‡ ”‡ƒ•‡‘ˆ—• Ž‡•–”‡‰–Šƒ†ˆ— –‹‘™Š‹ Š‹‰‡‡”ƒŽ†‘‘–Šƒ˜‡ƒ‹’ƒ –‘ ƒ –‹˜‹–‹‡•‘ˆ†ƒ‹Ž›Ž‹˜‹‰Ǥ‡„‡Ž‹‡˜‡–Šƒ––Š‡ƒ† Šƒ‰‡•ȋ‘ˆŽ‡••–Šƒͷ ‹ŽŽ‹‡–‡”•Ȍ†‡‘•–”ƒ–‡†‹‘—”•–—†›ƒ††–‘•— Š”‡•‡ƒ” Šƒ††‘—„––Šƒ––Š‡› ‡‰ƒ–‹˜‡Ž›ƒˆˆ‡ ––Š‡’ƒ–‹‡–•ǯƒ –‹˜‹–‹‡•‘ˆ†ƒ‹Ž›Ž‹˜‹‰Ǥ  “DIEAP flap harvesting causes significant DRA changes”.‹•—•‡†‹‘—”•–—†›ˆ‘” –Š‡‹–‡””‡ –—•†‹•–ƒ ‡‡ƒ•—”‡†Ǥ•‹• Šƒ”ƒ –‡”‹œ‡†ƒ•ƒ’ƒ–Š‘Ž‘‰‹ ™‹†‡‹‰‘ˆ –Š‡Ž‹‡ƒƒŽ„ƒǡ‘‡ ƒƒ”‰—‡–Šƒ–‹–‡””‡ –—•†‹•–ƒ ‡•Š‘—Ž†Šƒ˜‡„‡‡–Š‡–‡”—•‡†Ǥ Š‡‘‡ Žƒ–—”‡‹•†‹• —••‡†‘”‡‹†‡–ƒ‹Ž„‡Ž‘™Ǥ   ‘—Ž†’”‡•‡– Ž‹‹ ƒŽŽ›ƒ•ƒ•—’”ƒǦƒ†Ȁ‘”‹ˆ”ƒ—„‹Ž‹ ƒŽ„—Ž‰‡‹–Š‡ ‹†Ž‹‡Ǥȋͳ͵ͻȌŠ‡”‡‹•‘ˆƒ• ‹ƒŽ†‡ˆ‡ –‹˜‘Ž˜‡†ƒ‹‰‹–†‹ˆˆ‡”‡–ˆ”‘ƒ‘”†‹ƒ”› Š‡”‹ƒǤȋͳͶͲǡͳͶͳȌ‘‘—”‘™Ž‡†‰‡ǡ–Š‹•‹•–Š‡˜‡”›ˆ‹”•–•–—†›–Šƒ–Šƒ•‡ƒ•—”‡† Šƒ‰‡•ƒˆ–‡”Šƒ”˜‡•–‹‰ƒƒ„†‘‹ƒŽˆŽƒ’Ǥ‡ˆ‘—†–Šƒ–•—’”ƒ—„‹Ž‹ ƒŽȋœ‘‡Ȍ ™ƒ••‹‰‹ˆ‹ ƒ–Ž›†‡ ”‡ƒ•‡†™‹–Š•—”‰‡”›ǡ™Š‡”‡ƒ•‹ˆ”ƒ—„‹Ž‹ ƒŽȋœ‘‡•ƒ†Ȍ ™ƒ••‹‰‹ˆ‹ ƒ–Ž›‹ ”‡ƒ•‡†™‹–Š•—”‰‡”›Ǥ‘‘‹‰ƒ––Š‡•’‡ ‹ˆ‹ —„‡”•ǡ‡ƒ‹ œ‘‡†‡ ”‡ƒ•‡†ˆ”‘ʹ͵ǤͲ–‘ͳͻǤͷȋ͵Ǥͷ†‹ˆˆ‡”‡ ‡ǡPαͲǤͲ͵͸Ȍǡ‡ƒ‹ œ‘‡‹ ”‡ƒ•‡†ˆ”‘ͺǤʹ–‘ͳͳǤͺȋ͵Ǥ͸†‹ˆˆ‡”‡ ‡ǡPαͲǤͲ͵ͲȌǡƒ†‡ƒ ‹œ‘‡‹ ”‡ƒ•‡†ˆ”‘ͳǤͺ–‘ͷǤ͵ȋ͵Ǥͷ†‹ˆˆ‡”‡ ‡ǡPαͲǤͲ͵ʹȌǤ‡ƒ‹ œ‘‡ȋ—„‹Ž‹ ƒŽœ‘‡Ȍ†‡ ”‡ƒ•‡†‹•‹‰‹ˆ‹ ƒ–Ž›ˆ”‘ʹͻǤͲ–‘ʹ͹ǤͷǤ  ‡‡”ƒŽŽ›•’‡ƒ‹‰ǡ‘‡ ƒ•‡‡–Šƒ–Ž‹‡ƒƒŽ„ƒ‹•™‹†‡•–ƒ––Š‡—„‹Ž‹ ƒŽœ‘‡ ȋ̱͵ͲȌǡˆ‘ŽŽ‘™‡†„›•—’”ƒ—„‹Ž‹ ƒŽȋ̱ʹͲȌƒ†‹ˆ”ƒ—„‹Ž‹ ƒŽœ‘‡•ȋ̱ͳͲ ƒ†̱ͷȌǤŠ‹•‹•–Š‡ ƒ•‡„‘–Š’”‡Ǧƒ†’‘•–‘’‡”ƒ–‹˜‡Ž›ǡŠ‘™‡˜‡”ǡ–Š‡—„‡”• Šƒ‰‡ƒ•†‡• ”‹„‡†ƒ„‘˜‡Ǥ‡Š›’‘–Š‡•‹œ‡–Šƒ––Š‡†‡ ”‡ƒ•‡†•—’”ƒ—„‹Ž‹ ƒŽŽ›‹• ƒ—•‡†„›–Š‡‹ˆ‡”‹‘”ƒ†‡†‹ƒŽ‘„‹Ž‹œƒ–‹‘‘ˆ–Š‡—†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’‹ †‘‘”†‡ˆ‡ – Ž‘•—”‡ǤŠ‡ ƒ—•‡‘ˆ‹ ”‡ƒ•‡†‹ˆ”ƒ—„‹Ž‹ ƒŽ‹•’”‘„ƒ„Ž›‘”‡ —Ž–‹ˆƒ –‘”‹ƒŽƒ† ‘’Ž‡šǤ‡†‘ǯ–Šƒ˜‡ƒ Ž‡ƒ”Š›’‘–Š‡•‹•‘ˆ–Š‹•‹ˆ”ƒ—„‹Ž‹ ƒŽ ‹ ”‡ƒ•‡‘–Š‡”–Šƒ‘™‹‰–Šƒ–œ‘‡•ƒ† ‘˜‡”ƒ”‡ƒ•™Š‡”‡–Š‡ƒ„†‘‹ƒŽ™ƒŽŽ ‹–‡‰”‹–›‹•˜‹‘Žƒ–‡†–Š‡‘•–Ǥ  Ž–Š‘—‰Š–Š‡–‡”‹•—•‡† ‘•‹•–‡–Ž›‹‘—”•–—†›ǡƒ›’ƒ–‹‡–•†‹†‘– ‡š ‡‡†–Š‡’ƒ–Š‘Ž‘‰‹  —–Ǧ‘ˆˆ•’”‘’‘•‡†„›ƒ–Š‡–ƒŽǤȋͳͶʹȌŠ‡›’‡”ˆ‘”‡†ƒ ‘„‹‡† ƒ†ƒ˜‡”‹ ƒ†”ƒ†‹‘Ž‘‰‹ •–—†›ǡƒ†•—‰‰‡•–‡†–Š‡ˆ‘ŽŽ‘™‹‰ —–Ǧ‘ˆˆ•ǣDz‡Ž‘™–Š‡ƒ‰‡‘ˆ Ͷͷǡ†‹ƒ•–ƒ•‹• ƒ„‡†‡ˆ‹‡†ƒ•ƒ•‡’ƒ”ƒ–‹‘„‡–™‡‡–Š‡–™‘”‡ –—•Ǥ‹‡š ‡••‘ˆͳͲ ƒ„‘˜‡–Š‡—„‹Ž‹ —•ǡʹ͹ƒ––Š‡Ž‡˜‡Ž‘ˆ–Š‡—„‹Ž‹ ƒŽ”‹‰ǡƒ†ͻ„‡Ž‘™–Š‡ —„‹Ž‹ —•Ǥˆ–‡”–Š‡ƒ‰‡‘ˆͶͷǡ–Š‡ ‘””‡•’‘†‹‰˜ƒŽ—‡•ƒ”‡ͳͷǡʹ͹ǡƒ†ͳͶǤdzƒ•‡† ‘–Š‡‹” —–Ǧ‘ˆˆ•ǡ–Š‡ˆ‘ŽŽ‘™‹‰—„‡”•‘ˆ’ƒ–‹‡–•‹‘—”•–—†›Šƒ†ƒ’ƒ–Š‘Ž‘‰‹  ȋ—•‹‰–Š‡‡ƒ‡ƒ•—”‡†„›–Š‡–™‘”ƒ†‹‘Ž‘‰‹•–•ȌǣͳȌ‘‡ȋ•—’”ƒ—„‹Ž‹ ƒŽȌǣ ͳʹȀͳͶȋ’”‡‘’Ȍƒ†ͳͲȀͳͶȋ’‘•–‘’ȌǡʹȌ‘‡ȋ—„‹Ž‹ ƒŽȌǣ͹ȀͳͶȋ’”‡‘’Ȍƒ†ͺȀͳͶ ȋ’‘•–‘’Ȍǡƒ†͵Ȍ‘‡ȋ‹ˆ”ƒ—„‹Ž‹ ƒŽȌǣʹȀͳͶȋ’”‡‘’Ȍƒ†ͶȀͳͶȋ’‘•–‘’ȌǤ  Š‡ Šƒ‰‡•ˆ‘—†‹‘—”•–—†›ƒ”‡”ƒ–Š‡”Ž‹‹–‡†ȋŽ‡••–Šƒˆ‘—” ‹ŽŽ‹‡–‡”•ȌǡŠ‘™‡˜‡”ǡ–Š‡•–ƒ–‹•–‹ ƒŽ ‘’ƒ”‹•‘•›‹‡Ž†•‹‰‹ˆ‹ ƒ–PǦ˜ƒŽ—‡•ǤŠ‹•†‘‡• ‘–‡ ‡••ƒ”‹Ž›‡ƒ–Šƒ––Š‡ Šƒ‰‡•’Žƒ›ƒ‹’‘”–ƒ–’ƒ”–‹†‘‘”Ǧ•‹–‡ ‘”„‹†‹–›Ǥ‡˜‡”–Š‡Ž‡••ǡ™‡Š›’‘–Š‡•‹œ‡–Šƒ––Š‡‹ ”‡ƒ•‡†‹ˆ”ƒ—„‹Ž‹ ƒŽ‹‰Š–„‡ ƒˆƒ –‘” ‘–”‹„—–‹‰‹ ‘–‘—”ƒ„‘”ƒŽ‹–‹‡••‡‡ƒˆ–‡”˜ƒ”‹‘—•ƒ„†‘‹ƒŽˆŽƒ’ ’”‘ ‡†—”‡•Ȃ‡•’‡ ‹ƒŽŽ›ƒ„†‘‹ƒŽ„—Ž‰‹‰‹–Š‡‹†Ž‹‡ǤȋͶͷǡͶ͹ǡͷͲǡͷͳȌ”ƒ—ƒ†‹†ǡ

43 43 ‹ˆƒ –ǡ•Š‘™–Šƒ–‡˜‡•ƒŽŽ•ǡƒ••‡‡‹ˆ”ƒ—„‹Ž‹ ƒŽŽ›ǡ ƒ ƒ—•‡ƒ„†‘‹ƒŽ „—Ž‰‹‰‘”ƒ„†‘‹ƒŽ™ƒŽŽ’”‘–”—•‹‘ǤȋͳͶ͵Ȍ ‡ƒŽ•‘”‡’‘”–‡†–Šƒ–‡‹‰Š–’ƒ–‹‡–•™‹–Š †‹†‘–ƒ‹ˆ‡•–•‹‰‹ˆ‹ ƒ–ƒ„†‘‹ƒŽ’”‘–”—•‹‘Ǥ”ƒ—ƒ•—‰‰‡•–‡†ǡ–Š‡”‡ˆ‘”‡ǡ –Šƒ–ƒ„†‘‹ƒŽ’”‘–”—•‹‘•Š‘—Ž†”‡’Žƒ ‡ƒ•–Š‡’”‹‡‹†‹ ƒ–‘”‘ˆƒ„†‘‹ƒŽ™ƒŽŽ Žƒš‹–›Ǥ  ’‘”–ƒ–Ž›ǡƒ„†‘‹ƒŽ„—Ž‰‹‰ ƒ—•‡•”ƒ”‡Ž›ƒ›†‹• ‘ˆ‘”–ǡƒ† ‘•‡–‹  ‘ ‡”•ƒ”‡–Š‡‘•–ˆ”‡“—‡– ‘’Žƒ‹–ǤȋͳͶͶȌ‘‡’ƒ–‹‡–•†‘ǡŠ‘™‡˜‡”ǡ”‡’‘”– ’Š›•‹ ƒŽ•›’–‘•™Š‹ Š ‘—Ž†„‡”‡Žƒ–‡†–‘–Š‡Ȃˆ‘”‡šƒ’Ž‡ƒ„†‘‹ƒŽ †‹• ‘ˆ‘”–ƒˆ–‡”ˆ‘‘†‹‰‡•–‹‘ƒ†Ž‘™‡”„ƒ ’ƒ‹ǤȋͳͶͶǡͳͶͷȌŠƒ•ƒŽ•‘„‡‡ ƒ••‘ ‹ƒ–‡†™‹–ŠŽ‡••ƒ„†‘‹ƒŽ™ƒŽŽ—• Ž‡•–”‡‰–ŠȋͳͶ͸Ȍǡƒ†™‘”•‡’‡Ž˜‹ ˆŽ‘‘” ˆ— –‹‘ȋͳͶ͹ǡͳͶͺȌǤ–Š‡”•–—†‹‡•”‡’‘”–ˆ‡™‘”‘•‹‰‹ˆ‹ ƒ–ƒ••‘ ‹ƒ–‹‘•„‡–™‡‡ ƒ†’Š›•‹ ƒŽ•›’–‘•ȋͳͶͻǡͳͷͲȌǡƒ†ƒ•›•–‡ƒ–‹ ”‡˜‹‡™’—„Ž‹•Š‡†‹ʹͲͳͻ ‘ Ž—†‡†–Šƒ–‘•–‡˜‹†‡ ‡‹”‡•‡ƒ” Š‹•™‡ƒǤȋͳͷͲȌ‡†‘‘–•–”‘‰Ž›„‡Ž‹‡˜‡ –Šƒ– Šƒ‰‡• ƒ—•‡’ƒ‹ƒ†Ȁ‘”ˆ— –‹‘ƒŽ‹’ƒ‹”‡–ǡŠ‘™‡˜‡”ǡ–Š‹•‹•‘– ƒ††”‡••‡†‹‘—”•–—†›Ǥ  “DIEAP flap harvesting could cause persistent seromas”.—”‘„•‡”˜ƒ–‹‘‘ˆ ’‘•–‘’‡”ƒ–‹˜‡•‡”‘ƒ•ƒ††•–‘–Š‡•–—†‹‡•†‡‘•–”ƒ–‹‰–Šƒ–•‡”‘ƒ‹•ƒ”ƒ–Š‡” ˆ”‡“—‡– ˆŽƒ’†‘‘”Ǧ•‹–‡ ‘’Ž‹ ƒ–‹‘Ǥȋͷ͸ǡͳͷͳǦͳͷͶȌ— ŠˆŽ—‹† ‘ŽŽ‡ –‹‘•ƒ›„‡ †—‡–‘†ƒƒ‰‡‘ˆ–Š‡Ž‘‘•‡ƒ”‡‘Žƒ”Žƒ›‡”‘ˆ–Š‡ƒ–‡”‹‘””‡ –—••Š‡ƒ–Šǡ—‘„Ž‹–‡”ƒ–‡† †‡ƒ†•’ƒ ‡ȋƒˆ–‡”–Š‡†‡ˆ‡ – Ž‘•—”‡Ȍǡ’”‡ƒ–—”‡†”ƒ‹”‡‘˜ƒŽǡƒ†„‘†›Šƒ„‹–—•Ǥȋͳͷͷǡ ͳͷ͸Ȍ  ƒ†‡‰Š‹ƒ†ƒŽƒ–ƒƒ”„‹–”ƒ”‹Ž›†‡ˆ‹‡†•‡”‘ƒ•’”‡•‡–ƒˆ–‡”–Š”‡‡‘–Š•ƒ• Dz’‡”•‹•–‡–dzǤȋͳͷͳȌŠ‡›”‡’‘”–‡†–Š”‡‡’ƒ–‹‡–•–Šƒ–‡‡†‡†‡š ‹•‹‘‘ˆ–Š‡•‡”‘ƒ•ƒ  –‘ƒ Š‹‡˜‡’‡”ƒ‡–”‡•‘Ž—–‹‘ǤŽ–Š‘—‰Š‘—”’ƒ–‹‡–•™‡”‡‘–‹‡‡†‘ˆ•—”‰‹ ƒŽ ‹–‡”˜‡–‹‘ǡ–Š‡•‡•‡”‘ƒ• ƒ„‡ Žƒ••‹ˆ‹‡†ƒ•’‡”•‹•–‡–Ǥ‡ˆ‘—†‹–•—”’”‹•‹‰–Šƒ– •‡”‘ƒ•™‡”‡’”‡•‡––™‘›‡ƒ”•’‘•–‘’‡”ƒ–‹˜‡Ž›ǡƒ†“—‡•–‹‘ǣ ‘™ ƒ™‡’”‡˜‡– –Š‡ǫ   •–‡ƒ†‘ˆ Ž‘•‹‰–Š‡†‘‘”Ǧ•‹–‡Ž‹‡ƒ•–ƒ†ƒ”†ƒ„†‘‹‘’Žƒ•–›ǡ‹• ‘–‹‡–ƒŽǤ ‹’Ž‡‡–‡†ƒ–‡ Š‹“—‡ƒ‡†Dzdzȋ ƒ—ŽƒǦƒ••‹•–‡†ǡŽ‹‹–‡†—†‡”‹‹‰ǡƒ† ’”‘‰”‡••‹˜‡Š‹‰ŠǦ–‡•‹‘•—–—”‡ȌǤȋͳͷ͸ȌŠ‹•‘†‹ˆ‹ ƒ–‹‘Ž‡ƒ†–‘•‹‰‹ˆ‹ ƒ–Ž›†‡ ”‡ƒ•‡† †ƒ‹Ž›ƒ„†‘‹ƒŽ†”ƒ‹ƒ‰‡ǡ‡ƒ”Ž‹‡”†”ƒ‹”‡‘˜ƒŽǡƒ†ƒ†”ƒƒ–‹ ƒŽŽ›Ž‘™‡”•‡”‘ƒ ”ƒ–‡Ǥȋͳͷ͸Ȍƒ•‡†‘–Š‡•‡”‡•—Ž–•ǡ‹– ‘—Ž†„‡–Šƒ–‘—”’ƒ–‹‡–•™‘—Ž†Šƒ˜‡„‡‡ˆ‹–‡† ˆ”‘ƒDzdz–‡ Š‹“—‡‹–Š‡†‘‘”Ǧ•‹–‡ Ž‘•—”‡ǤŽ‡ƒ•‡•‡‡DzŽ‹‹ ƒŽ‹’Ž‹ ƒ–‹‘•ƒ† ˆ—”–Š‡””‡•‡ƒ” Šdzˆ‘”ƒ‡š–‡†‡††‹• —••‹‘ƒ†‘–Š‡”’‘••‹„Ž‡•‡”‘ƒǦ’”‡˜‡–‹‰ •–”ƒ–‡‰‹‡•Ǥ  “Hernias and abdominal bulging are not common complications of DIEAP flap surgery”.‘‡™Š‡”‹ƒ•‘”ƒ„†‘‹ƒŽ„—Ž‰‹‰™‡”‡ˆ‘—†‹‘—”•–—†›ǤŠ‹• ‘„•‡”˜ƒ–‹‘‹• ‘•‹•–‡–™‹–Š’”‹‘”‡–ƒǦƒƒŽ›•‡••Š‘™‹‰Ž‘™”ƒ–‡•ƒˆ–‡” ˆŽƒ’ Šƒ”˜‡•–‹‰ǤȋͶ͹ǡͷͳǡͺͶȌŠ‡•‡•–—†‹‡•Šƒ˜‡•—ƒ”‹œ‡††‡ ƒ†‡•‘ˆ”‡•‡ƒ” Š„›’‘‘Ž‹‰ ’‘™‡”ˆ”‘ƒ›‹†‹˜‹†—ƒŽ’—„Ž‹ ƒ–‹‘•Ǥ –Š‡‡–ƒǦƒƒŽ›•‹•’—„Ž‹•Š‡†„›ƒ‡–ƒŽǤǡ –Š‡’‘‘Ž‡†•—ƒ”› ‘’Ž‹ ƒ–‹‘”ƒ–‡•‘ˆŠ‡”‹ƒƒ†„—Ž‰‹‰™‡”‡ͲǤͺΨȋͻͷΨ ǣͲǤʹǦ ͳǤ͵ΨȌƒ†͵ǤͳΨȋͻͷΨ ǣͳǤ͸ǦͶǤ͸ΨȌ”‡•’‡ –‹˜‡Ž›ǤȋͷͳȌ— Š‡–ƒǦƒƒŽ›•‡•†‘”‡†— ‡ „‹ƒ•ƒ†›‹‡Ž†‘”‡”‡ƒŽ‹•–‹ —„‡”•ȋ ‘’ƒ”‡†–‘‹†‹˜‹†—ƒŽǡŽ‘™Ǧ’‘™‡”‡†•–—†‹‡•

44 44 Ž‹‡‘—”‘™ȌǤ  •†‘ —‡–‡†‹–Š‡ƒˆ‘”‡‡–‹‘‡†‡–ƒǦƒƒŽ›•‹•ǡ„—Ž‰‹‰‹•‘”‡ ‘‘ –ŠƒŠ‡”‹ƒˆ‘”ƒ–‹‘ǤȋͷͳȌ•’‡ ‹ƒŽŽ›–Š‡Ž‘™‡”ƒ„†‘‹ƒŽ„—Ž‰‡ǡ•‡‡‹ˆ”ƒ—„‹Ž‹ ƒŽŽ›ǡ ‹•ƒ••‘ ‹ƒ–‡†™‹–Š ˆŽƒ’•Ǥȋͳͷ͹ȌƒŠƒ„‡†‹ƒƒ†‘‡’‡”ˆ‘”‡†ƒ”‡–”‘•’‡ –‹˜‡ ”‡˜‹‡™‘ˆͳʹ͵ ˆŽƒ’•–‘Ž‘‘ˆ‘”ˆƒ –‘”•–Šƒ–ƒ›’”‡†‹•’‘•‡–‘–Š‡Ž‘™‡” ƒ„†‘‹ƒŽ„—Ž‰‡Ǥȋͳͷ͹Ȍ›”‡˜‹‡™‹‰–Š‡Ž‹–‡”ƒ–—”‡ǡ–Š‡›Šƒ†ˆ‘—†‹ ‹†‡ ‡•–Šƒ– ”ƒ‰‡†ˆ”‘ͲǤ͹Ψ–‘ͷΨƒ†™ƒ–‡†–‘Šƒ˜‡ƒ Ž‘•‡”Ž‘‘ǤŠ‡‹”•–ƒ–‹•–‹ ƒŽƒƒŽ›•‡•†‹† ‘–•Š‘™ƒ›•‹‰‹ˆ‹ ƒ–ƒ••‘ ‹ƒ–‹‘„‡–™‡‡’‘••‹„Ž‡‡š’Žƒƒ–‘”›ˆƒ –‘”•ȋ‡Ǥ‰Ǥƒ‰‡ǡ †‹ƒ„‡–‡•‡ŽŽ‹–—•ǡ–‘„ƒ ‘—•‡ǡ’”‡˜‹‘—•ƒ„†‘‹ƒŽ•—”‰‡”›ǡ—‹Žƒ–‡”ƒŽ‘”„‹Žƒ–‡”ƒŽ ”‡ ‘•–”— –‹‘ǡ’”‡˜‹‘—• Š‹Ž†„‹”–Šǡ‡– ǤȌǤŽ›ƒ™‡ƒ–”‡†™Š‡”‡—ŽŽ‹’ƒ”‘—•™‘‡ Šƒ†ƒŠ‹‰Š‡”‘ —””‡ ‡‘ˆƒ„†‘‹ƒŽ„—Ž‰‡ȋPαͲǤͲͺȌ™ƒ•‘–‡†Ǥ‘•‡“—‡–Ž›ǡƒ•ƒŽŽ ’”‡˜‡–ƒ–‹˜‡‡ˆˆ‡ –‘ˆ’”‡‰ƒ ›™ƒ••—‰‰‡•–‡†Ǥ Žƒ ‘ˆ•‹‰‹ˆ‹ ƒ–ƒ••‘ ‹ƒ–‹‘•ǡ Š‘™‡˜‡”ǡ–Š‡› ‘ Ž—†‡†–Šƒ––Š‡ˆ‘”ƒ–‹‘‘ˆ’‘•–‘’‡”ƒ–‹˜‡„—Ž‰‡‹•ƒ”ƒ†‘‡˜‡– ƒ†–Šƒ–‹– ƒ’‘–‡–‹ƒŽŽ›Šƒ’’‡–‘ƒ›‘‡Ǥ  Ž–Š‘—‰ŠƒŠƒ„‡†‹ƒƒ†‘‡†‹†‘–ˆ‹†ƒ’”‡†‹•’‘•‹‰ˆƒ –‘”–‘–Š‡Ž‘™‡” ƒ„†‘‹ƒŽ„—Ž‰‡ǡ‹–‹• Ž‡ƒ”–Šƒ––Š‡”ƒ–‡‘ˆ–Š‹• ‘’Ž‹ ƒ–‹‘Šƒ•‰”ƒ†—ƒŽŽ›†‡ ”‡ƒ•‡† •‹ ‡–Š‡”‡‰—Žƒ”—•‡‘ˆˆŽƒ’˜ƒ”‹ƒ–‹‘•Ǥȋͳͷ͹Ȍ”‘„—•–„‘†›‘ˆŽ‹–‡”ƒ–—”‡Šƒ• ’”‘’‘•‡†–Šƒ– ˆŽƒ’•ƒ”‡•—’‡”‹‘”–‘’‡†‹ Ž‡†ȋͺͶǡͳͷͺǡͳͷͻȌǡ—• Ž‡Ǧ •’ƒ”‹‰ȋͶ͹Ȍǡƒ†ˆ”‡‡ȋͶͻǡͷͳǡͳ͸ͲȌǤŠ‹•‹•’”‘„ƒ„Ž›†—‡–‘Ž‡••‹ƒ–”‘‰‡‹  †ƒƒ‰‡‘ˆ–Š‡ƒ–‡”‹‘””‡ –—••Š‡ƒ–Šƒ†”‡ –—•—• Ž‡•ǤŠ‡”‡‹•ǡŠ‘™‡˜‡”ǡ— Š Š‡–‡”‘‰‡‡‹–›‹•—”‰‹ ƒŽ–‡ Š‹“—‡•„‡–™‡‡’Žƒ•–‹ •—”‰‡‘•ƒ†‹ ”‘•—”‰‹ ƒŽ ‡–‡”•™Š‹ Šƒ‡•‹–†‹ˆˆ‹ —Ž––‘ ‘’ƒ”‡ƒ„†‘‹ƒŽˆŽƒ’‘—– ‘‡•Ǥ ‘”‹•–ƒ ‡ǡ„› ‹ ‘”’‘”ƒ–‹‰‡•Š‹–‘–Š‡ˆƒ• ‹ƒ”‡’ƒ‹”‹—• Ž‡Ǧ•’ƒ”‹‰ƒ†ˆ”‡‡ˆŽƒ’•ǡƒ‡– ƒŽǤ”‡’‘”–‡†–Šƒ–‘‡ ƒƒ Š‹‡˜‡Š‡”‹ƒȀ„—Ž‰‹‰”ƒ–‡•‡“—‹˜ƒŽ‡–‘ˆ–Š‘•‡ˆ‘”  ˆŽƒ’•Ǥȋͳ͸ͳȌ —”–Š‡”‘”‡ǡ”Ǥ˜§”†„‘”‰ƒ†”‘ˆǤƒ•‰ƒƒ”††‡‘•–”ƒ–‡†–Šƒ–‡˜‡ †‹ˆˆ‡”‡–‡•Š–›’‡• ƒ”‡•—Ž–‹•‹‰‹ˆ‹ ƒ–Ž›†‹ˆˆ‡”‡–„—Ž‰‹‰”ƒ–‡•ȋ‹’‡†‹ Ž‡† ˆŽƒ’•ȌǤȋͳͶͳȌŠ‡•‡’—„Ž‹ ƒ–‹‘•‡š‡’Ž‹ˆ›–Š‡•‹‰‹ˆ‹ ƒ–‹’ƒ –‘ˆ ‡”–ƒ‹ˆƒ –‘”•ȋˆŽƒ’ –›’‡ǡ Ž‘•‹‰–‡ Š‹“—‡ǡ‡•Š—•‡ǡ‡•Š–›’‡ǡ‡– ǤȌ‘Š‡”‹ƒȀ„—Ž‰‹‰”ƒ–‡•Ǥ  ††‹–‹‘ƒŽŽ›ǡ–Š‡”‡‹•ƒ™‹†‡˜ƒ”‹ƒ„‹Ž‹–›‹–‡”•‘ˆŠ‘™”‡•‡ƒ” Š‡”•Šƒ˜‡ƒ‡† ˆŽƒ’•ȋˆǤ‡šǤ†‡• ”‹„‹‰•ǦˆŽƒ’•ƒ• ˆŽƒ’•ȌǤŠ‹•Šƒ• Ž‘—†‡†—‹ˆ‘” ”‡’‘”–‹‰ƒ†ƒ†‡ ‘’ƒ”‹•‘•ƒ†‡–ƒǦƒƒŽ›•‡•Šƒ”†–‘ ‘’”‡Š‡†Ǥȋͳ͸ʹȌ— Š ˜ƒ”‹ƒ„‹Ž‹–› ƒ—•‡•ƒŽ•‘•—„•–ƒ–‹ƒŽ„‹ƒ•Ǥ—––‹‰ƒŽŽ•— Š„‹ƒ•ƒ•‹†‡ǡŠ‘™‡˜‡”ǡŽ‹–‡”ƒ–—”‡ •‡‡•”ƒ–Š‡”—ƒ‹‘—•ǣŠ‡ ˆŽƒ’•— ‡‡†•‹‡‡’‹‰Š‡”‹ƒȀ„—Ž‰‹‰”ƒ–‡•–‘ƒ ‹‹—Ǥ

Paper III “The majority of DIEAP flap patients are more satisfied with their postsurgical abdomen”. ͷͻΨ‘ˆ–Š‡ ‰”‘—’™‡”‡‘”‡•ƒ–‹•ˆ‹‡†™‹–Š–Š‡’‘•–•—”‰‹ ƒŽ ƒ„†‘‡ǤŠ‹•‘„•‡”˜ƒ–‹‘‹•‹ ‘ ‘”†ƒ ‡™‹–Š‹††ƒ‡–ƒŽǤ™Š‘”‡’‘”–‡†–Šƒ–ͷʹΨ ‘ˆ–Š‡‹”’ƒ–‹‡–•™‡”‡‡‹–Š‡”DzŠƒ’’›dz‘”Dz˜‡”›Šƒ’’›dz™‹–Š–Š‡‰Ž‘„ƒŽƒ‡•–Š‡–‹ ”‡•—Ž–‘ –Š‡ƒ„†‘‡ǡƒ†͸͸Ψ’”‡ˆ‡””‡†–Š‡‹”ƒ„†‘‡ƒˆ–‡”•—”‰‡”›ǤȋͷʹȌ‡ ‘•‹†‡”–Š‹•ƒ• ƒ‹’‘”–ƒ–‡••ƒ‰‡‹–Š‡’”‡‘’‡”ƒ–‹˜‡ ‘—•‡ŽŽ‹‰‘ˆ’ƒ–‹‡–•Ǥ‡•Š‘—Ž†ǡŠ‘™‡˜‡”ǡ „‡ ƒ”‡ˆ—Ž‘––‘’”‡•‡–ƒ‰Ž‘”‹ˆ‹‡†’‹ –—”‡‘ˆ–Š‡ƒ‡•–Š‡–‹ †‘‘”Ǧ•‹–‡‘—– ‘‡•ƒ• †‹• —••‡†„‡Ž‘™Ǥ

45 45 “Some DIEAP flap patients prefer their presurgical abdomen”. ͳͶΨ‘ˆ–Š‡  ‰”‘—’‹‘—”•–—†›™‡”‡‘–‘”‡•ƒ–‹•ˆ‹‡†™‹–Š–Š‡ƒ’’‡ƒ”ƒ ‡‘ˆ–Š‡ƒ„†‘‡ƒˆ–‡” •—”‰‡”›Ǥ‹††ƒ‡–ƒŽǤ”‡’‘”–‡†͵ͶΨǤȋͷʹȌŠ‡•‡—„‡”•‹†‹ ƒ–‡–Šƒ–’‘••‹„Ž›—’–‘ ͳȀ͵‘ˆ–Š‡’ƒ–‹‡–•ƒ”‡‘”‡•ƒ–‹•ˆ‹‡†™‹–Š–Š‡‹”’”‡•—”‰‹ ƒŽƒ„†‘‡ǤŠ‹•‹•ƒ‘–Š‡” ‹’‘”–ƒ–‡••ƒ‰‡–‘„”‹‰ˆ‘”™ƒ”†’”‡‘’‡”ƒ–‹˜‡Ž›Ǥ –‹•ƒŽ•‘ƒ ‘ ‡”™Š‹ Š™‡•Š‘—Ž† •Š‡†‘”‡Ž‹‰Š–‘ǤŽ‡ƒ•‡•‡‡DzŽ‹‹ ƒŽ‹’Ž‹ ƒ–‹‘•ƒ†ˆ—–—”‡”‡•‡ƒ” Šdzˆ‘”‘”‡ –Š‘—‰Š–•‘–Š‹•ƒ––‡”Ǥ  ˆ‘”–—ƒ–‡Ž›ǡ™‡†‹†‘–†‹”‡ –Ž›‹˜‡•–‹‰ƒ–‡–Š‡ ƒ—•‡‘ˆ†‹••ƒ–‹•ˆƒ –‹‘ƒ‘‰ –Š‡•‡’ƒ–‹‡–•Ǥ‡†‘‘™ǡŠ‘™‡˜‡”ǡ–Šƒ–ƒ›’ƒ–‹‡–•ȋ ‘ ‡‹˜ƒ„Ž›—’–‘ͶͲΨȌ Š‘‘•‡–Š‡ ˆŽƒ’ˆ‘”–Š‡‹”„”‡ƒ•–”‡ ‘•–”— –‹‘†—‡–‘–Š‡ƒ„†‘‹‘’Žƒ•–› ’‡”ˆ‘”‡†ǤȋͷʹȌ’‘‘”ƒ„†‘‹‘’Žƒ•–›‘—– ‘‡ƒ––Š‡†‘‘”Ǧ•‹–‡‹‰Š–„‡†‹ˆˆ‹ —Ž––‘ ƒ ‡’–ˆ‘”–Š‡•‡’ƒ–‹‡–•ƒ•’ƒ–‹‡–‡š’‡ –ƒ–‹‘•ƒ”‡‹ƒ”‰—ƒ„Ž›Š‹‰ŠŽ›”‡Ž‡˜ƒ–Ǥȋͳ͸͵Ȍ  –Š‡ƒ–‡”‹ƒŽ‘ˆ‹††ƒ‡–ƒŽǤǡ–Š‡‘•– ‘‘ ƒ—•‡•‘ˆ†‹••ƒ–‹•ˆƒ –‹‘™‡”‡ †‘‰Ǧ‡ƒ”•ȋͷͲΨȌǡ”‡•‹†—ƒŽƒ„†‘‹ƒŽ‘˜‡”Šƒ‰ȋͳͺΨȌǡƒ†–Š‡Š‘”‹œ‘–ƒŽ• ƒ”ȋͳʹ ΨȌǤȋͷʹȌ•™‡†‘‘–’‡”ˆ‘”ƒ›Ž‹’‘•— –‹‘ƒ†–Š‡ˆŽƒ’‹•‘ˆ–‡„ƒ•‡†‘ ’‡”‹—„‹Ž‹ ƒŽ’‡”ˆ‘”ƒ–‘”•ǡ™‡„‡Ž‹‡˜‡–Šƒ–†‘‰Ǧ‡ƒ”•ƒ†Š‹‰ŠǦ”‹†‹‰• ƒ”Ž‹‡• ‘—Ž†„‡ ’Žƒ—•‹„Ž‡‡š’Žƒƒ–‹‘•ˆ‘”–Š‡†‹••ƒ–‹•ˆƒ –‹‘‹‘—” ‘Š‘”–ƒ•™‡ŽŽǤ  “Few DIEAP flap patients go through secondary procedures at the donor-site (in our Department)”. ‹–Š‹–Š‡‡ƒȋȌˆ‘ŽŽ‘™Ǧ—’–‹‡‘ˆʹǤͶȋάͳǤͲȌ ›‡ƒ”•ǡ‘‡‘ˆ–Š‡ ͵Ͷ ˆŽƒ’’ƒ–‹‡–•‹’ƒ’‡”  ‘’Ž‡–‡†•‡ ‘†ƒ”›’”‘ ‡†—”‡•ƒ––Š‡†‘‘”Ǧ•‹–‡ ȋ‡Ǥ‰ǤŠ‡”‹ƒȀ„—Ž‰‡”‡’ƒ‹”ƒ†•‡ ‘†ƒ”›ƒ‡•–Š‡–‹ ”‡ˆ‹‡‡–’”‘ ‡†—”‡•ȌǤ— Š ’”‘ ‡†—”‡•ƒ”‡”ƒ”‡Ž›’‡”ˆ‘”‡†‹‘—”‡’ƒ”–‡–Ǥ  —”—„‡”•ƒ”‡‘–‹ƒ ‘”†ƒ ‡™‹–Š‘–Š‡”’—„Ž‹ ƒ–‹‘•ǡ•— Šƒ•–Š‡†‘‘”Ǧ •‹–‡”‡˜‹•‹‘”ƒ–‡•‘ˆ‹††ƒ‡–ƒŽǤȋͶ͸ΨȌȋͷʹȌǡƒ‹‡–ƒŽǤȋͳ͸Ǥ͸ΨȌȋͳ͸ͶȌǡƒ†ƒ‡‡– ƒŽǤȋͳͳǤͳΨȌȋͷͺȌǤ –Š‡‘”‹‰‹ƒŽƒ”–‹ Ž‡™”‹––‡„›ƒŒƒ–‡–ƒŽǤˆ”‘’’•ƒŽƒ‹˜‡”•‹–› ‘•’‹–ƒŽǡ•‡ ‘†ƒ”›†‘‘”Ǧ•‹–‡’”‘ ‡†—”‡•™‡”‡ƒŽ•‘ˆ‘—†–‘„‡ ‘‘Ž› ’‡”ˆ‘”‡†Ǥȋͷ͹Ȍ‘‰–Š‡‹”͵͸ͷ”‡˜‹‡™‡† ˆŽƒ’•ǡʹͲǤͻΨŠƒ†Ž‹’‘•— –‹‘ȋͳǤʹΨ ™‹–Š”‡’‡ƒ–Ž‹’‘•— –‹‘ȌǡͺǤ͵ΨŠƒ†• ƒ””‡˜‹•‹‘ǡƒ†ͳͶǤͳΨŠƒ††‘‰Ǧ‡ƒ” ‘””‡ –‹‘ ’‡”ˆ‘”‡†Ǥ‡ƒ–‹‡ˆ”‘’”‹ƒ”›–‘•‡ ‘†ƒ”›•—”‰‡”›ƒ––Š‡†‘‘”Ǧ•‹–‡™‡”‡ ”‡•’‡ –‹˜‡Ž›ͳͺǤͳȋͶͲǤͲȌǡʹͲǤͲǡƒ†ͳͻǤͷ‘–Š•‹–Š‹••–—†›Ǥ  ‡‡š’Žƒƒ–‹‘ˆ‘”‘—”Ž‘™—„‡”‘ˆ•‡ ‘†ƒ”›’”‘ ‡†—”‡• ‘—Ž†„‡–Š‡˜‡”› ˆ‡™†‘‘”Ǧ•‹–‡ ‘’Ž‹ ƒ–‹‘•ƒ –—ƒŽŽ›”‡‰‹•–‡”‡†ǣ›”‡˜‹‡™‹‰Œ‘—”ƒŽ†‘ —‡–• ”‡–”‘•’‡ –‹˜‡Ž›ǡ‹––—”‡†‘—––Šƒ–’ƒ–‹‡–•™‡”‡‡šƒ‹‡†–Š”‡‡Ǧ•‹š‘–Š• ’‘•–‘’‡”ƒ–‹˜‡Ž›ǡŠ‘™‡˜‡”ǡ–Š‡”‡™‡”‡‘•›•–‡ƒ–‹ ˆ‘ŽŽ‘™Ǧ—’”‘—–‹‡•”‡‰ƒ”†‹‰–Š‡ †‘‘”Ǧ•‹–‡ǤŠ‡’Žƒ•–‹ •—”‰‡‘•ˆ‘ —•‡†’”‹ƒ”‹Ž›‘–Š‡”‡ ‘•–”— –‡†„”‡ƒ•–ƒ†–Š‡ ’ƒ–‹‡–•ǯ ‘’Žƒ‹–•Ȁ“—‡•–‹‘•Ǥƒ–‹‡–•™‡”‡‘– ƒ”‡ˆ—ŽŽ›‡šƒ‹‡†ˆ‘”†‘‘”Ǧ•‹–‡ ‘”„‹†‹–‹‡•ƒ–‡ƒ Šˆ‘ŽŽ‘™Ǧ—’˜‹•‹–ǡƒ†™‡†‹†‰‡––Š‡‹’”‡••‹‘–Šƒ–‘•–’Žƒ•–‹  •—”‰‡‘•†‘‘–•›•–‡ƒ–‹ ƒŽŽ›’ƒŽ’ƒ–‡–Š‡ƒ„†‘‡ˆ‘”ƒ”‡ƒ•‘ˆ‹†—”ƒ–‹‘ ȋ•‡”‘ƒ•ȀŠ‡ƒ–‘ƒ•Ȁˆƒ–‡ ”‘•‹•Ȍ‘”Š‡”‹ƒ–‹‘Ǥ‘•‡“—‡–Ž›ǡ†‘‘”Ǧ•‹–‡ ‘’Ž‹ ƒ–‹‘•™Š‹ Šƒ”‡ǯ–˜‹•‹„Ž‡–‘–Š‡ƒ‡†‡›‡ƒ”‡‘–”‡‰‹•–‡”‡†ƒ† ‘ˆ”‘–‡† –Š”‘—‰Š•‡ ‘†ƒ”›†‘‘”Ǧ•‹–‡’”‘ ‡†—”‡•Ǥ  Š‡”‡Žƒ–‹˜‡Ž›•Š‘”–ˆ‘ŽŽ‘™Ǧ—’’‡”‹‘†‹•ƒ‘–Š‡””‡ƒ•‘ƒ„Ž‡‡š’Žƒƒ–‹‘Ǣ‹– ‘—Ž† „‡–Šƒ–’ƒ–‹‡–•™‡––Š”‘—‰Š•‡ ‘†ƒ”›’”‘ ‡†—”‡•†‘™–Š‡Ž‹‡Ǥ ˆƒ –ǡ•‘‡ ’ƒ–‹‡–•‘’–ˆ‘”ƒ‡•–Š‡–‹ ”‡ˆ‹‡‡–’”‘ ‡†—”‡•ƒ•Ž‘‰ƒ•‡‹‰Š–›‡ƒ”•ƒˆ–‡”–Š‡’”‹ƒ”›

46 46 •—”‰‡”›Ǥȋͷ͹Ȍ  ƒ•–Ž›ǡ†‹ˆˆ‡”‡ ‡•‹‘’‡”ƒ–‹˜‡–‡ Š‹“—‡ȋ‡Ǥ‰Ǥ‘„‹Žƒ–‡”ƒŽˆŽƒ’Šƒ”˜‡•–•Ȍƒ† ’ƒ–‹‡–†‡‘‰”ƒ’Š‹ •ȋ‡Ǥ‰ǤŽ‘™‡” ƒ†‘•‘‹‰Ȍ ‘—Ž†‡š’Žƒ‹–Š‡†‹ˆˆ‡”‡ ‡• •‡‡‹†‘‘”Ǧ•‹–‡”‡˜‹•‹‘”ƒ–‡•Ǥȋͳ͸Ͳǡͳ͸ͷȌ  “The majority of DIEAP flap patients experience “as expected” or “less than expected” amount and visibility of scarring”. ‹–‡”ƒ–—”‡”‡’‘”–•–Šƒ––Š‡†‘‘”Ǧ•‹–‡ • ƒ”‹•ƒ ‘•‹•–‡–’‘‹–‘ˆ“—‡•–‹‘ƒ† ‘•‹†‡”ƒ„Ž‡ƒš‹‡–›Ǥȋ͵ͷȌƒ› ˆŽƒ’ ’ƒ–‹‡–•ƒ”‡†‹••ƒ–‹•ˆ‹‡†™‹–Š‹–•Ž‘ ƒ–‹‘ƒ†ƒ’’‡ƒ”ƒ ‡Ǥȋ͵ͷǡͳ͸͸ȌŠ‡• ƒ”ƒ› „‡ ‘‡Š›’‡”–”‘’Š‹ ǡƒ–”‘’Š‹ ǡ†‹• ‘Ž‘”‡†ǡ™‹†‡‡†ǡ”‡–”ƒ –‡†ǡ‘”ƒ•›‡–”‹ ƒŽǤȋͳ͸͸Ȍ – ƒƒŽ•‘‘˜‡ ”ƒ‹ƒŽŽ›‹–Š‡Š‡ƒŽ‹‰’”‘ ‡••„‡ ‘‹‰˜‡”›˜‹•‹„Ž‡Ǥȋͳ͸͸Ȍ ƒ “—‡•–‹‘ƒ‹”‡Ǧ„ƒ•‡†•–—†›™‹–ŠͷͲͲ’ƒ–‹‡–•ǡ ‘› ‡‡–ƒŽǤ†‹• ‘˜‡”‡†–Šƒ––Š‡  †‘‘”Ǧ•‹–‡• ƒ”™ƒ•‹ˆƒ ––Š‡Ž‡ƒ•–’”‡ˆ‡””‡†ƒ‘‰ˆ‘—”•‡Ž‡ –‡†ƒ—–‘Ž‘‰‘—• ˆŽƒ’•Ǥȋͳ͸͹Ȍͷ͸Ψ‘ˆ–Š‡”‡•’‘†‡–•”ƒ‡†–Š‡ †‘‘”Ǧ•‹–‡Žƒ•–‹–‡”•‘ˆ • ƒ””‹‰Ȃ’”‘„ƒ„Ž›‘™‹‰–‘‹–•˜‹•‹„‹Ž‹–›‘–Š‡Ž‘™‡”ƒ„†‘‡ǤŠ‡’”‘’‘”–‹‘•‘ˆˆ‹”•– ’”‡ˆ‡”‡ ‡•™‡”‡ƒ•ˆ‘ŽŽ‘™•ǣͳȌ ȋ͵ͻǤͻͺΨȌǡʹȌ ȋʹ͸ǤͳͺΨȌǡ͵Ȍȋͳ͸Ǥͻ͹ΨȌǡƒ†  ȋͳ͸Ǥͺ͹ΨȌǤ  ‘‘”Ǧ•‹–‡• ƒ”• ‘—Ž†ƒŽ•‘Ž‡ƒ†–‘ƒ‡‡†ˆ‘”‹–‡”˜‡–‹‘Ǥƒ‹‡–ƒŽǤ”‡˜‹‡™‡† ʹʹͳ—‹Žƒ–‡”ƒŽ ˆŽƒ’•”‡–”‘•’‡ –‹˜‡Ž›ƒ†ˆ‘—†–Šƒ–Š›’‡”–”‘’Š‹ • ƒ”•‡‡†‹‰ –”‹ƒ ‹‘Ž‘‡‹Œ‡ –‹‘Ȁ• ƒ””‡˜‹•‹‘™ƒ•–Š‡‘•– ‘‘ ƒ—•‡‘ˆ•‡ ‘†ƒ”› ‹–‡”˜‡–‹‘ƒ––Š‡†‘‘”Ǧ•‹–‡ȋ͸ǤͻΨȌǤȋͳ͸ͶȌŠ‹•‹•ƒ‰‘‘†‡šƒ’Ž‡‘ˆŠ‘™‘ˆ–‡–Š‡ †‘‘”Ǧ•‹–‡• ƒ”‹•†‹• —••‡†ƒ† ‘ˆ”‘–‡†‹ Ž‹‹ ƒŽ’”ƒ –‹ ‡Ǥȋͳ͸͸Ȍ  –Š‡ ‘–”ƒ”›ǡͷͻΨ‘ˆ ˆŽƒ’’ƒ–‹‡–•‹’ƒ’‡” ”‡’‘”–‡†–Šƒ––Š‡ ƒ‘—–‘ˆ• ƒ””‹‰™ƒ•Dzƒ•‡š’‡ –‡†dzƒ†ͳ͹Ψ”‡’‘”–‡†DzŽ‡••–Šƒ‡š’‡ –‡†dzǤ —”–Š‡”‘”‡ǡͶͺΨ”‡’‘”–‡†–Šƒ––Š‡˜‹•‹„‹Ž‹–›‘ˆ• ƒ””‹‰™ƒ•Dzƒ•‡š’‡ –‡†dzƒ†ʹͶΨ ”‡’‘”–‡†DzŽ‡••–Šƒ‡š’‡ –‡†dzǤƒ• ƒŽ‡ˆ”‘Ͳ–‘ͳͲȋͲᐑ–„Ž‡‹•Š‹‰ǡͳͲα˜‡”› „Ž‡‹•Š‹‰Ȍǡ–Š‡ ‰”‘—’ƒ˜‡”ƒ‰‡†‘ͶǤͲ™Š‡†‡ ‹†‹‰‘Š‘™„Ž‡‹•Š‹‰–Š‡› ˆ‘—†–Š‡‹”ƒ„†‘‹ƒŽ• ƒ”Ǥ‡„‡Ž‹‡˜‡–Šƒ––Š‡•‡—„‡”•‹†‹ ƒ–‡–Šƒ–ƒ„†‘‹ƒŽ • ƒ””‹‰‹•ƒ•ƒŽŽ–‘‘†‡”ƒ–‡ƒ‡•–Š‡–‹ ’”‘„Ž‡‹‘—” ‘Š‘”–ǡƒ†–Šƒ–‘•–’ƒ–‹‡–• ƒ”‡•ƒ–‹•ˆ‹‡†ǤŠ‡•‡ƒ••—’–‹‘•ƒ”‡•—’’‘”–‡†„›–Š‡—„‡”•‘ˆ‹††ƒ‡–ƒŽǤ™Š‡”‡ ͹ͲΨ™Š‡”‡‡‹–Š‡”DzŠƒ’’›dz‘”Dz˜‡”›Šƒ’’›dz™‹–Š–Š‡ƒ’’‡ƒ”ƒ ‡‘ˆ–Š‡ƒ„†‘‹ƒŽ • ƒ”ǤȋͷʹȌ  —”‘„•‡”˜ƒ–‹‘• ‘—Ž†–‘•‘‡‡š–‡–•‹‰ƒŽ–Šƒ––Š‡”‡‹•‘†‡ˆ‹‹–‡‡‡†ˆ‘”–Š‡ •‘Ǧ ƒŽŽ‡†DzŽ‘™ ˆŽƒ’dzȋͺͷǡͺ͸ǡͳ͸ͺȌ‘”DzŽ‘™Ǧ”‹•‡• ƒ” ˆŽƒ’dzȋͳ͸ͻǡͳ͹ͲȌǤ –Š‡•‡ ‡–Š‘†•ǡ–Š‡• ƒ”‹•’Žƒ ‡†‹–Š‡Ž‘™‡”‘•–’ƒ”–‘ˆ–Š‡ƒ„†‘‡ǤȋͺͷȌ‘ƒ† ‘Ǧ ƒ—–Š‘”•ǡ–Š‡Dz‹˜‡–‘”•dz‘ˆ–Š‡Ž‘™ ˆŽƒ’–‡ Š‹“—‡ǡŠƒ˜‡•‹ ‡–Š‡‹”ʹͲͳ͸ ’—„Ž‹ ƒ–‹‘’”‘’‘•‡†–Šƒ––Š‹•‘†‹ˆ‹‡† ˆŽƒ’Šƒ•ƒ‡•–Š‡–‹ ƒ†˜ƒ–ƒ‰‡•‘˜‡”–Š‡ ‘˜‡–‹‘ƒŽ ˆŽƒ’Ǥȋͺͷǡͺ͸ǡͳ͸ͺȌŠ‡‡Šƒ ‡‡––‘–Š‡†‘‘”Ǧ•‹–‡‹•‡š’Žƒ‹‡† „›–Š‡Ž‘™‡”ƒ„†‘‹ƒŽ• ƒ”ȋ‘ˆ–‡ ‘ ‡ƒŽ‡†„›—†‡”™‡ƒ”Ȍƒ†ƒ–—”ƒŽ—„‹Ž‹ —•ȋƒ• ‘—„‹Ž‹ ‘’Žƒ•–›‹•’‡”ˆ‘”‡†ȌǤȋͳ͸ͺȌ‘’Ž‹ ƒ–‹‘”ƒ–‡•Šƒ˜‡ǡŠ‘™‡˜‡”ǡ„‡‡˜‡”›Š‹‰Š ȋ͵ͲǤͶΨ˜‡‘—• ‘‰‡•–‹‘ǡͳ͵Ψƒ„†‘‹ƒŽ„—Ž‰‡ǡͳ͵Ψˆƒ–‡ ”‘•‹•ȌǤȋͺͷȌ‡˜‡‘—–‘ˆ ʹ͵Ž‘™ ˆŽƒ’ ƒ•‡•‡‡†‡†•—”‰‹ ƒŽ‹–‡”˜‡–‹‘†—‡–‘˜‡‘—• ‘‰‡•–‹‘ǤȋͺͷȌ – •‡‡‡†ǡ–Š‡”‡ˆ‘”‡ǡ–Šƒ––Š‡—•‡‘ˆƒ‘Ǧ†‘‹ƒ–’‡”ˆ‘”ƒ–‘”‹–Š‡Ž‘™‡”ƒ„†‘‡ Œ‡‘’ƒ”†‹œ‡†–Š‡ˆŽƒ’™‹–Š˜‡‘—•‹•—ˆˆ‹ ‹‡ ›Ǥ ƒˆ‘ŽŽ‘™Ǧ—’’—„Ž‹ ƒ–‹‘„›–Š‡•ƒ‡ ”‡•‡ƒ” Š‡”ǡŠ‘™‡˜‡”ǡ–Š‡ ‘’Ž‹ ƒ–‹‘”ƒ–‡•™‡”‡•—„•–ƒ–‹ƒŽŽ›Ž‘™‡”‡†„›

47 47 ‹’Ž‡‡–‹‰•–”‹ –’ƒ–‹‡–•‡Ž‡ –‹‘ ”‹–‡”‹ƒǤȋͳ͸ͺȌŠ‡‹” ”‹–‡”‹ƒ™‡”‡„ƒ•‡†‘„‘†› Šƒ„‹–—•ƒ†’‡”ˆ‘”ƒ–‘” Šƒ”ƒ –‡”‹•–‹ •‡˜ƒŽ—ƒ–‡†„›’”‡‘’‡”ƒ–‹˜‡Ǥ  ‡•’‹–‡„‡‹‰ƒ„Ž‡–‘Ž‘™‡”–Š‡ ‘’Ž‹ ƒ–‹‘”ƒ–‡•ǡ™‡“—‡•–‹‘™Š‡–Š‡”–Š‡Ž‘™  ˆŽƒ’‹••‹‹Žƒ”Ž›ƒ’’Ž‹ ƒ„Ž‡ˆ‘”–ƒŽŽ‡”—”‘’‡ƒ’ƒ–‹‡–•™‹–Š’”‡•—ƒ„Ž›„‹‰‰‡” „”‡ƒ•–•Ǥƒ–‹‡–•‹ Ž—†‡†‹‘‡–ƒŽǤǯ••–—†‹‡•ƒ”‡‘”‡ƒ™‹–Šƒ‡ƒ ‘ˆʹ͵ǤͷǦ ʹͶǤͶǤȋͺͷǡͳ͸ͺȌŠ‡ȋ‘Ǧ–”‹‡†ȌŽ‘™ ˆŽƒ’Šƒ”˜‡•–‡†„›–Š‡‘”‡ƒ’Žƒ•–‹  •—”‰‡‘•Šƒ†ƒƒ˜‡”ƒ‰‡™‡‹‰Š–‘ˆ͸͵͵‰Ǥȋͳ͸ͺȌ ‘—”’ƒ’‡” ǡ–Š‡‡ƒȋ‘Ǧ –”‹‡†ȌˆŽƒ’™‡‹‰Š–™ƒ•ͳͲ͵ͺ‰Ǥ ƒ††‹–‹‘–‘•ƒŽŽ‡”ˆŽƒ’•ǡ–Š‡Ž‘™ ˆŽƒ’‘ˆˆ‡”• ƒ‰‡‡”ƒŽŽ›Ͷ–‘ͷ •Š‘”–‡”’‡†‹ Ž‡ƒ†•ƒŽŽ‡”’‡”ˆ‘”ƒ–‘”†‹ƒ‡–‡”•Ǥȋͳ͸ͺȌŠ‡”‡ƒ”‡ǡ ‹‘–Š‡”™‘”†•ǡ ‘•‹†‡”ƒ„Ž‡†‹•ƒ†˜ƒ–ƒ‰‡•‘ˆŽ‘™‡”‹‰–Š‡ ˆŽƒ’Ǥ  ˆ‘—”“—‡•–‹‘ƒ‹”‡•Šƒ†— ‘˜‡”‡†ƒŠ‹‰Š†‹••ƒ–‹•ˆƒ –‹‘™‹–Š–Š‡ƒ„†‘‹ƒŽ • ƒ””‹‰ǡ™‡™‘—Ž†Šƒ˜‡ˆ‡Ž–ƒ‰”‡ƒ–‡”‡‡†–‘‹’Ž‡‡–•— Š ˆŽƒ’‘†‹ˆ‹ ƒ–‹‘•Ǥ •–Š‡”‡•’‘•‡•™‡”‡‰‡‡”ƒŽŽ›’‘•‹–‹˜‡ǡ–Š‹•‹•‘–‹’‡”ƒ–‹˜‡Ǥ‡†‘ǡŠ‘™‡˜‡”ǡ„‡Ž‹‡˜‡ –Šƒ––Š‡ƒ„†‘‹ƒŽ• ƒ”‹•ƒƒ”‡ƒ‘ˆ‹’”‘˜‡‡–ǡƒ†–Šƒ–‘”‡•‘’Š‹•–‹ ƒ–‡†•—–—”‹‰ –‡ Š‹“—‡•ƒ––Š‡†‘‘”Ǧ•‹–‡ ‘—Ž†”‡•—Ž–‹Š‹‰Š‡”’ƒ–‹‡–•ƒ–‹•ˆƒ –‹‘Ǥ  ǮDzFew DIEAP flap patients experience negative abdominal contour changes”Ǥ „†‘‹ƒŽ ‘–‘—” Šƒ‰‡• ƒ„‘–Š„‡’‘•‹–‹˜‡ȋ‡Ǥ‰Ǥ’”‡Ǧ’”‡‰ƒ ›ǡˆŽƒ–ƒ„†‘‡Ȍ‘” ‡‰ƒ–‹˜‡ȋƒ„†‘‹ƒŽ„—Ž‰‹‰ƒ†Š‡”‹ƒȌǤŠ‡ƒ•’‡ –‘ˆ ‘–‘—” Šƒ‰‡•™ƒ•‘– ‘˜‡”‡†„›‹††ƒ‡–ƒŽǤȋͷʹȌ –Šƒ•ǡŠ‘™‡˜‡”ǡ„‡‡”‡’‘”–‡†‹‘–Š‡”•–—†‹‡•–Šƒ–ƒ”‡ „ƒ•‡†‘’Š›•‹ ƒŽ‡šƒ‹ƒ–‹‘•ȋͷͲȌƒ†‡–ƒǦƒƒŽ›•‡•ȋͶ͹ǡͷͳǡͺͶȌǤŠƒ‰‡–ƒŽǤ ”‡’‘”–‡†ƒŠ‡”‹ƒȀ„—Ž‰‡‹ ‹†‡ ‡‘ˆƒ’’”‘š‹ƒ–‡Ž›ͷΨƒ‘‰—‹Žƒ–‡”ƒŽ ˆŽƒ’• ™‹–Š’”‹ƒ”› Ž‘•—”‡ǤȋͷͲȌˆ–‡””‡˜‹‡™‹‰‡™‡”Ž‹–‡”ƒ–—”‡ǡ‘•–Š‡”‹ƒȀ„—Ž‰‡”ƒ–‡•ƒ”‡ ”ƒ–Š‡” Ž‘•‡–‘–Š‹•’‡” ‡–ƒ‰‡ǤȋͳͷͶǡͳ͹ͳȌŠ‡—•‡‘ˆ‡•Š›‹‡Ž†•‡˜‡Ž‘™‡””ƒ–‡•Ȃ ƒŽ–Š‘—‰Š‘–‡ ‡••ƒ”‹Ž›•‹‰‹ˆ‹ ƒ–Ž›Ž‘™‡”ǤȋͷͲǡͳ͹ͳȌ  Š‡•’”‘˜‹†‡†‹‘—”•–—†›ƒ††ƒ‡™’‡”•’‡ –‹˜‡Ǥ–‹ŽŽǡ–Š‡˜ƒŽ—‡‘ˆ–Š‡•‡ †ƒ–ƒƒ”‡†‡„ƒ–ƒ„Ž‡ƒ•ƒ„†‘‹ƒŽ ‘–‘—” Šƒ‰‡•Šƒ˜‡‘––”ƒ†‹–‹‘ƒŽŽ›„‡‡‡˜ƒŽ—ƒ–‡† ‹ƒ“—‡•–‹‘ƒ‹”‡Ǧ„ƒ•‡†ˆƒ•Š‹‘Ǥ ’ƒ’‡” ǡ’ƒ–‹‡–•ƒ•™‡”‡†™Š‡–Š‡”–Š‡›Šƒ˜‡ ‰‘––‡ƒ› Šƒ‰‡ȋ•Ȍ‘ˆƒ„†‘‹ƒŽ ‘–‘—”™‹–Š–Š‡ˆ‘ŽŽ‘™‹‰ƒ•™‡”ƒŽ–‡”ƒ–‹˜‡•ǣ Dz‘‡dzǡDz—Ž‰‹‰dzǡƒ†Dz ‡”‹ƒdzǤ ‡”‡™‡ˆƒ ‡ƒƒŒ‘”Ž‹‹–ƒ–‹‘ƒ•–Š‡”‡‹•‘ Ž‹‹ ƒŽ ‡šƒ‹ƒ–‹‘’‡”ˆ‘”‡†„›ƒ’Žƒ•–‹ •—”‰‡‘Ǥ‘”‡‘˜‡”ǡ™‡„‡Ž‹‡˜‡–Šƒ–‹–‹•‘– Ž‡ƒ”ˆ‘” ƒŽŽ’ƒ–‹‡–•™Šƒ–ƒŠ‡”‹ƒƒ†„—Ž‰‡Ž‘‘Ž‹‡ǡƒ†™Šƒ––Š‡†‹ˆˆ‡”‡ ‡„‡–™‡‡–Š‡–™‘ ‘ˆ–Š‡ƒ”‡Ǥ‘‡’ƒ–‹‡–•ƒ›‡˜‡Šƒ˜‡†‘‰Ǧ‡ƒ”•ƒ†Ȁ‘””‡•‹†—ƒŽƒ„†‘‹ƒŽ ‘˜‡”Šƒ‰ǡƒ†ƒ••—‡–Šƒ––Š‡•‡ ‘–‘—”ƒ„‘”ƒŽ‹–‹‡•”‡’”‡•‡–ƒŠ‡”‹ƒ‘”„—Ž‰‡Ǥ‡ •—‰‰‡•––Šƒ––Š‹•‹• ‘ ‡’–‹‘‹•–Š‡‡š’Žƒƒ–‹‘ˆ‘”–Š‡˜‡”›Š‹‰Š„—Ž‰‹‰”ƒ–‡•‡‡‹ ‘—”•–—†›ǡ™Š‡”‡ͳͳȀʹͻȋ͵ͺΨȌ”‡’‘”–‡†ƒ„—Ž‰‡Ǥ‘‡‘ˆ–Š‡’ƒ–‹‡–•ǡŠ‘™‡˜‡”ǡ ”‡’‘”–‡†ƒŠ‡”‹ƒǤ –™‘—Ž†Šƒ˜‡„‡‡„‘–Š‹–‡”‡•–‹‰ƒ†„‡‡ˆ‹ ‹ƒŽ–‘ ‘’Ž‡–‡ƒ ’Š›•‹ ƒŽ‡šƒ‹ƒ–‹‘‘ˆ–Š‹• ‘Š‘”––‘‰‡––Š‡–”—‡”ƒ–‡•‘ˆƒ„†‘‹ƒŽ ‘–‘—” Šƒ‰‡•Ǥ ‡”–ƒ‹Ž›ǡ–Š‡”‡ƒ”‡‡–Š‘†‘Ž‘‰‹ ƒŽˆŽƒ™•‹‘—”“—‡•–‹‘ƒ‹”‡Ǧ„ƒ•‡†•–—†›Ǥ –•ƒ› Ž‹‹–ƒ–‹‘•ƒ”‡ˆ—”–Š‡”†‹• —••‡†‹Dz‡–Š‘†‘Ž‘‰‹ ƒŽ ‘•‹†‡”ƒ–‹‘•dzǤ   ‘ Ž—•‹‘ǡ™‡„‡Ž‹‡˜‡–Šƒ–Š‡”‹ƒƒ†„—Ž‰‡•ƒ”‡ˆ‡™ƒ†ˆƒ”„‡–™‡‡ǡƒ† ”‡ˆ‡”–‘–Š‡’‡” ‡–ƒ‰‡•‘ˆƒˆ‘”‡‡–‹‘‡†‡–ƒǦƒƒŽ›•‡•Ǥ‘™Š‡”‹ƒƒ†„—Ž‰‹‰”ƒ–‡• ƒ”‡ƒŽ•‘•—’’‘”–‡†„›–Š‡•–—†›ȋ’ƒ’‡” Ȍ™Š‹ Š‘ˆˆ‡”•ƒ‘„Œ‡ –‹˜‡ƒ••‡••‡–Ǥ  “DIEAP flap patients are equally as satisfied with the abdomen as AP patients”.

48 48 Š‹•‹•–Š‡ˆ‹”•–•–—†›–Šƒ– ‘’ƒ”‡•’ƒ–‹‡–Ǧ”‡’‘”–‡†ƒ„†‘‹‘’Žƒ•–›‘—– ‘‡•ƒ† •ƒ–‹•ˆƒ –‹‘„‡–™‡‡ ˆŽƒ’ƒ†’ƒ–‹‡–•Ǥ ˆ ‘—Ž†„‡˜‹‡™‡†ƒ•ƒ‰‘Ž† •–ƒ†ƒ”†ǡ–Š‡‹•‹‰‹ˆ‹ ƒ–†‹ˆˆ‡”‡ ‡• ‘’ƒ”‹‰–Š‡–™‘’”‘ ‡†—”‡•†‘‘–•—’’‘”––Š‡ ‹†‡ƒ‘ˆ’”‘‰”‡••‹˜‡Ž›‘†‹ˆ›‹‰–Š‡ ˆŽƒ’ƒ„†‘‹‘’Žƒ•–›ƒ••—‰‰‡•–‡†‹ Ž‹–‡”ƒ–—”‡ǤȋͺͷǦͺ͹Ȍ  ƒ•‡†‘–Š‡•ƒ‡‹•‹‰‹ˆ‹ ƒ ‡ǡ‹–ƒ›„‡ƒ”‰—‡†–Š‡”‡‹•‘‘„˜‹‘—•‡‡†ˆ‘” •–ƒ†ƒ”†‹œ‹‰ƒ‡•–Š‡–‹ ”‡˜‹•‹‘•‘ˆ–Š‡†‘‘”Ǧ•‹–‡ƒˆ–‡” ˆŽƒ’„”‡ƒ•– ”‡ ‘•–”— –‹‘•ǤŠ‹•Šƒ•„‡‡•—‰‰‡•–‡†„›–ƒŽ†‡”‡–ƒŽǤȋ͵ͷȌŠ‡›’‡”ˆ‘”‡†ƒ ’”‘•’‡ –‹˜‡•‡”‹‡•‘ˆͷͳ’ƒ–‹‡–•™Š‘ƒŽŽ—†‡”™‡–ƒ‡•–Š‡–‹ ”‡˜‹•‹‘‘ˆ–Š‡†‘‘”Ǧ•‹–‡ †—”‹‰–Š‡•‡ ‘†•–ƒ‰‡‘ˆ–Š‡‹””‡ ‘•–”— –‹‘ȋ‘Ž‡••–Šƒ–Š”‡‡‘–Š•ƒˆ–‡”–Š‡‹” ‹‹–‹ƒŽ‘’‡”ƒ–‹‘ȌǤŠ‡‹”•–ƒ†ƒ”†‹œ‡†ƒ‡•–Š‡–‹ ”‡˜‹•‹‘ ‘•‹•–‡†‘ˆŽ‹’‘•— –‹‘‘ˆ–Š‡ ƒ„†‘‹ƒŽˆŽƒ’ƒ†‘•’—„‹•ǡ‡š ‹•‹‘ƒ†Ž‘™‡”‹‰‘ˆ–Š‡ƒ„†‘‹ƒŽ• ƒ”ǡƒ†ȋ‹ˆ ‹†‹ ƒ–‡†Ȍ”‡ –—•’Ž‹ ƒ–‹‘Ǥ‘‡š ‹•‡ƒ†Ž‘™‡”–Š‡ƒ„†‘‹ƒŽ• ƒ”ǡ—†‡”‹‹‰‘ˆ–Š‡ ƒ„†‘‹ƒŽˆŽƒ’™ƒ•”‡Ǧ†‘‡ƒ†–”ƒ•‡ –‹‘‘ˆ–Š‡—„‹Ž‹ —•™ƒ•’‡”ˆ‘”‡†ǤŠ‡ —„‹Ž‹ —•™ƒ•Žƒ–‡””‡Ž‘ ƒ–‡† ƒ—†ƒŽŽ›ƒ†ƒ Š‘”‡†–‘–Š‡ˆƒ• ‹ƒǤŠ‹••—”‰‹ ƒŽ”‘—–‹‡ –‘‘ƒƒ˜‡”ƒ‰‡‘ˆʹ͹‹—–‡•ƒ†ƒƒ‰‡†–‘Ž‘™‡”–Š‡†‘‘”Ǧ•‹–‡• ƒ”„›ƒ‡ƒ‘ˆ ͷǤͻ͵ ȋ”ƒ‰‡ǣͷǦ͹ ȌǤ‘‡™ ‘’Ž‹ ƒ–‹‘•ƒ––Š‡†‘‘”Ǧ•‹–‡™‡”‡•‡‡Ǥ••— Šǡ –Š‡›’”‘’‘•‡†–Šƒ–•–ƒ†ƒ”†‹œ‡†ƒ‡•–Š‡–‹ ”‡˜‹•‹‘•ƒ––Š‡†‘‘”Ǧ•‹–‡•Š‘—Ž†„‡ƒ ‹–‡‰”ƒŽ’ƒ”–‘ˆ–Š‡ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ  Ž–Š‘—‰Š’”‘‹•‹‰”‡•—Ž–•Šƒ˜‡„‡‡†‡‘•–”ƒ–‡†ǡ‘—””‡•‡ƒ” Š–‡ƒ†‘‡•‘– ‡ ‡••ƒ”‹Ž›ƒ‰”‡‡™‹–Š–Š‡ƒˆ‘”‡‡–‹‘‡† ˆŽƒ’‘†‹ˆ‹ ƒ–‹‘•‘”•–ƒ†ƒ”†‹œ‡† ƒ‡•–Š‡–‹ †‘‘”Ǧ•‹–‡”‡˜‹•‹‘•Ǥ ’ƒ’‡” ǡ–Š‡ ‰”‘—’• ‘”‡†ƒƒ˜‡”ƒ‰‡‘ˆ͹Ǥ͹ȋͲ α˜‡”›†‹••ƒ–‹•ˆ‹‡†ǡͳͲα˜‡”›•ƒ–‹•ˆ‹‡†Ȍ™Š‡”ƒ–‹‰–Š‡‹”•ƒ–‹•ˆƒ –‹‘™‹–Š–Š‡ ƒ’’‡ƒ”ƒ ‡‘ˆ–Š‡’‘•–•—”‰‹ ƒŽƒ„†‘‡ǤŠ‡‰”‘—’ǡŠ‘™‡˜‡”ǡŠƒ†ƒƒ˜‡”ƒ‰‡• ‘”‡ ‘ˆ͸Ǥ͹„‡‹‰„‘”†‡”Ǧ•‹‰‹ˆ‹ ƒ–Ž›Ž‘™‡” ‘’ƒ”‡†™‹–Š–Š‡ ‰”‘—’ȋPαͲǤͲͺͷȌǤ ‡”‡ǡ „›ƒ Š‹‡˜‹‰ƒ–Ž‡ƒ•–‡“—ƒŽŽ›‰‘‘†•ƒ–‹•ˆƒ –‹‘Ž‡˜‡Ž•ǡ–Š‡ ˆŽƒ’’”‘ ‡†—”‡•— ‡‡†• ‹„‘–Š”‡ ‘•–”— –‹‰–Š‡„”‡ƒ•–ƒ†‹‹ ‹‰ƒǤ‘’Ž‹ ƒ–‹‘• ƒ„‡ƒ˜‘‹†‡† ƒ†”‡•‘—” ‡• ƒ„‡•’ƒ”‡†„› ‘–‹—‹‰–‘†ƒ›ǯ• ˆŽƒ’’”ƒ –‹ ‡Ǥ  “The majority of DIEAP flap patients are satisfied with their body when dressed”. Š‹•“—‡•–‹‘ ‘—Ž† ‘˜‡”‹’ƒ”–Š‘™–Š‡’ƒ–‹‡–ˆ‡‡Ž•‹Š‡”‡˜‡”›†ƒ›Ž‹ˆ‡’‘•–Ǧ •—”‰‹ ƒŽŽ›ǤŽ–‡”ƒ–‹˜‡Ž›ǡ’ƒ–‹‡–• ‘—Ž†ˆ‡‡Ž— ‘ˆ‘”–ƒ„Ž‡™‹–Š–Š‡”‡ ‘•–”— –‹‘ ‘—– ‘‡•Ȃ„‘–Šƒ‡†ƒ††”‡••‡†Ǥ‘™‹‰–Šƒ–ͺ͸Ψ‘ˆ–Š‡ ‰”‘—’ˆ‡‡Ž •ƒ–‹•ˆ‹‡†™‹–Š–Š‡‹”„‘†›™Š‡†”‡••‡† ‘—Ž†„‡˜‹‡™‡†ƒ•’‘•‹–‹˜‡ˆ‡‡†„ƒ  ‘ˆ‹”‹‰ ƒ‰‘‘†„”‡ƒ•–”‡ ‘•–”— –‹‘‘†ƒŽ‹–›Ǥ  ‡„‡Ž‹‡˜‡–Šƒ––Š‹•‹•ƒƒ†‡“—ƒ–‡ƒ†‹’‘”–ƒ–“—‡•–‹‘–‘ƒ•„ƒ•‡†‘–Š‡ ’—„Ž‹ ƒ–‹‘Dz‡ƒ•‘•Š›‘‡Š‘ ƒ˜‡ƒ•–‡ –‘›‡ ‹†‡–‘ ƒ˜‡‘”‘––‘ ƒ˜‡ ”‡ƒ•–‡ ‘•–”— –‹‘dz™”‹––‡„›‡ƒ„›Ǥȋͳ͹ʹȌŠ”‘—‰Š•‡‹Ǧ•–”— –—”‡†‹–‡”˜‹‡™•ǡ ™Š‡”‡–Š‡’ƒ–‹‡–•™‡”‡ƒ•‡†–‘‰‹˜‡ƒDz›‡•dz‘”ƒDz‘dz–‘™Š‡–Š‡”‘”‘––Š‡ˆ‘ŽŽ‘™‹‰ ”‡ƒ•‘•™‡”‡‹’‘”–ƒ–ˆ‘”Š‡”‹†‡ ‹•‹‘‘ˆŠƒ˜‹‰ƒ„”‡ƒ•–”‡ ‘•–”— –‹‘ǡ–Š‡ ’”‘’‘”–‹‘‘ˆDz›‡•dz™‡”‡ƒ•ˆ‘ŽŽ‘™•ǣͳȌ‘„‡ƒ„Ž‡–‘™‡ƒ”ƒ›†‹ˆˆ‡”‡––›’‡•‘ˆ Ž‘–Š‹‰ȋͺͳΨȌǡʹȌ‘”‡‰ƒ‹ˆ‡‹‹‹–›ȋ͹͹ΨȌǡƒ†͵Ȍ‘ˆ‡‡Ž™Š‘Ž‡ƒ‰ƒ‹ȋ͹͹ΨȌǤ Š‡•‡–Š”‡‡”‡ƒ•‘• ‘—Ž†„‡Ž‹‡†–‘–Š‡Ž‡˜‡Ž‘ˆ„‘†›•ƒ–‹•ˆƒ –‹‘™Š‡†”‡••‡†ƒ• ‹˜‡•–‹‰ƒ–‡†‹‘—”•–—†›ǤŽ‘–Š‹‰ǡˆ‡‹‹‹–›ǡƒ†„‘†›‹–‡‰”‹–›ƒ”‡‹’‘”–ƒ– ‘—– ‘‡•ˆ‘”–Š‡„”‡ƒ•–”‡ ‘•–”— –‡†’ƒ–‹‡–•Ǥ

49 49  Š‡Š‹‰ŠŽ‡˜‡Ž‘ˆ•ƒ–‹•ˆƒ –‹‘™‹–Š‹–Š‡ ‰”‘—’‹‰Š–„‡‘”‡—•‡ˆ—Ž ‹ˆ‘”ƒ–‹‘ˆ‘”’ƒ–‹‡–••‡‡‹‰‡†‹ ƒŽƒ†˜‹ ‡–Šƒ–Š‡•‹‰‹ˆ‹ ƒ– ‘’ƒ”‹•‘™‹–Š–Š‡ ‰”‘—’ȋͷͷΨ•ƒ–‹•ˆ‹‡†™‹–Š–Š‡‹”„‘†›™Š‡†”‡••‡†ǡPαͲǤͲͲͻȌǤ•†‹• —••‡†—†‡” Dz‡–Š‘†‘Ž‘‰‹ ƒŽ ‘•‹†‡”ƒ–‹‘•dzǡ–Š‡•‡’ƒ–‹‡–‰”‘—’• ‘•–‹–—–‡–™‘”ƒ–Š‡”†‹ˆˆ‡”‡– ‘Š‘”–•‹–‡”•‘ˆ„ƒ ‰”‘—†ǡ„‘†›‹ƒ‰‡ǡ‘–‹˜ƒ–‹‘•ǡ‡š’‡ –ƒ–‹‘•ǡ‡– ǤŠ‡”‡ƒ”‡ǡ –Š‡”‡ˆ‘”‡ǡ ‘•‹†‡”ƒ„Ž‡Ž‹‹–ƒ–‹‘•‹–Š‹• ‘’ƒ”‹•‘Ǥ  “Significantly more AP patients experience an altered body image compared to DIEAP flap patients”.ƒ˜‹†Ǥƒ”™‡”ǡ’”‘ˆ‡••‘”‘ˆ’•› Š‘Ž‘‰›‹•—”‰‡”›ǡƒ† ‘Ǧ ƒ—–Š‘”•Šƒ˜‡†‡• ”‹„‡†–Šƒ––Š‡–‡”Dz„‘†›‹ƒ‰‡dz ‘•‹•–•‘ˆ–™‘ ‘’‘‡–•ǣͳȌ‘†› ‹ƒ‰‡‘”‹‡–ƒ–‹‘ȋŠ‘™‹’‘”–ƒ–„‘†›‹ƒ‰‡‹•ˆ‘”ƒ’‡”•‘Ȍǡƒ†ʹȌ‘†›‹ƒ‰‡ ‡˜ƒŽ—ƒ–‹‘ȋŠ‘™•ƒ–‹•ˆ‹‡†ƒ’‡”•‘‹•™‹–ŠŠ‹•‘”Š‡”‘™„‘†›ȌǤȋͳ͹͵Ȍ –Šƒ•„‡‡•Š‘™ –‘„‡ƒ‹’‘”–ƒ–‹‡˜ƒŽ—ƒ–‹‰‘–‹˜ƒ–‹‘•ˆ‘”ƒ†’•› Š‘Ž‘‰‹ ƒŽ”‡•’‘•‡•–‘ ƒ‡•–Š‡–‹ •—”‰‡”›Ǥȋͳ͹ͶǦͳ͹ͺȌ ‘”–Šƒ–”‡ƒ•‘ǡ–Š”‡‡“—‡•–‹‘•”‡‰ƒ”†‹‰„‘†›‹ƒ‰‡™‡”‡ ‹ Ž—†‡†‹–Š‡“—‡•–‹‘ƒ‹”‡Ǥ †‡ƒŽŽ›ǡƒ’•› Š‘‡–”‹ ƒŽŽ›˜ƒŽ‹†ƒ–‡†‹•–”—‡–•— Šƒ• ‘’™‘‘†ǯ•‘†› ƒ‰‡ ƒŽ‡ǡƒͳͲǦ‹–‡„”‡ƒ•– ƒ ‡”Ǧ•’‡ ‹ˆ‹ • ƒŽ‡—•‡†–‘•–—†› Šƒ‰‡•‘ˆ„‘†›‹ƒ‰‡ƒˆ–‡” ƒ ‡”–”‡ƒ–‡–ǡ•Š‘—Ž†Šƒ˜‡„‡‡‡’Ž‘›‡†Ǥȋͳ͹ͻȌŠ‹•‹• †‹• —••‡†‘”‡‹†‡–ƒ‹Ž‹Dz‡–Š‘†‘Ž‘‰‹ ƒŽ ‘•‹†‡”ƒ–‹‘•dzǤ  Š‡•‹‰‹ˆ‹ ƒ–Ž›Š‹‰Š‡”—„‡”‘ˆ’ƒ–‹‡–•‡š’‡”‹‡ ‹‰„‘†›‹ƒ‰‡ƒŽ–‡”ƒ–‹‘• ƒ‘‰’ƒ–‹‡–•˜‡”•—• ˆŽƒ’’ƒ–‹‡–•™ƒ•ƒ—‡š’‡ –‡†‘„•‡”˜ƒ–‹‘ƒ•–Š‡ ˆ‘”‡”Šƒ˜‡•—”‰‡”›–‘‘‡•‹–‡ȋƒ„†‘‡Ȍƒ†–Š‡Žƒ––‡”–™‘•‹–‡•ȋƒ„†‘‡ƒ† „”‡ƒ•–ȌǤͺͷΨ‘ˆ–Š‡‰”‘—’ ‘’ƒ”‡†–‘ͷͻΨ‘ˆ–Š‡ ‰”‘—’‡š’‡”‹‡ ‡†ƒ ƒŽ–‡”‡†„‘†›‹ƒ‰‡ȋPαͲǤͲͳ͸ȌǤŠ‡•‡™‡”‡‘•–’”‘„ƒ„Ž›’‘•‹–‹˜‡ƒŽ–‡”ƒ–‹‘•ƒ•ˆ‡™ ™‡”‡•ƒ†‘”ƒ‰”›ƒ„‘—––Š‡‹”’‘•–‘’‡”ƒ–‹˜‡„‘†›‹ƒ‰‡‹„‘–Š‰”‘—’•ǤŠ‡•‹‰‹ˆ‹ ƒ– †‹ˆˆ‡”‡ ‡‹„‘†›‹ƒ‰‡ƒŽ–‡”ƒ–‹‘•‹•ƒ˜ƒŽ—ƒ„Ž‡‘„•‡”˜ƒ–‹‘‹—†‡”•–ƒ†‹‰ƒ† ‹–‡”’”‡–‹‰–Š‡‘–Š‡””‡•—Ž–•Ǥ – ‘—Ž†„‡ƒ‹†‹ ƒ–‹‘‘ˆ–Š‡†‹ˆˆ‡”‡–„ƒ ‰”‘—†•ƒ† ‰‘ƒŽ•‘ˆ–Š‡–™‘’ƒ–‹‡–‰”‘—’•Ǥ – ‘—Ž†ƒŽ•‘”‡ˆŽ‡ ––Š‡ˆƒ ––Šƒ–ƒŽŽ ˆŽƒ’•™‡”‡ •‡ ‘†ƒ”›ǡ™Š‹ Š‹•ƒ••‘ ‹ƒ–‡†™‹–Š•‹‰‹ˆ‹ ƒ–Ž›‹’ƒ‹”‡†’”‡Ǧ”‡ ‘•–”— –‹‘„‘†› ‹ƒ‰‡ȋƒ†–Š‡”‡„›‰”‡ƒ–‡” Šƒ‰‡•™‹–Š•—”‰‡”›ȌǤȋͳͺͲȌŠ‹•‹•†‹• —••‡†‘”‡‹†‡–ƒ‹Ž Ȃ’Ž‡ƒ•‡•‡‡Dz‡–Š‘†‘Ž‘‰‹ ƒŽ ‘•‹†‡”ƒ–‹‘•dzǤ  —””‡•—Ž–•ƒ”‡‹‡‡’‹‰™‹–Š”‡ ‡–”‡’‘”–•ǣ†‡”‹–‘‡–ƒŽǤ†‡‘•–”ƒ–‡†–Šƒ– Šƒ•ƒ•‹‰‹ˆ‹ ƒ–’‘•‹–‹˜‡‹’ƒ –‘„‘†›‹ƒ‰‡ǡ•‡ŽˆǦ‡•–‡‡ǡƒ†‡–ƒŽŠ‡ƒŽ–Š ȋˆ‘—†‘‡ƒ†•‹š‘–Š•’‘•–‘’‡”ƒ–‹˜‡Ž›ȌǤȋͳ͹ͶȌ‹’”‘˜‡†„‘†›‹ƒ‰‡ƒˆ–‡”Šƒ• ƒŽ•‘„‡‡”‡’‘”–‡†„›–—‡”œ‡–ƒŽǤȋ͹͸ǡ͹͹ǡͳ͹ͷǡͳ͹ͺǡͳͺͳȌ –‡”•‘ˆ ˆŽƒ’•—”‰‡”›ǡ ƒ•‹‰‹ˆ‹ ƒ–‹’”‘˜‡‡–‘ˆ„‘†›‹ƒ‰‡Šƒ•„‡‡†‘ —‡–‡†„› ‘’‹‡‡–ƒŽǤȋͳͺʹȌ  “Abdominoplasty could increase sexual desire”.ͶͲΨ‘ˆ–Š‡‰”‘—’”‡’‘”–‡†ƒ ‹ ”‡ƒ•‡†•‡š—ƒŽ†‡•‹”‡ƒˆ–‡” ‘’Ž‡–‹‰•—”‰‡”›„‡‹‰•‹‰‹ˆ‹ ƒ–Ž›Š‹‰Š‡”–Šƒ–Š‡  ‰”‘—’ȋPαͲǤͲͲ͵ȌǤŠ‹•‹•‹ ‘ ‡”–™‹–Š’—„Ž‹ ƒ–‹‘•†‡‘•–”ƒ–‹‰ƒ•—„•–ƒ–‹ƒŽ ‹’”‘˜‡‡–‘ˆ•‡š—ƒŽ‹–›ƒˆ–‡”Ǥȋ͹͹ǡͳͺͳǡͳͺ͵Ȍ‡„‡Ž‹‡˜‡–Šƒ––Š‡ ƒ—•‡•‘ˆ–Š‹• Šƒ‰‡ƒ”‡—Ž–‹ˆƒ –‘”‹ƒŽǡ™Š‡”‡ˆƒ –‘”••— Šƒ•‹’”‘˜‡†„‘†›‹ƒ‰‡ǡ•‡š—ƒŽ ˆ— –‹‘‹‰ǡƒ†’ƒ”–‡”•ƒ–‹•ˆƒ –‹‘ƒ”‡ ‘†— ‹˜‡Ǥ 

50 50 “DIEAP flap surgery could decrease sexual desire”. —””‡–Ž›ǡ–Š‡”‡‹•Ž‹‹–‡† ‹ˆ‘”ƒ–‹‘‘–Š‡’•› Š‘•‡š—ƒŽ‹’ƒ –‘ˆ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŠ‡‘•– ”‡Ž‡˜ƒ–’—„Ž‹ ƒ–‹‘‹‰Š–„‡–Š‡‡˜ƒŽ—ƒ–‹‘‘ˆ–Š‡‹’ƒ –‘ˆ†‡Žƒ›‡†‹’Žƒ–ƒ†  ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘‘„‘†›‹ƒ‰‡ƒ†•‡š—ƒŽ•ƒ–‹•ˆƒ –‹‘’‡”ˆ‘”‡†„› ‘’‹‡‡– ƒŽǤȋͳͺʹȌ ‘”„‘–Š”‡ ‘•–”— –‹‘‘†ƒŽ‹–‹‡•ǡ–Š‡›ˆ‘—†ƒ•‹‰‹ˆ‹ ƒ–Ž›‹’”‘˜‡†•‡š—ƒŽ •ƒ–‹•ˆƒ –‹‘ƒ–•‹šƒ†ʹͲ‘–Š•’‘•–‘’‡”ƒ–‹˜‡Ž›ȋ ‘’ƒ”‡†–‘’”‡‘’‡”ƒ–‹˜‡•–ƒ–—•ȌǤ Š‡›†‹†ǡŠ‘™‡˜‡”ǡ†‘ —‡–ƒ–”‡†‘ˆ‹’Žƒ–Ǧ”‡ ‘•–”— –‡†’ƒ–‹‡–•„‡‹‰‘”‡ •‡š—ƒŽŽ›•ƒ–‹•ˆ‹‡†–Šƒ ˆŽƒ’’ƒ–‹‡–•ȋP=ͲǤͲ͹ȌǤ ’ƒ’‡” ǡͳ͹Ψ‘ˆ–Š‡ ‰”‘—’ƒ•™‡”‡†–Šƒ––Š‡‹”•‡š—ƒŽ†‡•‹”‡ƒ –—ƒŽŽ› ™‘”•‡‡†Ǥ‡†‹†—ˆ‘”–—ƒ–‡Ž›‘–‡š’Ž‘”‡–Š‡”‡ƒ•‘•™Š›–Š‡•‡’ƒ–‹‡–•‡š’‡”‹‡ ‡† –Š‹• Šƒ‰‡ǤŠ‡„—”†‡‘ˆ„”‡ƒ•– ƒ ‡”†‹•‡ƒ•‡ƒ†‘ ‘Ž‘‰‹ ƒŽ–”‡ƒ–‡–•ȋ‡Ǥ‰Ǥ Š‘”‘ƒŽ–Š‡”ƒ’›Ȍƒ”‡ ‘ˆ‘—†‹‰ˆƒ –‘”•™Š‹ Š‹‰Š–‡š’Žƒ‹’ƒ”–•‘ˆ–Š‹•’‹ –—”‡Ǥ‡ „‡Ž‹‡˜‡–Šƒ– Šƒ‰‡•–‘–Š‡†‘‘”Ǧ•‹–‡”‡‰‹‘ƒŽ•‘ƒˆˆ‡ –•‡š—ƒŽ†‡•‹”‡Ǥ•ƒƒ––‡”‘ˆˆƒ –ǡ ‹††ƒ‡–ƒŽǤ”‡’‘”–‡†–Šƒ–’ƒ–‹‡–•‡š’Žƒ‹‡†–Šƒ–’ƒ”–‹ —Žƒ”Ž›–Š‡†‘‘”Ǧ•‹–‡• ƒ”ƒ† ƒ„†‘‹ƒŽ‘˜‡”Šƒ‰ ‘—Ž†’”‡˜‡––Š‡ˆ”‘‰‡––‹‰ƒ‡†ǤȋͷʹȌ  †‡ ”‡ƒ•‡‘ˆ•‡š—ƒŽ†‡•‹”‡ ‘—Ž†„‡•‡‡ƒ•ƒ‡Ž‡‡–‹•‡š—ƒŽ†›•ˆ— –‹‘Ǥ Š‹•‹•ƒ™‡ŽŽǦ‘™ ŠƒŽŽ‡‰‡ƒ‘‰„”‡ƒ•– ƒ ‡”’ƒ–‹‡–•ǣ ƒ’ƒ‹•Š ”‘••Ǧ •‡ –‹‘ƒŽ•–—†›’—„Ž‹•Š‡†‹ʹͲͳͺǡˆ‘”‹•–ƒ ‡ǡ•‹‰‹ˆ‹ ƒ–†‹ˆˆ‡”‡ ‡•‹–Š‡’”‡•‡ ‡‘ˆ •‡š—ƒŽ†›•ˆ— –‹‘„‡ˆ‘”‡ȋ͵ʹǤͳΨȌƒ†ƒˆ–‡”ȋͻͳǤʹΨȌ„”‡ƒ•– ƒ ‡”ȋP=ͲǤͲͲʹȌ™‡”‡ ˆ‘—†ǤȋͳͺͶȌƒ•–‡ –‘› ƒ—•‡†•—„•–ƒ–‹ƒŽŽ›‘”‡•‡š—ƒŽ†›•ˆ— –‹‘–Šƒ‹–Š‡ •ƒ‡•–—†›Ǥ••— Šǡ”‡•–‘”‹‰’”‡Ǧ ƒ ‡”•‡š—ƒŽ‹–›„‡ ‘‡•ƒ’”‹‡‘–‹˜ƒ–‹‘ƒ‘‰ ’ƒ–‹‡–•‘’–‹‰ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥȋͳ͸͵Ȍ  ‡•’‹–‡–Š‡‹’‘”–ƒ ‡‘ˆ•‡š—ƒŽ‹–›ƒ‘‰’‘•–Ǧƒ•–‡ –‘›’ƒ–‹‡–•ǡ‹–‹• ˆ”‡“—‡–Ž›—ƒ††”‡••‡†„›’Žƒ•–‹ •—”‰‡‘•Ǥȋͳͺͷǡͳͺ͸Ȍ‘”‡‘˜‡”ǡ„‘–Š ƒ ‡”’ƒ–‹‡–• ȋ‡•’‡ ‹ƒŽŽ›ˆ‡ƒŽ‡Ȍƒ†’Žƒ•–‹ •—”‰‡‘•‡š’‡”‹‡ ‡•‹‰‹ˆ‹ ƒ–„ƒ””‹‡”•–‘™ƒ”†• †‹• —••‹‰–Š‹•ƒ––‡”Ǥȋͳͺͷǡͳͺ͹ȌŠ‹• ƒ—•‡•ƒ‹ˆ‘”ƒ–‹‘‰ƒ’ƒ†—”‡ƒŽ‹•–‹  ‡š’‡ –ƒ–‹‘•Ǥ‡„‡Ž‹‡˜‡–Šƒ–’Žƒ•–‹ •—”‰‡‘••Š‘—Ž†”‘—–‹‡Ž›†‹• —••’‘••‹„Ž‡ •‡š—ƒŽ‹–› Šƒ‰‡•™‹–Š’ƒ–‹‡–•ǤŠ‹•‹‰Š–„‡‡•’‡ ‹ƒŽŽ›‹’‘”–ƒ–ƒ‘‰ȋ›‘—‰‡”Ȍ ’ƒ–‹‡–• ‘•‹†‡”‹‰”‹•Ǧ”‡†— ‹‰ƒ•–‡ –‘›ƒ†„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥȋͳͺ͸Ȍ”‹––‡ ’ƒ–‹‡–‹ˆ‘”ƒ–‹‘‹•ƒ‰‘‘†ƒ††‡†—‹–Š‹•‹ˆ‘”ƒ–‹‘’”‘ ‡••Ǥ  “DIEAP flap patients are overall satisfied with their breast reconstruction”.ͻ͹Ψ‘ˆ –Š‡ ‰”‘—’™‡”‡‘˜‡”ƒŽŽ•ƒ–‹•ˆ‹‡†ǤŠ‹•‹•ƒ•–”‘‰‡••ƒ‰‡Ǥ††‹–‹‘ƒŽŽ›ǡ–Š‡†ƒ–ƒ •Š‘™‹‰–Šƒ–ͻ͹Ψ™‘—Ž†Šƒ˜‡‰‘‡–Š”‘—‰Š–Š‡•ƒ‡‘’‡”ƒ–‹‘ƒ‰ƒ‹ƒ†ͻ͵Ψ™‘—Ž† ”‡ ‘‡†–Š‡‘’‡”ƒ–‹‘–‘‘–Š‡”’ƒ–‹‡–•ǡ•—„•–ƒ–‹ƒ–‡–Š‹•‘„•‡”˜ƒ–‹‘ǤŠ‹•Š‹‰ŠǦ Ž‡˜‡Ž•ƒ–‹•ˆƒ –‹‘‘ˆ ˆŽƒ’’ƒ–‹‡–•Šƒ•„‡‡™‡ŽŽǦ†‘ —‡–‡†‹’”‡˜‹‘—•Ž‘‰Ǧ –‡”ǡˆ‘ŽŽ‘™Ǧ—’”‡•‡ƒ” ŠǤȋͳͺǡͳͺͺȌ  

51 51 6 Methodological considerations

Š‡‡–Š‘†‘Ž‘‰‹ ƒŽ ‘•‹†‡”ƒ–‹‘•ƒ”‡†‹• —••‡†‹•Š‘”–’Š”ƒ•‡•ˆ‘”’ƒ’‡” Ǧ Ǥ ‡–Š‘†‘Ž‘‰‹ ƒŽ™‡ƒ‡••‡•ƒ†•–”‡‰–Š•ƒ”‡”‡’‘”–‡†ǤŠ‡ ‘•‹†‡”ƒ–‹‘‘ˆ ™‡ƒ‡••‡•ˆ‘ŽŽ‘™•–Š‡ˆ‘ŽŽ‘™‹‰•‡“—‡ ‡ǣͳȌ–—†›†‡•‹‰ǡʹȌƒ–‹‡–•ǡ͵Ȍ •–”—‡–•ǡ ͶȌ–ƒ–‹•–‹ ƒŽƒƒŽ›•‹•ǡƒ†ͷȌ‹• ‡ŽŽƒ‡‘—•Ǥ–”‡‰–Š•ƒ”‡†‹• —••‡†‹ˆ”‡‡–‡š–Ǥ  Paper I Study design 1) Standardized zones: Š‡•–ƒ†ƒ”†‹œ‡†œ‘‡•‘—–Ž‹‡†‹–Š‡•–—†›Šƒ˜‡–Š‡ ˆ‘ŽŽ‘™‹‰Ž‹‹–ƒ–‹‘•ǣ a. Varying number of perfusion sites:Š‡œ‘‡•™‡”‡ ‘’‘•‡†‘ˆ‘‡–”‹ƒ‰Ž‡ ȋœ‘‡ͳȌƒ†–Š”‡‡”‡ –ƒ‰Ž‡•ȋœ‘‡•ʹǦͶȌǤŠ‡–”‹ƒ‰Ž‡Šƒ†ˆ‡™‡”’‡”ˆ—•‹‘•‹–‡• ‘’ƒ”‡†™‹–Š–Š‡”‡ƒ‹‹‰œ‘‡•ǤŠ‡•ƒŽŽ‡•–œ‘‡‹ Ž—†‡†‹‘—”•–—†› Šƒ†͸ͳ’‡”ˆ—•‹‘•‹–‡•ǤŠ‡‹’ƒ –‘ˆ•’ƒ–‹ƒŽǦ–‡’‘”ƒŽ’‡”ˆ—•‹‘Š‡–‡”‘‰‡‡‹–› ȋ’‘••‹„Ž›‹–”‘†— ‹‰‡””‘”Ȍ‹ ”‡ƒ•‡•™‹–Šˆ‡™‡”’‡”ˆ—•‹‘•‹–‡•ǤŠ‡”‡‹•‘ ‡•–ƒ„Ž‹•Š‡†Ž‘™‡”Ž‹‹–‹–‡”•‘ˆ’‡”ˆ—•‹‘•‹–‡•ˆ‘”˜ƒŽ‹†‡ƒ•—”‡‡–•Ǥ b. Postsurgical umbilicus’ location and perfusion: ‡‘„•‡”˜‡†–Šƒ––Š‡ ’‘•–•—”‰‹ ƒŽŽ‘ ƒ–‹‘‘ˆ–Š‡—„‹Ž‹ —•˜ƒ”‹‡†Ǥ ͵ͷΨȋ͹ȀʹͲȌ‘ˆ–Š‡’ƒ–‹‡–•–Š‡ ’‘•–•—”‰‹ ƒŽ—„‹Ž‹ —•™ƒ•Ž‘ ƒ–‡†‹œ‘‡͵ǡ‹ͷΨȋͳȀʹͲȌ‹œ‘‡Ͷƒ†‹͸Ͳ ΨȋͳʹȀʹͲȌ’ƒ”–Ž›‹„‘–Šœ‘‡•͵ƒ†ͶǤŠ‡—„‹Ž‹ —•Šƒ† Ž‡ƒ”Ž›ƒ‰”‡ƒ–‡” ’‡”ˆ—•‹‘ ‘’ƒ”‡†™‹–Šƒ†Œƒ ‡–ƒ”‡ƒ•Ǥ –™ƒ•ǡ‡˜‡”–Š‡Ž‡••ǡ‹ Ž—†‡†‹–Š‡ œ‘‡•ǯ‡ƒ’‡”ˆ—•‹‘ˆ‘”•‡˜‡”ƒŽ”‡ƒ•‘•ǤŽ‡ƒ•‡•‡‡†‹• —••‹‘ˆ‘”’ƒ’‡” Ǥ‡ Š›’‘–Š‡•‹œ‡–Šƒ––Š‡—„‹Ž‹ —•‹‰Š–„‡ƒˆƒ –‘”‹ Ǧ•–ƒ”–‹‰–Š‡Ž‘ ƒŽ ”‡’‡”ˆ—•‹‘ƒ†ƒ‰‹‘‰‡‡•‹•‹–Š‡—†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’ǡƒ†ǡ„›–Šƒ–ǡ •Š‘—Ž†„‡‹ Ž—†‡†‹‡ƒ•—”‹‰‹–Š‡œ‘‡•ǯ’‡”ˆ—•‹‘Ǥ 2) No observer variability assessment: ••‡••‡–‘ˆ‘„•‡”˜‡”˜ƒ”‹ƒ„‹Ž‹–›‹• ‹–‡†‡†–‘‰‹˜‡–Š‡”‡ƒ†‡”ƒ“—ƒ–‹–ƒ–‹˜‡‡ƒ•—”‡‘ˆ–Š‡ƒ‰‹–—†‡‘ˆƒ‰”‡‡‡– „‡–™‡‡‘„•‡”˜‡”•ǤȋͳͺͻȌ— Šƒ••‡••‡–•‹†‹ ƒ–‡–Š‡‡–Š‘†’”‡ ‹•‹‘Ǥ –”ƒǦƒ† ‹–‡”Ǧ‘„•‡”˜‡”˜ƒ”‹ƒ„‹Ž‹–›ƒ”‡–›’‹ ƒŽ’”‡ ‹•‹‘‡ƒ•—”‡•ǡ™Š‹ Šˆ‘”‘•–‘ˆ–Š‡–‹‡ ƒ”‡’”‘˜‹†‡†ƒ•ƒ’’ƒ•–ƒ–‹•–‹ •ȋˆ‘” ƒ–‡‰‘”‹ ƒŽ†ƒ–ƒȌǤȋͳͺͻȌŠ‡ƒ’’ƒ ‘‡ˆˆ‹ ‹‡– ”ƒ‰‡•ˆ”‘Ǧͳ–‘Ϊͳȋ’”ƒ –‹ ƒŽŽ›Ͳ–‘ΪͳȌǡ™Š‡”‡Ͳ‹†‹ ƒ–‡•–Šƒ––Š‡ƒ‰”‡‡‡– „‡–™‡‡–Š‡–™‘‘„•‡”˜‡”•‹•‘„‡––‡”–Šƒ’—”‡ Šƒ ‡ǤȋͳͻͲȌƒŽ—‡•„‡–™‡‡ͲǤ͸Ǧ ͲǤ͹ͻƒ”‡‹–‡”’”‡–‡†ƒ•‘†‡”ƒ–‡ƒ‰”‡‡‡–ǡƒ†˜ƒŽ—‡•‘”‡–ŠƒͲǤͺͲƒ”‡ ‹–‡”’”‡–‡†ƒ••–”‘‰ƒ‰”‡‡‡–ǤȋͳͺͻȌƒš‹—˜ƒŽ—‡‘ˆΪͳ‹†‹ ƒ–‡•’‡”ˆ‡ – ƒ‰”‡‡‡–ȋƒ†–Šƒ––Š‡‘„•‡”˜‡”•ƒ‰”‡‡†‘‡˜‡”›–Š‹‰ȌǤ ‘”—‡”‹ ƒŽ†ƒ–ƒǡ–Š‡ ƒ‰‹–—†‡‘ˆƒ‰”‡‡‡–‹•’”‘˜‹†‡†ƒ•‹–”ƒ Žƒ•• ‘””‡Žƒ–‹‘ ‘‡ˆˆ‹ ‹‡–ȋ ȌȂ•‡‡ „‡Ž‘™Ǥ  Š‡•–—†›™‘—Ž† Ž‡ƒ”Ž›Šƒ˜‡„‡‡ˆ‹––‡†ˆ”‘ƒ••‡••‹‰–Š‡ˆ‘ŽŽ‘™‹‰‘„•‡”˜‡” ˜ƒ”‹ƒ„‹Ž‹–›‡ƒ•—”‡•‹–‡”•‘ˆ–Š‡ —•‡ǣȋͳͻͳȌ a. Repeatability (intra-observer variability): ‘”‹–”ƒǦ‘„•‡”˜‡”˜ƒ”‹ƒ„‹Ž‹–›–Š‡ ‘„•‡”˜‡”’‡”ˆ‘”•–™‘‡ƒ•—”‡‡–•‘ˆ‡ƒ Š•ƒ’Ž‡—†‡”‹†‡–‹ ƒŽ ‘†‹–‹‘•ǤŠ‡”‡ƒˆ–‡”–Š‡˜ƒ”‹ƒ„‹Ž‹–›„‡–™‡‡ƒŽŽ–Š‡ ‘—’Ž‡†‡ƒ•—”‡‡–•ƒ”‡

52 52 ƒŽ —Žƒ–‡†ǤŠ‹• ƒŽ —Žƒ–‹‘’”‘˜‹†‡•ƒ Ž—‡‹–‡”•‘ˆ–Š‡ƒ„‹Ž‹–›‘ˆ‘‡‘„•‡”˜‡” –‘ ‘‡—’™‹–Š–Š‡•ƒ‡”‡•—Ž–‘ƒ•‡ ‘†‡ƒ•—”‡‡–’‡”ˆ‘”‡†‘–Š‡ •ƒ‡•ƒ’Ž‡Ǥ ’ƒ’‡” ǡ‘Ž›–Š‡ˆ‹”•–ƒ—–Š‘”’‡”ˆ‘”‡†–Š‡ ‡ƒ•—”‡‡–• ‘ ‡ǤŽ–Š‘—‰Š–Š‡ˆ‘—”œ‘‡•™‡”‡•–ƒ†ƒ”†‹œ‡†ǡ‹– ‘—Ž†„‡–Šƒ––Š‡œ‘‡•™‡”‡ †‡ˆ‹‡††‹ˆˆ‡”‡–Ž›‹ƒ•‡ ‘†‡ƒ•—”‡‡–ȋ’‘••‹„Ž› Šƒ‰‹‰–Š‡—„‡”‘ˆ ’‡”ˆ—•‹‘—‹–•‡ƒ•—”‡†ȌǤ•‹–”ƒǦ‘„•‡”˜‡”˜ƒ”‹ƒ„‹Ž‹–›™ƒ•‘–‡•–‹ƒ–‡†ǡ –Š‡”‡‹• ‘•‡“—‡–Ž›ƒ— ‡”–ƒ‹–›‹–‡”•‘ˆ–Š‡‡–Š‘†’”‡ ‹•‹‘Ǥ Šƒ• „‡‡•Š‘™ǡŠ‘™‡˜‡”ǡ–‘Šƒ˜‡ƒ‰‘‘†”‡’‡ƒ–ƒ„‹Ž‹–›‹•–—†›‹‰Š—ƒ•‹ ‹ ”‘ ‹” —Žƒ–‹‘ǤȋͳͻʹȌ b. Reproducibility (inter-observer variability): ‘”‹–‡”Ǧ‘„•‡”˜‡”˜ƒ”‹ƒ„‹Ž‹–›ǡ –Š‡ƒ„‹Ž‹–›‘ˆƒ•‡ ‘†‘„•‡”˜‡”–‘ ‘‡—’™‹–Š–Š‡•ƒ‡‡ƒ•—”‡‡–ƒ•–Š‡ ˆ‹”•–‘„•‡”˜‡”‹• ƒŽ —Žƒ–‡†Ǥ•‹‰‹ˆ‹ ƒ–˜ƒ”‹ƒ„‹Ž‹–›„‡–™‡‡–™‘‘„•‡”˜‡”• ‹†‹ ƒ–‡ƒ•›•–‡ƒ–‹ ‡””‘”‹–Š‡‡ƒ•—”‡‡–‘ˆ‘‡‘”„‘–Š‘„•‡”˜‡”ȋ•ȌǤȋͳͻͳȌ •‘Ž›–Š‡ˆ‹”•–ƒ—–Š‘”’‡”ˆ‘”‡†–Š‡‡ƒ•—”‡‡–•ǡƒ‹–‡”Ǧ‘„•‡”˜‡” ˜ƒ”‹ƒ„‹Ž‹–› ƒŽ —Žƒ–‹‘™ƒ•‘–‘„–ƒ‹‡†Ǥ›Šƒ˜‹‰–™‘‘”‘”‡‘„•‡”˜‡”•ǡ™‡ ‘—Ž†Šƒ˜‡Ž‹‹–‡†•— Š„‹ƒ•ƒ† ƒŽ —Žƒ–‡†‹–‡”Ǧ‘„•‡”˜‡”˜ƒ”‹ƒ„‹Ž‹–›Ǥ‹‹Žƒ”–‘ ”‡’‡ƒ–ƒ„‹Ž‹–›ǡ Šƒ•„‡‡•Š‘™–‘Šƒ˜‡ƒ‰‘‘†”‡’”‘†— ‹„‹Ž‹–›ǤȋͳͻʹȌ c. Reliability (ICC; intraclass correlation coefficient): ‡Ž‹ƒ„‹Ž‹–›•ƒ›••‘‡–Š‹‰ ƒ„‘—––Š‡’”‡ ‹•‹‘‘ˆ–Š‡‡–Š‘†‹–Š‡’ƒ”–‹ —Žƒ”•ƒ’Ž‡–Šƒ–‹•„‡‹‰ ‡˜ƒŽ—ƒ–‡†ȋƒ‹‰‹–•‘‡™Šƒ–†‹ˆˆ‡”‡–ˆ”‘”‡’‡ƒ–ƒ„‹Ž‹–›ƒ† ”‡’”‘†— ‹„‹Ž‹–›ȌǤȋͳͻͳȌ‡Ž‹ƒ„‹Ž‹–›‹•ǡ‹‘–Š‡”™‘”†•ǡ•–”‘‰Ž›‹ˆŽ—‡ ‡†„›–Š‡ ˜ƒ”‹ƒ„‹Ž‹–›‘ˆ–Š‡–”—‡˜ƒŽ—‡•‹–Š‡’‘’—Žƒ–‹‘Ǥ –†‡’‡†•‘–Š‡’‘’—Žƒ–‹‘‹ ™Š‹ Š‡ƒ•—”‡‡–•ƒ”‡ƒ†‡ǡƒ† ƒ‘–„‡†‹”‡ –Ž›—•‡†ƒ•ƒ‡ƒ•—”‡‘ˆ ’”‡ ‹•‹‘Ǥ‡Ž‹ƒ„‹Ž‹–›‹•‘ˆ–‡ƒ••‡••‡†„› ǤȋͳͻͳȌ ”ƒ‰‡•ˆ”‘Ͳ–‘ΪͳǤ –‹• Š‹‰Šȋ Ž‘•‡–‘ͳȌ‹ˆ‡ƒ•—”‡‡–‡””‘”•ƒ”‡•ƒŽŽ‹ ‘’ƒ”‹•‘–‘–Š‡–”—‡ †‹ˆˆ‡”‡ ‡•‹–Šƒ–’ƒ”–‹ —Žƒ”’‘’—Žƒ–‹‘ǡƒ†Ž‘™ȋ Ž‘•‡–‘ͲȌ‹ˆ‘•–‘ˆ–Š‡ ˜ƒ”‹ƒ„‹Ž‹–›‹•†—‡–‘‡ƒ•—”‡‡–‡””‘”Ǥ  ƒƒŽ•‘„‡‹–‡”’”‡–‡†‹ƒ‘”‡ •’‡ ‹ˆ‹ ƒ‡”ǣ ‘ˆ͹ͺ؏‡ƒ•–Šƒ–͹ͺΨ‘ˆ–Š‡˜ƒ”‹ƒ„‹Ž‹–›‹ ‡ƒ•—”‡‡–•ƒ”‡†—‡–‘‰‡—‹‡†‹ˆˆ‡”‡ ‡•ǡ™‹–Š–Š‡”‡ƒ‹‹‰ʹʹΨ ”‡’”‡•‡–‹‰‡””‘”•‹–Š‡‡ƒ•—”‡‡–’”‘ ‡••ƒ†–Š‡‘„•‡”˜‡”ȋ•Ȍ ‹˜‘Ž˜‡†Ǥȋͳͻ͵Ȍ

Patients 1) A priori sample size calculation was based on questionable estimates:  ƒ’Ž‡•‹œ‡‹•ƒˆ— –‹‘ ‘•‹•–‹‰‘ˆˆ‘—”ˆƒ –‘”•Ǣ–Š‡•‹‰‹ˆ‹ ƒ ‡Ž‡˜‡ŽȋȽȌǡ’‘™‡” ȋͳǦȾȌǡ˜ƒ”‹ƒ ‡ȋ•–ƒ†ƒ”††‡˜‹ƒ–‹‘Ȍǡƒ†–Š‡‡ˆˆ‡ –•‹œ‡ǤȋͳͻͶǡͳͻͷȌȾ‹•–Š‡ ’”‘„ƒ„‹Ž‹–›‘ˆ‘–”‡Œ‡ –‹‰ƒˆƒŽ•‡—ŽŽŠ›’‘–Š‡•‹•ȋ–›’‡ ‡””‘”ǡ†‡• ”‹„‡†„‡Ž‘™ȌǤ• •— Šǡ’‘™‡”ȋͳǦȾȌ‹•–Š‡’”‘„ƒ„‹Ž‹–›‘ˆ‘–ƒ‹‰–Š‹•–›’‡‘ˆ‡””‘”. ‡’Š”ƒ•‡†ǡ ’‘™‡”‡ƒ•—”‡•–Š‡ƒ„‹Ž‹–›‘ˆƒ–‡•––‘”‡Œ‡ ––Š‡—ŽŽŠ›’‘–Š‡•‹•™Š‡‹–•Š‘—Ž†„‡ ”‡Œ‡ –‡†ǤȋͳͻͶȌ’‘™‡”‘ˆͺͲΨ‹•‰‡‡”ƒŽŽ›–Š‡‹‹—ƒ ‡’–‡†Ž‡˜‡ŽȂ‡ƒ‹‰ –Š‡”‡‹•ƒ‡‹‰Š–‹–‡ Šƒ ‡‘ˆ†‡–‡ –‹‰ƒ†‹ˆˆ‡”‡ ‡‘ˆ–Š‡ Š‘•‡‡ˆˆ‡ –•‹œ‡ǤȋͳͻͶȌ  Š‡•ƒ’Ž‡•‹œ‡‘ˆͳͶ ˆŽƒ’’ƒ–‹‡–•‹’ƒ’‡” ™ƒ•„ƒ•‡†‘ƒƒ’”‹‘”‹ •ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘’‡”ˆ‘”‡†„›•—’‡”˜‹•‘”•ސ•‡–Šƒ†‹†Š‘Ž†–ǤŠ‡› ’‡”ˆ‘”‡† • ƒ•‘ˆ„‘–Š–Š‡†‘‘”Ǧ•‹–‡ȋ’ƒ’‡” Ȍƒ†–Š‡Šƒ”˜‡•–‡† ˆŽƒ’ ȋͳͻ͸ȌǤ›—•‹‰–Š‡•‘ˆ–™ƒ”‡ƒ’Ž‡‘™‡”ʹǤͲȋ ǡ”‘ǡǤǤȌǡƒ†–Š‡

53 53 ‡ƒ•ǡ•ǡƒ†‡ˆˆ‡ –•‹œ‡•‘ˆ–™‘’”‡˜‹‘—• ’—„Ž‹ ƒ–‹‘•ȋͳͻ͹ǡͳͻͺȌǡ–Š‡›ˆ‘—† –Šƒ–•ƒ’Ž‡•‹œ‡•‘ˆ•‹šƒ†–‡™‡”‡‡‡†‡†–‘ƒ Š‹‡˜‡ͺͲΨ’‘™‡”ȋ™‹–ŠƒͷΨ •‹‰‹ˆ‹ ƒ ‡Ž‡˜‡ŽȌǤŠ‡ͳͶ’ƒ–‹‡–•‹ Ž—†‡†•Š‘—Ž†„‡•ƒ–‹•ˆƒ –‘”›Ǥ  –Š‡‘–Š‡”Šƒ†ǡ Šƒ•‘–„‡‡’”‡˜‹‘—•Ž›—•‡†‹‡˜ƒŽ—ƒ–‹‰ ‹ ”‘ ‹” —Žƒ–‹‘‹ ˆŽƒ’•—”‰‡”›ǡƒ†–Š‡’—„Ž‹ ƒ–‹‘•—•‡†™‡”‡‘‡ Ž‹‹ ƒŽ •–—†›‘”ƒ†‹ƒŽˆ‘”‡ƒ”ˆŽƒ’•ƒ†‘‡‡š’‡”‹‡–ƒŽ”ƒ–‘†‡Ž•–—†›ǤŠ‡–Š‡”–Š‡•‡ ‡•–‹ƒ–‡•™‡”‡ƒ†‡“—ƒ–‡ˆ‘”ƒ •–—†›‘ ˆŽƒ’•ƒ”‡“—‡•–‹‘ƒ„Ž‡Ǥ  •–‡ƒ†‘ˆ—•‹‰‡•–‹ƒ–‡•ˆ”‘–Š‡•‡–™‘’—„Ž‹ ƒ–‹‘•ǡ™‡ ‘—Ž†Šƒ˜‡•’‡ ‹ˆ‹‡† –Š‡‡ˆˆ‡ –•‹œ‡ƒ†˜ƒ”‹ƒ ‡ȋ•–ƒ†ƒ”††‡˜‹ƒ–‹‘Ȍ‘—”•‡Ž˜‡•Ǥ— Š•’‡ ‹ˆ‹ ƒ–‹‘™‘—Ž†ǡ Š‘™‡˜‡”ǡŠƒ˜‡„‡‡ƒ”„‹–”ƒ”›ƒ†‹˜‘Ž˜‡†•‘‡‰—‡••™‘”Ǥ‘–Š‡–Š‘†•ƒ”‡ǡ‹ ‘–Š‡”™‘”†•ǡ•—„•–ƒ†ƒ”†Ǥ ‘”†‡”–‘†‡ƒŽ™‹–Š–Š‹•Ž‹‹–ƒ–‹‘ǡ™‡Šƒ˜‡’‡”ˆ‘”‡†’‘•–ǦŠ‘ ’‘™‡”ƒ† •ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•„ƒ•‡†‘–Š‡ƒ –—ƒŽ‘„•‡”˜‡††ƒ–ƒ‹’ƒ’‡” ǤŽ‡ƒ•‡•‡‡ Dz‘•–ǦŠ‘ ’‘™‡”ƒ†•ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•dzǤ 2) Small sample size:  ͳͶ’ƒ–‹‡–• ‘•–‹–—–‡ƒ”ƒ–Š‡”•ƒŽŽ•ƒ’Ž‡•‹œ‡ƒ†‹‰Š–”‡’”‡•‡–ƒ —†‡”’‘™‡”‡†•–—†›Ǥ –†‹†ǡŠ‘™‡˜‡”ǡ”‡•‡„Ž‡–Š‡—„‡”‘ˆ’ƒ–‹‡–•‹ Ž—†‡†‹ •‹‹Žƒ”•–—†‹‡•’—„Ž‹•Š‡†ƒ––Š‡–‹‡Ǣ ƒŽŽ‘ ȋͳͲ’ƒ–‹‡–•ȌȋͳͻͻȌǡ ‘Ž‡–ƒŽǤȋͳͷ ’ƒ–‹‡–•ȌȋʹͲͲȌǡ‘‘‹‡–ƒŽǤȋ͵Ͳ’ƒ–‹‡–•ȌȋʹͲͳȌǡƒ††‡‡‡”†‡–ƒŽǤȋʹͲ’ƒ–‹‡–•ȌȋʹͲʹȌǤ ˆ–Š‡•–—†›‹•‹†‡‡†—†‡”’‘™‡”‡†ǡ–Š‡Ž‘™•–ƒ–‹•–‹ ƒŽ’‘™‡”™‹ŽŽ‡‰ƒ–‹˜‡Ž› ƒˆˆ‡ ––Š‡Ž‹‡Ž‹Š‘‘†–Šƒ–ƒ‘‹ƒŽŽ›•–ƒ–‹•–‹ ƒŽŽ›•‹‰‹ˆ‹ ƒ–ˆ‹†‹‰ƒ –—ƒŽŽ›”‡ˆŽ‡ –• ƒ–”—‡†‹ˆˆ‡”‡ ‡ǤȋʹͲ͵Ȍ ‘–Š‡”™‘”†•ǡŽ‘™’‘™‡”‡ƒ•–Šƒ––Š‡ Šƒ ‡‘ˆ †‹• ‘˜‡”‹‰†‹ˆˆ‡”‡ ‡•–Šƒ–ƒ”‡‰‡—‹‡Ž›–”—‡‹•Ž‘™Ǥ  Š›’‘–Š‡•‹•–‡•–‹‰ǡ‘‡•’‡ƒ•‘ˆDz–›’‡ dzƒ†Dz–›’‡ dz‡””‘”•‹–‡”•‘ˆ–Š‡ ’‘–‡–‹ƒŽ‡””‘”•–Šƒ–”‡•‡ƒ” Š‡”•ˆƒ ‡ǤȋͳͻͷȌ‘‹––‹‰ƒ–›’‡ ‡””‘”‹•–‘”‡Œ‡ ––Š‡ —ŽŽŠ›’‘–Š‡•‹•™Š‡‹–‹•ƒ –—ƒŽŽ›–”—‡ȋƒˆƒŽ•‡’‘•‹–‹˜‡ƒ••‘ ‹ƒ–‹‘ȌǤŠ‡’”‘„ƒ„‹Ž‹–› ‘ˆ–Š‹•Šƒ’’‡‹‰‹•‡“—ƒŽ–‘–Š‡•–ƒ–‹•–‹ ƒŽ•‹‰‹ˆ‹ ƒ ‡Ž‡˜‡ŽȋȽȌǤ–›’‡ ‡””‘” ‘ —”•™Š‡™‡ˆƒ‹Ž–‘”‡Œ‡ –ƒˆƒŽ•‡—ŽŽŠ›’‘–Š‡•‹•ȋƒˆƒŽ•‡‡‰ƒ–‹˜‡ƒ••‘ ‹ƒ–‹‘ȌǤ – ‹•‹’‘”–ƒ––‘ ‘•‹†‡”•— Š’‘–‡–‹ƒŽ‡””‘”•™Š‡‹–‡”’”‡–‹‰–Š‡†ƒ–ƒǤ‡‡ ‹‰Ǥ ͳ͸Ǥ

Fig. 16 Type I and type II errors in hypothesis testing. Used with kind permission from Dr Hollestein (Department of Dermatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands) 

54 54 3) Patients operated in 2008-2009: Š‡’ƒ–‹‡–•‹ Ž—†‡†™‡”‡‘’‡”ƒ–‡† ƒ’’”‘š‹ƒ–‡Ž›ƒ†‡ ƒ†‡ƒ‰‘ǤŠ‡›‹‰Š–ǡ–Š‡”‡ˆ‘”‡ǡ‘–”‡’”‡•‡– —””‡–’”ƒ –‹ ‡ ƒ†”‡•—Ž–• ‘•‹†‡”‹‰Ž‡ƒ”‹‰Ǧ —”˜‡ǡ–‡ Š‹ ƒŽ‹’”‘˜‡‡–•ǡ”‡†— ‡†‘’‡”ƒ–‹‰ –‹‡ǡƒ†‘™Ž‡†‰‡‰ƒ‹‡†–Š”‘—‰Š”‡•‡ƒ” ŠǤŠ‡•—”‰‹ ƒŽ–‡ Š‹“—‡ƒ––Š‡†‘‘”Ǧ •‹–‡Šƒ•ǡŠ‘™‡˜‡”ǡ„‡‡‘”‡‘”Ž‡••— Šƒ‰‡†•‹ ‡–Š‡‹–”‘†— –‹‘‘ˆ ˆŽƒ’ „”‡ƒ•–”‡ ‘•–”— –‹‘‹ʹͲͲͲ‹‘—”‡’ƒ”–‡–Ǥ‘•–‹’”‘˜‡‡–•Šƒ˜‡‹˜‘Ž˜‡† –Š‡•—”‰‡”›ƒ––Š‡”‡ ‹’‹‡–Ǧ•‹–‡ȋ‡Ǥ‰Ǥ”‹„Ǧ•’ƒ”‹‰ƒ’’”‘ƒ Š–‘–Š‡ •ƒ†–Š‡—•‡‘ˆ ˜‡‘—• ‘—’Ž‡”ȌǤ™ƒ•‹–”‘†— ‡†‹ʹͲͲ͹Ǥ 4) Only secondary, unilateral DIEAP flap breast reconstructions: ŽŽ’ƒ–‹‡–• ‹ Ž—†‡†—†‡”™‡–•‡ ‘†ƒ”›ǡ—‹Žƒ–‡”ƒŽ„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŠ‡•–—†›†‘‡•ǡ –Š‡”‡ˆ‘”‡ǡ‘–•ƒ›ƒ›–Š‹‰ƒ„‘—–‡‹–Š‡”’”‹ƒ”›„”‡ƒ•–”‡ ‘•–”— –‹‘ǡ„‹Žƒ–‡”ƒŽ  ˆŽƒ’•ǡƒ†Ȁ‘”„‹’‡†‹ Ž‡† ˆŽƒ’•ȋ‹ ‘”’‘”ƒ–‹‰ƒ’‡†‹ Ž‡ˆ”‘‡ƒ Š  ȌǤŠ‡•–—†‹‡†‘—– ‘‡• ‘—Ž†„‡†‹ˆˆ‡”‡–‹–Š‡•‡ ‹” —•–ƒ ‡•Ǥ•–—†› ’—„Ž‹•Š‡†„›‘‘—‡–ƒŽǤ†‹†ǡŠ‘™‡˜‡”ǡ•—‰‰‡•––Šƒ–†‘‘”Ǧ•‹–‡‘”„‹†‹–›†‘‡•‘– †‹ˆˆ‡”ƒ–‡”‹ƒŽŽ›„›–Š‡–›’‡‘ˆ ˆŽƒ’—•‡†ǡƒ†‹•Žƒ”‰‡Ž›•‹‹Žƒ”‹—‹Žƒ–‡”ƒŽǡ „‹Žƒ–‡”ƒŽǡƒ†„‹’‡†‹ Ž‡†„”‡ƒ•–”‡ ‘•–”— –‹‘•ǤȋͳͷͶȌŠ‹•™ƒ•‡ Š‘‡†‹–Š‡ ˆ‹†‹‰•‘ˆƒ•›•–‡ƒ–‹ ”‡˜‹‡™’—„Ž‹•Š‡†‹ʹͲͳͶǤȋʹͲͶȌ 5) Medication lists were not examined:‡†‹†‘–‰‘–Š”‘—‰Š–Š‡‡†‹ ƒ–‹‘Ž‹•–•‘ˆ –Š‡’ƒ–‹‡–•‹ Ž—†‡†ǤŠ‹•‹•ƒ•‘—” ‡‘ˆ‡””‘”ǤŠ‡—•‡‘ˆ•‘‡‡†‹ ƒ–‹‘ǡˆ‘” ‡šƒ’Ž‡‹–”ƒ–‡•ǡ ‘—Ž†Šƒ˜‡ƒ•‹‰‹ˆ‹ ƒ–‹’ƒ –‘–Š‡‹ ”‘ ‹” —Žƒ–‘”›†›ƒ‹ •Ǥ

Instruments 1) LDPI: Š‡”‡ƒ”‡•‡˜‡”ƒŽ‡–Š‘†‘Ž‘‰‹ ƒŽ•Š‘”– ‘‹‰• ‘ ‡”‹‰–Š‡ —•‡†‹ –Š‡•–—†›ǣ a. LDPI scan depth: ƒ•‡†‘–Š‡†‡’–Š‘ˆ–Š‡ • ƒ•ȋͲǤͷǦͳȌȋͻ͹Ȍǡ‘‡ ƒ ƒ”‰—‡–Šƒ––Š‡ ‹•–”—‡–ƒ••‡••‡•‘Ž›–Š‡˜‡”›•—’‡”ˆ‹ ‹ƒŽ’ƒ”–‘ˆ–Š‡ ƒ„†‘‹ƒŽ•‹ǤȋͻͺȌƒ—”‡–ƒ† ‘Ǧƒ—–Š‘”•’‡”ˆ‘”‡†‡ Š‘‰”ƒ’Š‹  ‡ƒ•—”‡‡–•‘ˆ–Š‡•‹–Š‹ ‡••ƒ†”‡’‘”–‡†–Šƒ––Š‡‡ƒ•‹–Š‹ ‡•• ȋ‡’‹†‡”‹•Ϊ†‡”‹•Ȍ‹–Š‡ƒ„†‘‹ƒŽ”‡‰‹‘‹•ƒŽ‘•–ʹȋ‡ƒͳǤͻͳǡͻͷ Ψ ǣͳǤͺͺǦͳǤͻͷȌǤȋʹͲͷȌŠ‡›‡šƒ‹‡†ʹͲͷ™‘‡ƒ†ͳ͵͹‡ƒ†Šƒ†‘ •‹‰‹ˆ‹ ƒ–‰‡†‡”†‹ˆˆ‡”‡ ‡•‹–‡”•‘ˆ•‹–Š‹ ‡••‹–Š‡ƒ„†‘‹ƒŽ”‡‰‹‘Ǥ —”• ƒ•†‘‘–ǡ–Š‡”‡ˆ‘”‡ǡ†‹”‡ –Ž›• ƒ–Š‡„Ž‘‘†’‡”ˆ—•‹‘‹•—„†‡”ƒŽ ’Ž‡š—•Ȃ™Š‹ Š‹••‡‡ƒ•–Š‡ƒ‹˜ƒ• —Žƒ”•—’’Ž›–‘–Š‡•‹Ǥȋ͸͸Ȍ•–Š‡ •—„†‡”ƒŽ’Ž‡š—•Šƒ•ƒš‹ƒŽŽ›‘”‹‡–‡†˜‡••‡Ž•–Šƒ–‡–‡”ƒ†•—’’Ž›–Š‡’ƒ’‹ŽŽƒ”› †‡”‹•ǡŠ‘™‡˜‡”ǡ–Š‡ • ƒ•†‘ƒ••‡•••‹’‡”ˆ—•‹‘™Š‹ Š‹•†‡”‹˜‡†ˆ”‘ –Š‹•’Ž‡š—•ǤŠ‹•‹••—’’‘”–‡†„›ƒ‰‹‘‰”ƒ’Š‹ ƒ† ƒ†ƒ˜‡”‹ •–—†‹‡•–Šƒ– †‘ —‡–‡†–Šƒ–˜‡••‡Ž•ˆ”‘•—„†‡”ƒŽ’Ž‡š—•ˆ‘”–Š‡•—„‡’‹†‡”ƒŽ’Ž‡š—• ƒ––Š‡„‘—†ƒ”›‘ˆ’ƒ’‹ŽŽƒ”›ƒ†”‡–‹ —Žƒ”†‡”‹•ǡƒ†Žƒ–‡”ƒ‡š–‡•‹˜‡‡–™‘” ‘ˆ•—’‡”ˆ‹ ‹ƒŽ ƒ’‹ŽŽƒ”‹‡•ǤȋͳͲͶǡʹͲ͸ǡʹͲ͹Ȍ ‘”–Šƒ–”‡ƒ•‘ǡ–Š‡•–—†›ǯ•ƒ••‡••‡– ‘ˆ —–ƒ‡‘—•„Ž‘‘†’‡”ˆ—•‹‘‹–Š‡—†‡”‹‡†•‹‹•’”‘„ƒ„Ž›ƒ†‡“—ƒ–‡Ǥ –‹•ǡ Š‘™‡˜‡”ǡ‹ƒ†‡“—ƒ–‡‹–‡”•‘ˆƒ••‡••‹‰–Š‡’‡”ˆ—•‹‘‘ˆ–Š‡•—„ —–ƒ‡‘—• –‹••—‡•‘ˆ–Š‡†‘‘”ˆŽƒ’ȋƒ† ‘—Ž†–Š‡”‡„›‘–„‡—•‡†–‘’”‡†‹ –ƒ”‡ƒ• •—• ‡’–‹„Ž‡–‘†‡‡’‡”–‹••—‡ ‘’Ž‹ ƒ–‹‘••— Šƒ•ˆƒ–‡ ”‘•‹•ȌǤ b. LDPI scan duration: ˜‡”› • ƒŽƒ•–‡†ˆ‘”–™‘Ǧ–Š”‡‡‹—–‡•ǤŠ‹•—•–„‡ ‘•‹†‡”‡†ƒ•ƒ’‘–‡–‹ƒŽ•‘—” ‡‘ˆ‡””‘”„‡ ƒ—•‡‘ˆ–Š‡‘”ƒŽ’Š›•‹‘Ž‘‰‹ ƒŽ

55 55 ˜ƒ”‹ƒ–‹‘•‹•‹‹ ”‘ ‹” —Žƒ–‹‘‘˜‡”–‹‡ǤȋͺͺǡʹͲͺǡʹͲͻȌ—”‹‰• ƒ•ǡ‹–‹• ƒŽ•‘Ž‹‡Ž›–Šƒ––Š‡’ƒ–‹‡–‘˜‡•Ǥ c. LDPI scan resolution (low): ‘™”‡•‘Ž—–‹‘™ƒ•—•‡†‹‘—”•–—†›ǤŠ‹•‡ƒ• –Šƒ––Š‡•–‡’Ž‡‰–Šȋ–Š‡ƒ”‡ƒ„‡‹‰•–—†‹‡†’‡”‡ƒ•—”‡‡–•‹–‡Ȍ‹• ƒ’’”‘š‹ƒ–‡Ž›͵ȋƒ–ʹͷ †‹•–ƒ ‡ˆ”‘•‹ȌǤȋͻͺȌ –‡”•‘ˆ —–ƒ‡‘—• ‹ ”‘ ‹” —Žƒ–‹‘ǡ͵‹•ƒ”ƒ–Š‡”„‹‰•–‡’Ž‡‰–Šǡƒ†–Š‡”‡ ‘—Ž†„‡•’ƒ–‹ƒŽǦ –‡’‘”ƒŽ†‹ˆˆ‡”‡ ‡•™‹–Š‹–Š‹••–‡’Ž‡‰–Š™Š‹ Šƒ”‡‘–”‡‰‹•–‡”‡†Ǥ d. External variables: ‘”›”‡–ƒŽǤ”‡’‘”–‡†‹–Š‡‹”•–—†›–Šƒ– ‹•ƒ ‡š–”‡‡Ž›•‡•‹–‹˜‡–‘‘ŽǤȋͻͶȌƒ”‹ƒ„Ž‡••— Šƒ•–‹••—‡–‡’‡”ƒ–—”‡ǡƒ„‹‡–Ž‹‰Š–ǡ ‡†‹ ƒ–‹‘ǡƒ†–Š‡ƒ‰‡‘ˆ–Š‡’ƒ–‹‡– ƒŠƒ˜‡ ‘•‹†‡”ƒ„Ž‡‹’ƒ –‘–Š‡ ’‡”ˆ—•‹‘‡ƒ•—”‡‡–•Ǥ‡–”‹‡†–‘Ž‹‹––Š‡‡š–‡–‘ˆ•— Š˜ƒ”‹ƒ„Ž‡•„›Šƒ˜‹‰ ƒ•‡–†‹•–ƒ ‡„‡–™‡‡–Š‡ ƒ Š‹‡ƒ†’ƒ–‹‡–ȋ͵ͷ Ȍƒ†’‡”ˆ‘”‹‰ ‡ƒ•—”‡‡–•—†‡” ‘•–ƒ–Ž‹‰Š–ƒ†–‡’‡”ƒ–—”‡ȋʹʹιȌǤ †‡ƒŽŽ›ǡ–Š‡ • ƒ‡”Š‡ƒ†•Š‘—Ž†„‡’”‘–‡ –‡†ˆ”‘ƒ„‹‡–Ž‹‰Š–„‡ˆ‘”‡ƒ”‡ ‘”†‹‰–‘ƒ˜‘‹† ‘’–‹ ƒŽ‹–‡”ˆ‡”‡ ‡Ǥȋͻ͵ȌŠ‹•™ƒ•‘–†‘‡‹‘—”•–—†›Ǥ  ‘”‡‘˜‡”ǡ–Š‡”‡™‡”‡’”‘„ƒ„Ž›•‘‡‘˜‡”Ž‘‘‡† ‘ˆ‘—†‹‰ˆƒ –‘”•‹ ƒ††‹–‹‘–‘–Š‡‘‡•‡–‹‘‡†ƒ„‘˜‡Ǥ‘˜‡‹‡–Ž›ǡŠ‘™‡˜‡”ǡ‡˜‡”›’ƒ–‹‡–™ƒ• Š‡”‘™ ‘–”‘Ž‹‘—”•–—†›ǤŠ‡’‡”ˆ—•‹‘‘ˆ‘‡œ‘‡™ƒ• ‘’ƒ”‡†™‹–Š–Šƒ– ‘ˆƒ‘–Š‡”œ‘‡™‹–Š‹–Š‡•ƒ‡• ƒȂ–Š‡”‡„›”‡†— ‹‰–Š‡’‘–‡–‹ƒŽ„‹ƒ•‘ˆ ‡š–‡”ƒŽ˜ƒ”‹ƒ„Ž‡•Ǥ e. LDPI blood perfusion units: Š‡ •‘ˆ–™ƒ”‡ ƒŽ —Žƒ–‡†‡ƒ„Ž‘‘†’‡”ˆ—•‹‘ —‹–•ȋȌ™‹–Š‹–Š‡•–ƒ†ƒ”†‹œ‡†œ‘‡•ǤŽ–Š‘—‰Š–Š‹•‹•ƒ“—ƒ–‹–ƒ–‹˜‡ ‡ƒ•—”‡‡–ǡ‹–†‘‡•‘–‰‹˜‡ƒ”‡ƒŽ˜ƒŽ—‡‘ˆ„Ž‘‘†ˆŽ‘™–Š”‘—‰Šƒ‰‹˜‡˜‘Ž—‡ ‘”ƒ••‘ˆ–‹••—‡™‹–Š‹ƒ–‹‡’‡”‹‘†Ǥ ƒ††‹–‹‘ǡ–Š‡”‡‹•‘ƒ˜ƒ‹Žƒ„Ž‡ ‘˜‡”•‹‘ȋ ƒŽ —Žƒ–‹‰Ž„Ž‘‘†ȀŽ–‹••—‡Ȁ•‡ ‘†‘”Ž„Ž‘‘†Ȁ‰ –‹••—‡Ȁ•‡ ‘†Ȍˆ”‘–Š‡—„‡”‘ˆ•ǤŠ‡”‡‹•ǡŠ‘™‡˜‡”ǡƒ†‘ —‡–‡† Ž‹‡ƒ”‹–›„‡–™‡‡•ƒ†”‡ƒŽ„Ž‘‘†’‡”ˆ—•‹‘ǤȋͻͺȌ

Statistical analysis  1) Multiple comparisons:  ‘•‹†‡”ƒ„Ž‡—„‡”‘ˆ ‘’ƒ”‹•‘•™‡”‡ ‘’Ž‡–‡†‹ ‘—”•–—†›Ǥ‡ƒ’‡”ˆ—•‹‘—‹–•™‡”‡ ‘’ƒ”‡†„‡–™‡‡œ‘‡•ƒ†–‹‡•Ǥ •— Š —Ž–‹’Ž‡ ‘’ƒ”‹•‘•–Š‡”‡‹•ƒ”‡ƒŽ Šƒ ‡‘ˆ–›’‡ ‡””‘”•ȋˆƒŽ•‡’‘•‹–‹˜‡ ƒ••‘ ‹ƒ–‹‘•ȌǤ•‹‰‹ˆ‹ ƒ ‡Ž‡˜‡Ž‘ˆͲǤͲͷ‡–ƒ‹Ž•–Šƒ–‘‡‹‡˜‡”›ʹͲ–‡•–•™‹ŽŽ„‡ •–ƒ–‹•–‹ ƒŽŽ›•‹‰‹ˆ‹ ƒ–„›’—”‡ Šƒ ‡™Š‡–Š‡”‡‹•‹ˆƒ –‘–Š‹‰–‘ˆ‹†ǤȋͳͻͷȌ  ‘Ž‹‹––Š‡‡š–‡–‘ˆ–›’‡ ‡””‘”•ǡƒŽŽ’ƒ‹”™‹•‡ ‘’ƒ”‹•‘•™‡”‡ ‘’Ž‡–‡†™‹–Š –Š‡‘ˆ‡””‘‹ ‘””‡ –‹‘Ǥ ‡”‡ǡ–Š‡•‹‰‹ˆ‹ ƒ ‡Ž‡˜‡Ž‹•†‹˜‹†‡†„›–Š‡—„‡”‘ˆ ‹†‡’‡†‡–Š›’‘–Š‡•‹•–‡•–•ǤȋͳͻͷȌ ˆʹͷ ‘’ƒ”‹•‘•ƒ”‡ ‘’Ž‡–‡†ǡˆ‘”‹•–ƒ ‡ǡ –Š‡•‹‰‹ˆ‹ ƒ ‡Ž‡˜‡Ž‘ˆͲǡͲͷ‹•†‘™•‹œ‡†–‘ͲǡͲͲʹȋͲǡͲͷȀʹͷȌǤ‘‡„‡Ž‹‡˜‡–Šƒ––Š‡ ‘ˆ‡””‘‹ ‘””‡ –‹‘‹•–‘‘ ‘•‡”˜ƒ–‹˜‡ƒ†’ƒ”ƒ†‘š‹ ƒŽŽ› ƒ—•‡•ƒ‹ ”‡ƒ•‡†”‹• ‘ˆ–›’‡ ‡””‘”•ȋˆƒŽ•‡‡‰ƒ–‹˜‡ƒ••‘ ‹ƒ–‹‘•ȌǤȋʹͳͲȌ ‘–Š‡”™‘”†•ǡ™‹–Š‘—––Š‡ ‘””‡ –‹‘™‡ ‘—Ž†Šƒ˜‡ˆ‘—†‘”‡•–ƒ–‹•–‹ ƒŽ•‹‰‹ˆ‹ ƒ– ‘’ƒ”‹•‘•ȋ’‘••‹„Ž› ”‡’”‡•‡–‹‰–”—‡†‹ˆˆ‡”‡ ‡•ȌǤ 2) Linear mixed models with random intercept:‹‡ƒ”‹š‡†‘†‡ŽƒƒŽ›•‹•™‡”‡ ’‡”ˆ‘”‡†‹ ‘ŽŽƒ„‘”ƒ–‹‘™‹–Š•Ž‘‡–”‡‘ˆ‹‘•–ƒ–‹•–‹ •ƒ†’‹†‡‹‘Ž‘‰›ǡ ‡•‡ƒ” Š—’’‘”–‡”˜‹ ‡•ǡ•Ž‘‹˜‡”•‹–› ‘•’‹–ƒŽǤ••—’–‹‘•ȋ‘”ƒŽ

56 56 †‹•–”‹„—–‹‘•‘ˆ–Š‡”‡•‹†—ƒŽ–‡”ƒ†”ƒ†‘‹–‡” ‡’–Ȍ™‡”‡ƒ••‡••‡†™‹–Š„‘–Š †‡• ”‹’–‹˜‡‡–Š‘†•ƒ†•–ƒ–‹•–‹ ƒŽ–‡•–•ǤŠ‹•‘†‡Ž™ƒ• Š‘•‡†—‡–‘–Š‡”‡’‡ƒ–‡†ǡ Ž—•–‡”‡†ǡƒ† ‘””‡Žƒ–‡†‡ƒ•—”‡‡–•ˆ‘—†‹‘—”•–—†›Ǥ‡‰”‡••‹‘‘†‡Ž• ƒ••—‡‹†‡’‡†‡–‡ƒ•—”‡‡–•ǡƒ† ‘—Ž†ǡ–Š‡”‡ˆ‘”‡ǡ‘–„‡—•‡†Ǥ  Miscellaneous: 1) The recipient vessels were not recorded: Š‡‹–‡”ƒŽƒƒ”›˜‡••‡Ž•ȋ Ȍ —•‡†ƒ•”‡ ‹’‹‡–˜‡••‡Ž‹ ˆŽƒ’•—”‰‡”›‹‘—”‡’ƒ”–‡–ƒ”‡‹†‹”‡ – ‘–‹—‹–›™‹–Š–Š‡•—’‡”‹‘”‡’‹‰ƒ•–”‹ ˜‡••‡Ž•ȋ ‹‰Ǥ͸Ȍƒ† ‘–”‹„—–‡–‘–Š‡ ’‡”ˆ—•‹‘‘ˆ–Š‡‡’‹‰ƒ•–”‹ ƒ” ƒ†‡ǤŠ‹•ƒ” ƒ†‡ˆ‘”•–Š‡†‘‹ƒ–„Ž‘‘†•—’’Ž›–‘ –Š‡”‡ –—•ƒ„†‘‹‹•—• Ž‡•ƒ†–Š‡‘˜‡”Ž›‹‰•‹ǤȋͳͲ͹Ȍ‡”‰¤”†‡–ƒŽǤŠƒ˜‡ †‡‘•–”ƒ–‡†–Šƒ––Š‡—•‡‘ˆ‹–‡”ƒŽƒƒ”›ƒ”–‡”›ȋ ȌŠƒ•ƒ•‹‰‹ˆ‹ ƒ–‡ˆˆ‡ – ‘ƒ„†‘‹ƒŽ•‹’‡”ˆ—•‹‘ǤȋͳͲ͹Ȍ‡Š›’‘–Š‡•‹œ‡–Šƒ––Š‡—•‡‘ˆ‹–‡”ƒŽ ƒƒ”›ƒ”–‡”›’‡”ˆ‘”ƒ–‘”•ȋ Ȍǡ’”‡•‡”˜‹‰–Š‡ƒ”–‡”‹ƒŽ„Ž‘‘†ˆŽ‘™–Š”‘—‰Š  –‘–Š‡‡’‹‰ƒ•–”‹ ƒ” ƒ†‡ǡ™‹ŽŽ’”‘˜‹†‡„‡––‡” —–ƒ‡‘—•„Ž‘‘†ˆŽ‘™‹–Š‡ ”ƒ‹ƒŽŠƒŽˆ ‘ˆ–Š‡ƒ„†‘‡Ǥ•™‡†‹†‘–†‹ˆˆ‡”‡–‹ƒ–‡„‡–™‡‡’ƒ–‹‡–•Šƒ˜‹‰ ‘”  —•‡†ƒ•”‡ ‹’‹‡–˜‡••‡Žǡ–Š‹•‹•’‘–‡–‹ƒŽ„‹ƒ•Ǥ ‹•ǡŠ‘™‡˜‡”ǡŠƒ”†Ž›‡˜‡”—•‡†‹ ‘—”‡’ƒ”–‡–ȋƒ†™ƒ•’”‘„ƒ„Ž›‘–‹–”‘†— ‡†„ƒ ‹ʹͲͲͺǦʹͲͲͻȌǤ

Strengths: ͳȌ”‘•’‡ –‹˜‡†‡•‹‰ǡʹȌ‘•‡ —–‹˜‡’ƒ–‹‡–•ȋ‡Ž‹‹ƒ–‹‰‡”‘ŽŽ‡–„‹ƒ•Ȍǡ ͵Ȍ • ƒ•™‡”‡’‡”ˆ‘”‡†„›‘‡”‡•‡ƒ” Š‡”ȋ•‡‹‘”ƒ—–Š‘”ȌǡͶȌ  ‡ƒ•—”‡‡–•™‡”‡’‡”ˆ‘”‡†„›‘‡”‡•‡ƒ” Š‡”ȋˆ‹”•–ƒ—–Š‘”ȌǡͷȌ ‹•ƒ”‡Ž‹ƒ„Ž‡ –‘‘Ž‹ƒ••‡••‹‰ƒ†‘‹–‘”‹‰ —–ƒ‡‘—•„Ž‘‘†ˆŽ‘™ȋͻͳǡͻͶǡʹͳͳǦʹͳͶȌǡ͸ȌŠ‡•’ƒ–‹ƒŽ ƒ†–‡’‘”ƒŽ•›•–‡Ǧ”‡Žƒ–‡†‘‹•‡‹ Šƒ•„‡‡ˆ‘—†–‘„‡Ž‡••–ŠƒͲǤ͵Ψƒ†ͲǤͷ Ψ‘ˆ–Š‡ƒš‹—˜ƒŽ—‡ǡ”‡•’‡ –‹˜‡Ž›ȋʹͳͷȌǡ͹ȌŠ‡ ‹•–”—‡–‹†— ‡•‘ ’”‡••—”‡ƒ”–‡ˆƒ –•†—”‹‰‹ƒ‰‹‰ǡͺȌ‡ƒ•—”‡‡–•™‡”‡–ƒ‡’‡”’‡†‹ —Žƒ”–‘–Š‡ •‹–‘’”‡˜‡–†‹ˆˆ‡”‹‰†‹•–ƒ ‡ƒ†‹ ‹†‡–ƒ‰Ž‡•ȋ™Š‹ Š ƒ—•‡ƒ˜ƒ”‹ƒ–‹‘‹–Š‡ —„‡”‘ˆ ‘Š‡”‡ ‡ƒ”‡ƒ•‘–Š‡†‡–‡ –‘”•—”ˆƒ ‡ƒ†–Š‡”‡„›ƒƒŽ–‡”ƒ–‹‘‹–Š‡ •›•–‡ƒ’Ž‹ˆ‹ ƒ–‹‘ˆƒ –‘”ȌȋʹͳͷȌǡͻȌ‹’‡”ˆ—•‹‘™ƒ•‡ƒ•—”‡†ƒ–—Ž–‹’Ž‡•‹–‡• ™Š‹ ŠŽ‹‹–•–Š‡‹’ƒ –‘ˆ’‡”ˆ—•‹‘Š‡–‡”‘‰‡‡‹–›ƒ†˜ƒ”‹ƒ„‹Ž‹–›ȋʹͳ͸ȌǡͳͲȌ˜‡”› ’ƒ–‹‡–™ƒ•Š‡”‘™ ‘–”‘Žȋ–Š‡’‡”ˆ—•‹‘‘ˆ‘‡œ‘‡™ƒ• ‘’ƒ”‡†™‹–Š–Šƒ–‘ˆ ƒ‘–Š‡”œ‘‡™‹–Š‹–Š‡•ƒ‡• ƒȂ–Š‡”‡„›”‡†— ‹‰–Š‡‹’ƒ –‘ˆ‡š–‡”ƒŽ˜ƒ”‹ƒ„Ž‡•Ȍǡ ƒ†ͳͳȌ–ƒ–‹•–‹ ‹ƒ’‡”ˆ‘”‡†ƒ’’”‘’”‹ƒ–‡•–ƒ–‹•–‹ ƒŽƒƒŽ›•‡•ȋŽ‹‡ƒ”‹š‡†‘†‡Ž• ™‹–Šƒ”ƒ†‘‹–‡” ‡’–ȌǤ

Paper II Study design 1) Volume calculations are superior to two-dimensional measurements: ’ƒ’‡” ǡƒ–‡”‘’‘•–‡”‹‘”†‹ƒ‡–‡”ȋȌƒ†–”ƒ•˜‡”•‡†‹ƒ‡–‡”ȋȌ™‡”‡‡ƒ•—”‡†‹ ˆ‘—”•–ƒ†ƒ”†‹œ‡†œ‘‡•ǤŠ‡•‡œ‘‡• ‘•–‹–—–‡”ƒ–Š‡””ƒ†‘Ž›•‡Ž‡ –‡† ”‘••Ǧ •‡ –‹‘•‘ˆ–Š‡”‡ –—•—• Ž‡•Ǥ•–Š‡—• Ž‡„‡ŽŽ›˜ƒ”‹‡••Ž‹‰Š–Ž›‹‹–••‹œ‡ƒ†ˆ‘” ƒŽ‘‰‹–• ‘—”•‡ǡˆ‘—” ”‘••Ǧ•‡ –‹‘•‘ˆˆ‡”Ž‹‹–‡†‹ˆ‘”ƒ–‹‘Ǥ

57 57 ‡•‹†‡•ǡ‡ƒ•—”‹‰‘Ž›ˆ‘—”œ‘‡•„‡ ‘‡•’”‘„Ž‡ƒ–‹  ‘•‹†‡”‹‰–Š‡ †‹‡•‹‘ƒŽ—• Ž‡ Šƒ‰‡• ƒ—•‡†„›–Š‡–‡†‹‘—•‹–‡”•‡ –‹‘•ȋ–Š‡ˆ‹„”‘—• „ƒ†• ”‘••‹‰–Š‡”‡ –—•—• Ž‡•Š‘”‹œ‘–ƒŽŽ›ȌǤ‘•–ƒ„†‘‡•Šƒ˜‡–Š”‡‡’ƒ‹”‡† –‡†‹‘—•‹–‡”•‡ –‹‘•†‡ˆ‹‹‰–Š‡Dz•‹š’ƒ dzǤȋʹͳ͹ȌŠ‡—• Ž‡‰‡–•‹ ”‡ƒ•‹‰Ž› •ƒŽŽ‡”ƒ•‹–ƒ’’”‘ƒ Š‡•–Š‡•‡ˆ‹„”‘—•„ƒ†•Ȃƒ†‡•’‡ ‹ƒŽŽ›–Š‡ †‡ ”‡ƒ•‡•Ǥȋʹͳ͹Ȍ‘”‡‘˜‡”ǡ–Š‡”‡‹•ƒŠ‹‰Š‡”—„‡”‘ˆ’‡”ˆ‘”ƒ–‘”•’‡”•“—ƒ”‡ ‡–‹‡–‡”‘”‹‰‹ƒ–‹‰‹–Š‡‹–‡”•‡ –‹‘• ‘’ƒ”‡†™‹–Š”‡ƒ‹‹‰—• Ž‡ǤȋʹͳͺȌ ›’Žƒ ‹‰ƒœ‘‡†‹”‡ –Ž›‘‘” Ž‘•‡–‘ƒ–‡†‹‘—•‹–‡”•‡ –‹‘ǡ˜ƒ”‹ƒ„‹Ž‹–›ƒ† ‡ƒ•—”‡‡–‡””‘”ƒ”‡‹–”‘†— ‡†Ǥ‘‡‘ˆ–Š‡ ”‘••Ǧ•‡ –‹‘•™‡”‡ˆ‘”–—ƒ–‡Ž› ’Žƒ ‡††‹”‡ –Ž›‘ƒ–‡†‹‘—•‹–‡”•‡ –‹‘ǡŠ‘™‡˜‡”ǡ–Š‡”ƒ†‹‘Ž‘‰‹•–•”‡’‘”–‡†–Šƒ– •‘‡‡ƒ•—”‡‡–•™‡”‡ Ž‘•‡Ǥ  ‘Ž—‡ ƒŽ —Žƒ–‹‘•ǡƒ•’‡”ˆ‘”‡†„› ƒ‡–ƒŽǤǡ’”‘˜‹†‡ƒ— Š„‡––‡” ‡–Š‘†‘Ž‘‰›ƒ†‹‹‹œ‡–Š‡‹’ƒ –‘ˆ–Š‡‘„•‡”˜‡”„‹ƒ•†‹• —••‡†Ǥȋͳ͵ʹȌ 2) No observer variability assessment reported: •†‹• —••‡†ˆ‘”’ƒ’‡” Ǥ  ‘‘„•‡”˜‡”˜ƒ”‹ƒ„‹Ž‹–›ƒ••‡••‡–™ƒ•”‡’‘”–‡†‹–Š‡’—„Ž‹•Š‡†ƒ”–‹ Ž‡Ǥ•–Š‡ ‡ƒ•—”‡‡–•™‡”‡’‡”ˆ‘”‡†‘Ž›‘ ‡„›‡ƒ Š”ƒ†‹‘Ž‘‰‹•–ǡ™‡†‘ǯ–Šƒ˜‡†ƒ–ƒ •‡–•–‘ ƒŽ —Žƒ–‡‹–”ƒǦ‘„•‡”˜‡”˜ƒ”‹ƒ„‹Ž‹–›ȋ”‡’‡ƒ–ƒ„‹Ž‹–›ȌǤ‡†‘ǡŠ‘™‡˜‡”ǡŠƒ˜‡–Š‡ ’‘••‹„‹Ž‹–›‘ˆ‡ƒ•—”‹‰–Š‡ƒ‰”‡‡‡–„‡–™‡‡–Š‡–™‘”ƒ†‹‘Ž‘‰‹•–•Ǣ‹–‡”Ǧ‘„•‡”˜‡” ˜ƒ”‹ƒ„‹Ž‹–›ȋ”‡’”‘†— ‹„‹Ž‹–›ȌǤ•–Š‡†ƒ–ƒƒ”‡—‡”‹ ƒŽǡ–Š‹•ƒ‰”‡‡‡–‹•’”‘˜‹†‡†ƒ• ǣͳȌǣ αͲǤͻ͹ǡʹȌ‡ –—•—• Ž‡ǣ αͲǤͺ͹ǡƒ†͵Ȍ‡ –—•—• Ž‡ǣ αͲǤͻͲǤŠ‡ ••Š‘™•–”‘‰ƒ‰”‡‡‡–•„‡–™‡‡–Š‡”ƒ†‹‘Ž‘‰‹•–•”‡‰ƒ”†‹‰–Š‡ ǡǡƒ†‡ƒ•—”‡‡–•ǤŠ‡Žƒ†ǦŽ–ƒ’Ž‘–•™‡”‡ƒŽ•‘•ƒ–‹•ˆƒ –‘”›ˆ‘” ƒŽŽ–Š”‡‡ ‘’ƒ”‹•‘•Ǥ 3) Contour abnormalities might not be visible in supine, resting position: ŽŽ • ƒ•™‡”‡’‡”ˆ‘”‡†™‹–Š”‡•–‹‰’ƒ–‹‡–•‹•—’‹‡’‘•‹–‹‘Ǥ – ‘—Ž†„‡’‘••‹„Ž‡ –Šƒ–•‘‡’ƒ–‹‡–•Šƒ† ‘–‘—”ƒ„‘”ƒŽ‹–‹‡•ǡ‡Ǥ‰Ǥ„—Ž‰‹‰ǡ–Šƒ–™‡”‡‘– Ž‡ƒ”Ž› ˜‹•‹„Ž‡‘‘—”• ƒ•Ǥ›—•‹‰Š‹‰ŠǦˆ”‡“—‡ ›—Ž–”ƒ•‘—†‹†‹ˆˆ‡”‡––”— ƒŽ ’‘•‹–‹‘•ȋƒ†™‹–ŠƒŽ•ƒŽ˜ƒƒ‡—˜‡”ȌǡŠ‘‰‡–ƒŽǤ•Š‘™‡†–Šƒ–ƒ„†‘‹ƒŽ™ƒŽŽ Žƒš‹–›™ƒ••–ƒ–‹•–‹ ƒŽŽ›Š‹‰Š‡•–‹–Š‡—’”‹‰Š–’‘•‹–‹‘ǡˆ‘ŽŽ‘™‡†„›͵Ͳ†‡‰”‡‡•‘ˆ –”— ƒŽˆŽ‡š‹‘ǡƒ†Ž‘™‡•–‹–Š‡•—’‹‡’‘•‹–‹‘ǤȋʹͳͻȌŠ‡†‡–‡ –‹‘‘ˆŠ‡”‹ƒ•™ƒ• ƒŽ•‘‡Šƒ ‡†—†‡”†›ƒ‹  ‘†‹–‹‘•Ǥ••— Šǡ–Š‡•–—†›†‡•‹‰ƒ†‹•–”—‡– —•‡†‹‘—”•–—†›‹‰Š–‘–„‡ƒ†‡“—ƒ–‡‹ƒ••‡••‹‰ ‘–‘—”ƒ„‘”ƒŽ‹–‹‡•Ǥ 4) Physical examination of the abdomen and strength/functionality assessment would have provided valuable information: ›’‡”ˆ‘”‹‰ƒ’Š›•‹ ƒŽ ‡šƒ‹ƒ–‹‘‘ˆ–Š‡ƒ„†‘‡–™‘›‡ƒ”•’‘•–‘’‡”ƒ–‹˜‡Ž›ǡ‘”‡†‘‘”Ǧ•‹–‡‘”„‹†‹–› ȋ‡Ǥ‰Ǥƒ„†‘‹ƒŽ„—Ž‰‹‰Ȍ ‘—Ž†Šƒ˜‡„‡‡— ‘˜‡”‡†ǤŠ›•‹ ƒŽˆ‹†‹‰• ‘—Ž†Šƒ˜‡ „‡‡†‹”‡ –Ž›”‡Žƒ–‡†ƒ† ‘’ƒ”‡†–‘ˆ‹†‹‰•ƒ†˜‹ ‡Ǧ˜‡”•ƒǤ ‹‹Žƒ”Ž›ǡ•–”‡‰–ŠȀˆ— –‹‘ƒŽ‹–›ƒ••‡••‡–•™‘—Ž††‡ˆ‹‹–‡Ž›Šƒ˜‡‹’”‘˜‡†–Š‡ Ž‹‹ ƒŽ‹’ƒ –‘ˆ‘—”•–—†›ǤŠ‡’”‘•’‡ –‹˜‡ǡ•‹‰Ž‡Ǧ•—”‰‡‘•–—†›’‡”ˆ‘”‡†„›‡‡ ‡–ƒŽǤ—•‹‰—’’‡”ƒ†Ž‘™‡”ƒ„†‘‹ƒŽ—• Ž‡ˆ— –‹‘–‡•–•‹•ƒ‰‘‘†‡šƒ’Ž‡‘ˆ •— Šƒ••‡••‡–•Ǥȋͳʹ͹Ȍ

Patients

58 58 1) No a priori power or sample size calculation performedǣ’”‹‘”‹’‘™‡”ƒ† •ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•’Žƒ›ƒ‡›”‘Ž‡‹†‡•‹‰‹‰ƒ†’Žƒ‹‰’”‘•’‡ –‹˜‡ •–—†‹‡•Ǥƒ’‡” †‹†‘–ǡ†‡•’‹–‡„‡‹‰’”‘•’‡ –‹˜‡ǡ‹ Ž—†‡•— Š ƒŽ —Žƒ–‹‘•ǤŠ‡ ƒ‹”‡ƒ•‘ˆ‘”–Š‹•‡–Š‘†‘Ž‘‰‹ ƒŽŽ‹‹–ƒ–‹‘™ƒ•–Š‡ƒ„•‡ ‡‘ˆ’”‘’‡”‡ˆˆ‡ –•‹œ‡• ȋ Ž‹‹ ƒŽ‡ƒ‹‰ˆ—Ž†‹ˆˆ‡”‡ ‡•ȌǣŠ‡”‡‹•ƒŽƒ ‘ˆŽ‹–‡”ƒ–—”‡–Šƒ–Šƒ•‹˜‡•–‹‰ƒ–‡† ˆ— –‹‘ƒŽŽ›‹’‘”–ƒ–†‡‰”‡‡•‘ˆ’‘•–‘’‡”ƒ–‹˜‡—• Ž‡ƒ–”‘’Š›Ǥ‡†‘‘–‘™ǡ ˆ‘”‹•–ƒ ‡ǡ™Š‡–Š‡”ƒ‹ƒ–”‘‰‡‹ ǡ—‹Žƒ–‡”ƒŽʹͲΨǡͶͲΨǡ‘”͸ͲΨ”‡†— –‹‘‹ ”‡ –—•—• Ž‡–Š‹ ‡••ȋȌƒ†Ȁ‘”™‹†–ŠȋȌ”‡•—Ž–‹ƒ‡˜‹†‡–Ž›™‡ƒ‡” ƒ„†‘‹ƒŽ™ƒŽŽǤ‘™‡”ƒ†•ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•™‘—Ž†ǡ–Š‡”‡ˆ‘”‡ǡŠƒ˜‡„‡‡ „ƒ•‡†‘‰—‡••™‘”Ȃƒ†–Š‡”‡„›’‘–‡–‹ƒŽŽ›„‡‘ˆŽ‹‹–‡†˜ƒŽ—‡Ǥ••— Šǡ™‡ Š‘•‡ ‘—”•ƒ’Ž‡•‹œ‡‹’ƒ’‡” „›”‡˜‹‡™‹‰’”‡˜‹‘—•Ž›’—„Ž‹•Š‡†Ž‹–‡”ƒ–—”‡™‹–Š ”‡•‡„Ž‹‰”‡•‡ƒ” Šˆ‘ —•ƒ†‡–Š‘†‘Ž‘‰›Ǥ›–Š‡—•‡‘ˆ–Š‡‘„•‡”˜‡††ƒ–ƒǡ Š‘™‡˜‡”ǡ’‘•–ǦŠ‘  ƒŽ —Žƒ–‹‘•Šƒ˜‡„‡‡’‡”ˆ‘”‡†ˆ‘”’ƒ’‡” ǤŽ‡ƒ•‡•‡‡Dz‘•–Ǧ Š‘ ’‘™‡”ƒ†•ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•dzǤ 2) Small sample size: •†‹• —••‡†ˆ‘”’ƒ’‡” Ǥ 3) Patients operated in 2013-2014: •†‹• —••‡†ˆ‘”’ƒ’‡” Ǥ 4) Non-consecutive patient enrollment: ŽŽ’ƒ–‹‡–•Šƒ†—†‡”‰‘‡ƒ•–‡ –‘›ƒ•ƒ ”‡•—Ž–‘ˆ ƒ ‡”ǡƒ†ƒŽŽ—†‡”™‡–•‡ ‘†ƒ”›—‹Žƒ–‡”ƒŽ„”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Šƒ  ˆŽƒ’ǤŠ‡’ƒ–‹‡–•‹ Ž—†‡†‹–Š‡•–—†›™‡”‡ǡŠ‘™‡˜‡”ǡ‘– ‘•‡ —–‹˜‡Ž› ‡”‘ŽŽ‡†ǤŠ‹• ‘—Ž† ƒ—•‡‡”‘ŽŽ‡–„‹ƒ•Ǥ 5) Two flaps can be considered as ms-TRAM flaps: •–Š‡”‡ –—•—• Ž‡™ƒ• ’ƒ”–‹ƒŽŽ›†‹˜‹†‡†‹–™‘ ƒ•‡•ǡ–Š‡•‡ˆŽƒ’• ƒ„‡ ‘•‹†‡”‡†ƒ••ǦˆŽƒ’•ƒ• •—‰‰‡•–‡†„›‡ŽŽƒ”‘ ‡‡–ƒŽǤ‹ʹͲͳͻǤȋͳ͸ʹȌ••— Šǡ–Š‡ˆŽƒ’••Š‘—Ž†Šƒ˜‡„‡‡ ‡š Ž—†‡†ˆ”‘–Š‡•–—†›‘”ƒ‡†•ǦǤŠ‡˜ƒ”‹ƒ„‹Ž‹–›‹•—”‰‹ ƒŽ–‡ Š‹“—‡ ƒ—•‡•„‹ƒ•ǤŠ‹•‹•ƒ‰‘‘†‡šƒ’Ž‡‘ˆ–Š‡Žƒ ‘ˆ•–ƒ†ƒ”†‘˜‡”–Š‡›‡ƒ”•™‹–Š ”‡•’‡ ––‘–‡ Š‹ ƒŽ’”‡ ‹•‹‘ƒ†’”‘ ‡†—”ƒŽ Žƒ••‹ˆ‹ ƒ–‹‘ǡ™Š‹ ŠŠƒ•ƒ†‡ ‘—– ‘‡•Šƒ”†–‘ƒƒŽ›œ‡Ǥȋͳ͸ʹȌ 6) Only secondary, unilateral DIEAP flap breast reconstructions: •†‹• —••‡†ˆ‘” ’ƒ’‡” Ǥ 7) Parity was not recorded: ƒ”‹–›‹•‹’‘”–ƒ–ˆ‘”ƒ—„‡”‘ˆ”‡ƒ•‘•ǣ ‹”•–Ž›ǡ ™‹†‡‹‰‘ˆ–Š‡Ž‹‡ƒƒŽ„ƒ‹•ƒ™‡ŽŽǦƒ ‡’–‡† ‘•‡“—‡ ‡‘ˆ’”‡‰ƒ ›ǡƒ† Ž‹–‡”ƒ–—”‡Šƒ•”‡’‘”–‡†ƒ’‘•‹–‹˜‡ƒ••‘ ‹ƒ–‹‘„‡–™‡‡’ƒ”‹–›ƒ†ǤȋʹʹͲǦʹʹʹȌ „†‘‹ƒŽ™ƒŽŽŽƒš‹–›‘ —”•„‘–Š†—‡–‘–Š‡‡ Šƒ‹ ƒŽ•–”‡••ƒ†ƒ•ƒ”‡•—Ž–‘ˆ Š‘”‘ƒŽ Šƒ‰‡•‘ˆ ‘‡ –‹˜‡–‹••—‡•Ǥȋʹʹ͵Ȍ‡ ‘†Ž›ǡ’”‡‰ƒ ›Šƒ•„‡‡•Š‘™ –‘ƒŽ–‡”–Š‡†‹‡•‹‘•‘ˆ–Š‡”‡ –—•ƒ„†‘‹‹•—• Ž‡•ǣ ƒʹͲͳͻ’—„Ž‹ ƒ–‹‘ǡ ƒ‡•‡–ƒŽǤ‘„•‡”˜‡†–Šƒ––Š‡‡ƒ™‹†–Š‘ˆ‡ƒ Š”‡ –—•—• Ž‡™ƒ••‹‰‹ˆ‹ ƒ–Ž› ™‹†‡‡†ˆ”‘͸ ‹—ŽŽ‹’ƒ”‘—•–‘͸Ǥ͸ͳ ƒˆ–‡”‘‡’”‡‰ƒ ›ǡƒ†͹ ƒˆ–‡”–™‘ ’”‡‰ƒ ‹‡•Ǥȋʹʹ͵ȌŠ‹”†Ž›ǡƒŠƒ„‡†‹ƒƒ†‘‡”‡’‘”–‡†ƒ™‡ƒ–”‡†™Š‡”‡ —ŽŽ‹’ƒ”‘—•™‘‡Šƒ†ƒŠ‹‰Š‡”‘ —””‡ ‡‘ˆƒ„†‘‹ƒŽ„—Ž‰‡ȋPαͲǤͲͺȌǡƒ† •—‰‰‡•–‡†ƒ•ƒŽŽ’”‡˜‡–ƒ–‹˜‡‡ˆˆ‡ –‘ˆ’”‡‰ƒ ›‹–‡”•‘ˆ„—Ž‰‹‰Ǥȋͳͷ͹Ȍƒ•‡† ‘–Š‡•‡†ƒ–ƒǡ‹–•‡‡•ƒ•’ƒ”‹–›’Žƒ›•ƒ‹’‘”–ƒ–”‘Ž‡‹ƒ„†‘‹ƒŽ™ƒŽŽ Šƒ‰‡• ƒ†Žƒš‹–›Ǥ‡•Š‘—Ž†ǡ–Š‡”‡ˆ‘”‡ǡŠƒ˜‡”‡ ‘”†‡†’ƒ”‹–›ƒ†ƒ†Œ—•–‡†–Š‡•–ƒ–‹•–‹ ƒŽ –‡•–•ƒ ‘”†‹‰Ž›Ǥ  Instrument

59 59 1) CT scans of a moving abdominal wall causes measurement errorsǣŠ‡‘˜‹‰ ƒ„†‘‹ƒŽ™ƒŽŽȋ‡•’‡ ‹ƒŽŽ›†—‡–‘”‡•’‹”ƒ–‹‘Ȍ™‹ŽŽ‹–”‘†— ‡•‘‡— ‡”–ƒ‹–›‹ –‡”•‘ˆ–Š‡•–ƒ†ƒ”†‹œ‡†œ‘‡•‘—–Ž‹‡†ǤŠ‡œ‘‡‹‰Š–‡†—’•Ž‹‰Š–Ž› ”ƒ‹ƒŽ‘” ƒ—†ƒŽ–‘‹–•ƒ –—ƒŽŽ‘ ƒ–‹‘Ǥ 2) Two different CT machines: Š‡ƒŒ‘”‹–›‘ˆ• ƒ•ȋʹͶ‘ˆʹͺȌ™‡”‡’‡”ˆ‘”‡† ™‹–Š‘‡ƒ Š‹‡ȋ͸ͶǦ”‘™•›•–‡Ȍǡƒ†–Š‡”‡ƒ‹‹‰• ƒ•™‡”‡’‡”ˆ‘”‡† ™‹–Šƒ‘–Š‡”ƒ Š‹‡ȋ͵ʹͲǦ”‘™•›•–‡ȌǤŠ‹•™ƒ•‘–’Žƒ‡†ƒ†Šƒ’’‡‡††—‡–‘ ƒ˜ƒ‹Žƒ„‹Ž‹–›‹••—‡•ǤŠ‡—•‡‘ˆ–™‘ƒ Š‹‡•ƒ†”‘™Ǧ•›•–‡• ‘—Ž† ƒ—•‡ ‡ƒ•—”‡‡–‡””‘”•ǡŠ‘™‡˜‡”ǡ–Š‹•Ž‹‹–ƒ–‹‘‹•’”‘„ƒ„Ž›ƒ”‰‹ƒŽǤŠ‡”ƒ†‹‘Ž‘‰‹•–• ‹˜‘Ž˜‡†ƒ†‡•—”‡–Šƒ–‹ƒ‰‡’ƒ”ƒ‡–‡”•ȋǡǡ‡– ǤȌ™‡”‡ Ž‘•‡–‘‹†‡–‹ ƒŽǤ 3) Non-contrast enhanced CT is not adequate to determine cause of morphological changes: Š‡‡–‹‘Ž‘‰›‘ˆ–Š‡‘”’Š‘Ž‘‰‹ ƒŽ Šƒ‰‡•ˆ‘—†‹‘—” •–—†›”‡ƒ‹••’‡ —Žƒ–‹˜‡Ǥ – ‘—Ž†„‡ ƒ—•‡†„› Š”‘‹ ‡†‡ƒǡ‹ ”‡ƒ•‡† ‹–”ƒ—• —Žƒ”ˆƒ–ǡ• ƒ”ˆ‘”ƒ–‹‘ƒ†Ȁ‘”—• Ž‡ƒ–”‘’Š›Ǥ‘–”ƒ•–Ǧ‡Šƒ ‡†ǡ  ǡƒ‰‡–‹ ”‡•‘ƒ ‡‡Žƒ•–‘‰”ƒ’Š›ǡƒ†—Ž–”ƒ•‘—†‡Žƒ•–‘‰”ƒ’Š›ƒ”‡„‡––‡” ‘†ƒŽ‹–‹‡•–‘‹˜‡•–‹‰ƒ–‡•— Šƒ––‡”•Ǥ 4) Radiation exposure: Š‡’ƒ–‹‡–•‹ Ž—†‡†™‡”‡‡š’‘•‡†ˆ‘”‡š–”ƒ”ƒ†‹ƒ–‹‘ ‡š’‘•—”‡–‘–Š‡ƒ„†‘‹ƒŽ”‡‰‹‘ǤŽ‡ƒ•‡•‡‡Dz–Š‹ ƒŽ ‘•‹†‡”ƒ–‹‘•dzǤ

Statistical analysis 1) Multiple comparisons: •†‹• —••‡†ˆ‘”’ƒ’‡” Ǥ‘ˆ‡””‘‹ ‘””‡ –‹‘™ƒ•‘–—•‡† ‹’ƒ’‡” Ǥ 2) Non-parametric tests: ‡ Š‘•‡–‘—•‡‹Ž ‘š‘‹‰ƒ–‡•––‘ ‘’ƒ”‡’ƒ‹”‡† •ƒ’Ž‡•ȋ‹•–‡ƒ†‘ˆƒ’ƒ”ƒ‡–”‹ ’ƒ‹”‡†Ǧ•ƒ’Ž‡•tǦ–‡•–Ȍƒ†ƒǦŠ‹–‡›UǦ–‡•––‘ ‘’ƒ”‡‹†‡’‡†‡–•ƒ’Ž‡•ȋ‹•–‡ƒ†‘ˆƒ’ƒ”ƒ‡–”‹ –™‘•ƒ’Ž‡tǦ–‡•–ȌǤŠ‹•™ƒ• †‘‡‘™‹‰Ž›†—‡–‘–Š‡•ƒŽŽ•ƒ’Ž‡•‹œ‡™Š‡”‡‹–‹•†‹ˆˆ‹ —Ž––‘ƒ••—‡‘”ƒŽŽ› †‹•–”‹„—–‡††ƒ–ƒǤ ‹Ž ‘š‘‹‰ƒ–‡•–‹•ƒ‘Ǧ’ƒ”ƒ‡–”‹ –‡•–ˆ‘”’ƒ‹”‡†•ƒ’Ž‡•™Š‹ Š†‘‡• ‘–ƒ‡ƒ••—’–‹‘•ƒ„‘—–‘”ƒŽ‹–›ǤȋʹʹͶȌ –‹•—•‡†–‘†‡–‡”‹‡™Š‡–Š‡”–Š‡”‡ ‹•ƒ‡†‹ƒ†‹ˆˆ‡”‡ ‡„‡–™‡‡–Š‡’ƒ‹”‡†•ƒ’Ž‡•„‡‹‰•–—†‹‡†ǤȋʹʹͶȌŠ‡–‡•– ™‘”•„›”ƒ‹‰–Š‡†ƒ–ƒ‹—‡”‹ ƒŽ‘”†‡”ƒ†ƒƒŽ›œ‹‰–Š‡•‡”ƒ•ȋ”ƒ–Š‡”–Šƒ –Š‡ƒ –—ƒŽ‡ƒ•—”‡‡–•‘„–ƒ‹‡†ȌǤȋʹʹͷȌ‹ˆˆ‡”‡ ‡•„‡–™‡‡‡ƒ Šƒ– Š‡†’ƒ‹”‹• ƒŽ —Žƒ–‡†„›”‡’Žƒ ‹‰–Š‡‹”ƒ„•‘Ž—–‡˜ƒŽ—‡•™‹–Š–Š‡‹”‘”†‡”‡†”ƒ•ǤŠ‡ ‘„•‡”˜ƒ–‹‘•ƒ”‡†‹• ƒ”†‡†™Š‡”‡–Š‡†‹ˆˆ‡”‡ ‡‹•œ‡”‘Ǥ†‡”–Š‡—ŽŽŠ›’‘–Š‡•‹•ǡ –Š‡•—‘ˆ’‘•‹–‹˜‡ƒ†‡‰ƒ–‹˜‡”ƒ••Š‘—Ž†„‡•‹‹Žƒ”Ǥ ƒǦŠ‹–‡›UǦ–‡•–‹•ƒ‘–Š‡”‘Ǧ’ƒ”ƒ‡–”‹ –‡•–Ǥ –‹•—•‡†–‘–‡•–™Š‡–Š‡” –Š‡”‡ƒ”‡†‹ˆˆ‡”‡ ‡•‹–Š‡†‹•–”‹„—–‹‘•‘”‡†‹ƒ•‘ˆ–™‘‹†‡’‡†‡– •ƒ’Ž‡•Ǥȋʹʹ͸Ȍ‡•–‹‰†‹ˆˆ‡”‡ ‡•‹†‹•–”‹„—–‹‘•‹•’‡”ˆ‘”‡†„›”ƒ‹‰†ƒ–ƒ ƒ ‘”†‹‰–‘‹–••‹œ‡ƒ†‹””‡•’‡ –‹˜‡‘ˆ–Š‡•ƒ’Ž‡ȋ‰”‘—’Ȍ‹–„‡Ž‘‰•–‘ǤŠ‡Š‹‰Š‡•– ”ƒ‹•ƒ••‹‰‡†–‘–Š‡Š‹‰Š‡•–˜ƒŽ—‡ǤŠ‡ǡ–Š‡”ƒ•‘ˆ‡ƒ Š‹†‡’‡†‡–•ƒ’Ž‡‹• ƒ˜‡”ƒ‰‡†ƒ†–Š‡•ƒ’Ž‡•ǯ‡ƒ”ƒ•ƒ”‡–‡•–‡†ˆ‘”•–ƒ–‹•–‹ ƒŽ•‹‰‹ˆ‹ ƒ ‡Ǥ ˆ–Š‡ †‹•–”‹„—–‹‘•ƒ”‡‹†‡–‹ ƒŽȋ—ŽŽŠ›’‘–Š‡•‹•Ȍǡ–Š‡‡ƒ”ƒ™‹ŽŽ„‡–Š‡•ƒ‡ˆ‘”„‘–Š •ƒ’Ž‡•Ǥ‡•–‹‰†‹ˆˆ‡”‡ ‡•‹‡†‹ƒ•ǡƒ‘”‡ˆƒ‹Ž‹ƒ”˜ƒŽ—‡‘ˆ ‡–”ƒŽ–‡†‡ ›ǡ ‘—Ž†„‡’‡”ˆ‘”‡†™‹–ŠƒǦŠ‹–‡›UǦ–‡•–‹ˆ–Š‡†‹•–”‹„—–‹‘•ƒ”‡•‹‹Žƒ”Ž› •Šƒ’‡†Ǥȋʹʹ͸Ȍ

60 60 ‘’ƒ”‹‰’ƒ”ƒ‡–”‹ ƒ†‘Ǧ’ƒ”ƒ‡–”‹ –‡•–•ǡ–Š‡”‡‹•ƒ”‡Žƒ–‹˜‡Ž‘••‘ˆ’‘™‡” ȋ’”‘„ƒ„‹Ž‹–›‘ˆˆ‹†‹‰•–ƒ–‹•–‹ ƒŽŽ›•‹‰‹ˆ‹ ƒ–”‡•—Ž–•™Š‡”‡†‹ˆˆ‡”‡ ‡•‡š‹•–Ȍ„› —•‹‰–Š‡Žƒ––‡”ǤȋʹʹͷȌ‘Ǧ’ƒ”ƒ‡–”‹ –‡•–•‘ˆˆ‡”ǡ‹‘–Š‡”™‘”†•ǡƒŽ‘™‡” ‘’’‘”–—‹–›–‘†‡–‡ –‰‡—‹‡†‹ˆˆ‡”‡ ‡•Ǥ‘Ǧ’ƒ”ƒ‡–”‹ –‡•–•Šƒ˜‡ƒŽ•‘–Š‡ †‹•ƒ†˜ƒ–ƒ‰‡‘ˆ’”‘˜‹†‹‰‡•–‹ƒ–‡•‘ˆ‡ˆˆ‡ –•‹œ‡ƒ•†‹ˆˆ‡”‡ ‡‹‡†‹ƒ•ȋ™‹–Šƒͻͷ Ψ Ȍ‹ƒ›‘ ƒ•‹‘•ǤŠ‹•‹•‘”‡†‹ˆˆ‹ —Ž––‘‹–‡”’”‡––Šƒ‡•–‹ƒ–‡•‘ˆ †‹ˆˆ‡”‡ ‡‹‡ƒ•ȋ™‹–ŠƒͻͷΨ Ȍƒ•’”‡•‡–‡†„›’ƒ”ƒ‡–”‹ –‡•–•Ǥ  —” Š‘‹ ‡‘ˆ—•‹‰‘Ǧ’ƒ”ƒ‡–”‹ –‡•–•™ƒ•ǡ‹ˆƒ –ǡ•‘Ž‡Ž›„ƒ•‡†‘•ƒ’Ž‡•‹œ‡ǡ ƒ†‘–„›ƒˆ‘”ƒŽ‹˜ƒŽ‹†ƒ–‹‘‘ˆ‘”ƒŽ‹–›ȋ–Š”‘—‰Š•–ƒ–‹•–‹ ƒŽƒƒŽ›•‡•ȋ‡Ǥ‰Ǥ ‘Ž‘‰‘”‘˜Ǧ‹”‘˜–‡•–ƒ†Šƒ’‹”‘Ǧ‹Ž–‡•–Ȍ‘”‰”ƒ’Š‹ ƒŽ†‹•’Žƒ›•ȋ‡Ǥ‰Ǥ Š‹•–‘‰”ƒ•ȌȌǤ•’ƒ”ƒ‡–”‹ –‡•–•ƒ”‡’”‡ˆ‡”ƒ„Ž‡ǡ‹– ‘—Ž†„‡–Šƒ–™‡•Š‘—Ž†Šƒ˜‡ ƒ••—‡†‘”ƒŽ‹–›ƒ†—•‡†•— Š–‡•–•ˆ‘”‘—”†ƒ–ƒǤ‘‰‡–ƒ‹†‹ ƒ–‹‘ǡ™‡ ‘—Ž† Šƒ˜‡ ‘’Ž‡–‡†„‘–Š’ƒ”ƒ‡–”‹ ƒ†‘Ǧ’ƒ”ƒ‡–”‹ –‡•–•ƒ† ‘’ƒ”‡†–Š‡”‡•—Ž–•ǡ ™‹–Š•‹‹Žƒ””‡•—Ž–••‹‰ƒŽ‹‰–Šƒ–’ƒ”ƒ‡–”‹ –‡•–•™‡”‡ƒ’’Ž‹ ƒ„Ž‡ˆ‘”‘—”†ƒ–ƒǤ ‘”‡‘˜‡”ǡ‹ˆ–Š‡†‹•–”‹„—–‹‘‘ˆ†ƒ–ƒ™ƒ•‹†‡‡†•‡™‡†ǡ™‡ ‘—Ž†Šƒ˜‡–”ƒ•ˆ‘”‡† –Š‡†ƒ–ƒ–‘ƒ‡–Š‡ƒ˜ƒ‹Žƒ„Ž‡ˆ‘”’ƒ”ƒ‡–”‹ –‡•–•Ǥ  ‘ Ž—•‹‘ǡƒ„‡––‡”‡ˆˆ‘”– •Š‘—Ž†Šƒ˜‡„‡‡ƒ†‡–‘ƒ••‡••–Š‡ƒ˜ƒ‹Žƒ„‹Ž‹–›‘ˆ’ƒ”ƒ‡–”‹ t-–‡•–•ˆ‘”‘—”†ƒ–ƒǤ 3) Pearson’s correlation test was used to calculate associations: Š‡‡ƒ”•‘ǯ• ‘””‡Žƒ–‹‘–‡•–‹•—•‡†–‘†‡–‡”‹‡–Š‡•–”‡‰–Šƒ††‹”‡ –‹‘‘ˆƒŽ‹‡ƒ” ”‡Žƒ–‹‘•Š‹’„‡–™‡‡–™‘ ‘–‹—‘—•˜ƒ”‹ƒ„Ž‡•Ǥȋʹʹ͹Ȍ –‰‡‡”ƒ–‡•–Š‡‡ƒ”•‘ǯ• ‘””‡Žƒ–‹‘ ‘‡ˆˆ‹ ‹‡–ȋrȌ™Š‹ Š”ƒ‰‡•ˆ”‘Ǧͳȋ’‡”ˆ‡ –‡‰ƒ–‹˜‡Ž‹‡ƒ”ƒ••‘ ‹ƒ–‹‘Ȍ –‘Ϊͳȋ’‡”ˆ‡ –’‘•‹–‹˜‡Ž‹‡ƒ”ƒ••‘ ‹ƒ–‹‘ȌǤ‡”‘‹†‹ ƒ–‡•‘ƒ••‘ ‹ƒ–‹‘„‡–™‡‡–Š‡ –™‘˜ƒ”‹ƒ„Ž‡•Ǥȋʹʹ͹Ȍ‡†‹†‘–ˆ‹†ƒ›•‹‰‹ˆ‹ ƒ– ‘””‡Žƒ–‹‘„‡–™‡‡ǣͳȌƒ† ”‡ –—•—• Ž‡ Šƒ‰‡•ǡ‘”ʹȌ Šƒ‰‡•ƒ† Ȁƒ‰‡Ǥ  ‡†‹†ǡŠ‘™‡˜‡”ǡˆ‹†ƒ•‹‰‹ˆ‹ ƒ– ‘””‡Žƒ–‹‘ȋr αǦͲǤ͹͸ǡPαͲǤͲͲ͵Ȍ„‡–™‡‡  ƒ†ƒ‰‡Ȃ‡ƒ‹‰–Šƒ–‘Ž†‡”’ƒ–‹‡–•Šƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž›Ž‘™‡” ǤŽ–Š‘—‰Š–Š‹• ‹‰Š–„‡˜‡”›–”—‡ǡƒ•‹‰‹ˆ‹ ƒ– ‘””‡Žƒ–‹‘†‘‡•‘–‹’Ž› ƒ—•ƒŽ‹–›ȋ‘”ƒ›†‹”‡ – ƒ••‘ ‹ƒ–‹‘„‡–™‡‡–Š‡˜ƒ”‹ƒ„Ž‡•ƒ–ƒŽŽȌǤ™‘˜ƒ”‹ƒ„Ž‡• ƒǡ‹ˆƒ –ǡ„‡ ‘””‡Žƒ–‡† „‡ ƒ—•‡„‘–ŠŠƒ˜‡ƒ•‹‰‹ˆ‹ ƒ–†‡‰”‡‡‘ˆ ‘””‡Žƒ–‹‘™‹–Šƒ–Š‹”†˜ƒ”‹ƒ„Ž‡ǤȋʹʹͺȌŠ‹• ‹•™‘”–Š‡–‹‘‹‰™Š‡—•‹‰‡ƒ”•‘ǯ• ‘””‡Žƒ–‹‘–‡•––‘ ƒŽ —Žƒ–‡ƒ••‘ ‹ƒ–‹‘•Ǥ  –‡”•‘ˆ–‡•–ƒ••—’–‹‘•ǡ™‡ Š‡ ‡†ˆ‘”‘—–Ž‹‡”•—•‹‰• ƒ––‡”’Ž‘–•Ǥ ‘”ƒŽ‹–›–‡•–•ȋ‡Ǥ‰Ǥ‘Ž‘‰‘”‘˜Ǧ‹”‘˜–‡•–ƒ†Šƒ’‹”‘Ǧ‹Ž–‡•–Ȍ™‡”‡‘– ’‡”ˆ‘”‡†ǡƒ†–”ƒ•ˆ‘”ƒ–‹‘‘ˆ†ƒ–ƒ™ƒ• ‘•‡“—‡–Ž›‘– ‘•‹†‡”‡†Ǥ  Miscellaneous 1) Statistically significant comparisons do not necessarily mean considerable donor-site morbidity: •—†‡”Ž‹‡†‹Dz‹• —••‹‘‘ˆƒ‹ˆ‹†‹‰•dz•‡˜‡”ƒŽ‘ˆ–Š‡ •–ƒ–‹•–‹ ƒŽŽ›•‹‰‹ˆ‹ ƒ– ‘’ƒ”‹•‘•ƒ”‡„ƒ•‡†‘‡ƒ†‹ˆˆ‡”‡ ‡•‘ˆƒˆ‡™ ‹ŽŽ‹‡–‡”•ǤŽŽ•‹‰‹ˆ‹ ƒ– ‘’ƒ”‹•‘•‘ˆ‡ƒ”‡ –—•—• Ž‡‡ƒ•—”‡‡–•™‡”‡ Ž‡••–Šƒˆ‹˜‡‹ŽŽ‹‡–‡”•†‹ˆˆ‡”‡–ǤŽŽ•‹‰‹ˆ‹ ƒ– ‘’ƒ”‹•‘•‘ˆ–Š‡‡ƒ ‡ƒ•—”‡‡–•™‡”‡Ž‡••–Šƒˆ‘—”‹ŽŽ‹‡–‡”•†‹ˆˆ‡”‡–Ǥ‡•’‹–‡›‹‡Ž†‹‰•‹‰‹ˆ‹ ƒ– PǦ˜ƒŽ—‡•‹Š›’‘–Š‡•‹•–‡•–‹‰ǡ‘‡•Š‘—Ž†‘–ƒ—–‘ƒ–‹ ƒŽŽ›ƒ ‡’–•— Š”‡•—Ž–•ƒ• ‘•‹†‡”ƒ„Ž‡†‘‘”Ǧ•‹–‡‘”„‹†‹–›Ǥ ‘”‹•–ƒ ‡ǡƒ‡ƒ†‹ˆˆ‡”‡ ‡‘ˆ‘‡ ‹ŽŽ‹‡–‡”‹œ‘‡ȋPαͲǤͲ͵ͺȌ‹‰Š–‘–„‡”‡ ‘‰‹œƒ„Ž‡ˆ‘”–Š‡’ƒ–‹‡–•Ǥ  ‡†‘‘–‘™–Š‡‹‹ƒŽ Ž‹‹ ƒŽŽ›‹’‘”–ƒ–†‹ˆˆ‡”‡ ‡•ȋ Ȍ†‹• —••‹‰

61 61 –Š‡•‡ƒ––‡”•ǤŠ‡ ‹•–Š‡•ƒŽŽ‡•–ȋƒ„•‘Ž—–‡Ȍ†‹ˆˆ‡”‡ ‡‹• ‘”‡™Š‹ Š’ƒ–‹‡–• ’‡” ‡‹˜‡ƒ•„‡‡ˆ‹ ‹ƒŽǤ‹ˆˆ‡”‡ ‡•‹• ‘”‡••ƒŽŽ‡”–Šƒ–Š‡ ƒ”‡ ‘•‹†‡”‡† —‹’‘”–ƒ–‹†‡’‡†‡–‘ˆ–Š‡‹”•–ƒ–‹•–‹ ƒŽ•‹‰‹ˆ‹ ƒ ‡ǤȋͳͻͶȌ 2) The recipient vessels were not recorded:•†‹• —••‡†ˆ‘”’ƒ’‡” ǤŠ‡—•‡‘ˆ  ȋ‡†Ǧ–‘Ǧ‡†Ȍ ‘—Ž†Šƒ˜‡ ƒ—•‡†”‡†— ‡†„Ž‘‘†•—’’Ž›–‘–Š‡”‡ –—•—• Ž‡• ’‘–‡–‹ƒŽŽ›‰‹˜‹‰”‹•‡–‘—• Ž‡ƒ–”‘’Š›Ǥ 3) Varying perforator number, perforator row, myotomies, and rectus muscle divisions: Š‡”‡™ƒ•‘ ‘•‹•–‡ ›‹–‡”•‘ˆ–Š‡•—”‰‹ ƒŽƒ’’”‘ƒ Šƒ†–‡ Š‹“—‡ —•‡†ǣ‹‡’ƒ–‹‡–•Šƒ†‘‡’‡”ˆ‘”ƒ–‘”ǡ™Š‡”‡ƒ•–Š‡”‡ƒ‹‹‰ˆ‹˜‡’ƒ–‹‡–•Šƒ†–™‘ ’‡”ˆ‘”ƒ–‘”•Ǥ‹‰Š–ˆŽƒ’•™‡”‡„ƒ•‡†‘‡†‹ƒŽ’‡”ˆ‘”ƒ–‘”•ǡˆ‘—”ˆŽƒ’•‘Žƒ–‡”ƒŽ ’‡”ˆ‘”ƒ–‘”•ǡƒ†–™‘ˆŽƒ’•‘‘‡’‡”ˆ‘”ƒ–‘”ˆ”‘‡ƒ Š”‘™Ǥ‡†‹••‡ –‹‘”‡“—‹”‡† –™‘›‘–‘‹‡•ǡƒ†–Š‡”‡ –—•—• Ž‡™ƒ•’ƒ”–‹ƒŽŽ›†‹˜‹†‡†‹–™‘ ƒ•‡•ȋƒ• †‹• —••‡†ƒ„‘˜‡ȌǤ‡–”‘•’‡ –‹˜‡Ž›ǡ™‡™‘—Ž†Šƒ˜‡Ž‹‡†–‘Šƒ˜‡‘”‡†‡ˆ‹‡† ‹ Ž—•‹‘ ”‹–‡”‹ƒȂƒŽ•‘™Š‡‹– ‘‡•–‘–Š‡•—”‰‹ ƒŽǦ–‡ Š‹ ƒŽƒ•’‡ –ƒ†’‡”ˆ‘”ƒ–‘” —•‡Ǥ‘’ƒ”‹•‘•‘ˆ†‘‘”Ǧ•‹–‡‘”„‹†‹–›„‡–™‡‡ ˆŽƒ’•Šƒ”˜‡•–‡†‹•— Š ˜ƒ”›‹‰ƒ‡”•ƒ”‡“—‡•–‹‘ƒ„Ž‡Ǥ‡™‘—Ž†Šƒ˜‡Šƒ†ƒ‘”‡Š‘‘‰‡‘—• ‘Š‘”–ǡ ‹ˆ ˆŽƒ’•™‹–Š’‡”ˆ‘”ƒ–‘”•ˆ”‘„‘–Š”‘™•ǡ‘”‡–Šƒ‘‡›‘–‘›ǡ‘””‡ –—• —• Ž‡†‹˜‹•‹‘™‡”‡‡š Ž—†‡†ǤŠ‹•™‘—Ž†ǡŠ‘™‡˜‡”ǡŠƒ˜‡”‡†— ‡†–Š‡•ƒ’Ž‡•‹œ‡Ǥ 4) Preoperative CT scans did not cover the most cranial aspects of the abdomen: ”‡‘’‡”ƒ–‹˜‡• ƒ• ‘˜‡”‡†–Š‡ƒ„†‘‹ƒŽ™ƒŽŽˆ”‘–Š‡•‡ ‘†Ž—„ƒ”˜‡”–‡„”ƒ–‘ –Š‡’—„‹ •›’Š›•‹•ƒ•’‡”•–ƒ†ƒ”†’”‘–‘ ‘ŽǤŠ‡’‘•–‘’‡”ƒ–‹˜‡• ƒ• ‘˜‡”‡†–Š‡ Ž‡‰–Šˆ”‘–Š‡š‹’Š‘‹†’”‘ ‡••–‘–Š‡’—„‹ •›’Š›•‹•Ǥ•–Š‡’”‡‘’‡”ƒ–‹˜‡• ƒ• ™‡”‡ƒ””‘™‡”ǡ™‡™‡”‡‘–ƒ„Ž‡–‘ ‘’ƒ”‡–Š‡‘•– ”ƒ‹ƒŽƒ•’‡ –•‘ˆ–Š‡ ƒ„†‘‹ƒŽ™ƒŽŽȋ’”‡‘’‡”ƒ–‹˜‡˜•’‘•–‘’‡”ƒ–‹˜‡ȌǤސ•‡–Š‡–ƒŽǤŠƒ˜‡†‡‘•–”ƒ–‡† –Šƒ––Š‡‰”‡ƒ–‡•–—• Ž‡ƒ–”‘’Š›‹•Ž‘ ƒ–‡†Œ—•–„‡Ž‘™–Š‡š‹’Š‘‹†’”‘ ‡••ƒ†ƒ„‘˜‡ –Š‡’—„‹ •›’Š›•‹•Ǥȋͺ͵Ȍˆ‘”–—ƒ–‡Ž›ǡ–Š‡•‡œ‘‡•™‡”‡‘–‹˜‡•–‹‰ƒ–‡†‹‘—” •–—†›†—‡–‘–Š‡ƒ””‘™‡”™‹†‘™—•‡†‹’”‡‘’‡”ƒ–‹˜‡• ƒ•Ǥ 5) Microvascular clips revealed the operated side: Š‡”ƒ†‹‘Ž‘‰‹•–•™‡”‡‘”‹‰‹ƒŽŽ› „Ž‹†‡†–‘–Š‡•‹†‡‘ˆ•—”‰‡”›ǡŠ‘™‡˜‡”ǡ‹ ”‘˜ƒ• —Žƒ” Ž‹’•‡ƒ•‹Ž›”‡˜‡ƒŽ‡†–Š‡ ‘’‡”ƒ–‡†•‹†‡ǤŠ‹• ‘—Ž† ƒ—•‡‘„•‡”˜‡”„‹ƒ•Ǥ 6) Incidentalomas:  ‹†‡–ƒŽˆ‹†‹‰•ǡƒŽ•‘‘™ƒ•‹ ‹†‡–ƒŽ‘ƒ•ǡ™‡”‡”‡ ‘”†‡†Ǥ ƒ–‹‡–•†‘‘–‡ ‡••ƒ”‹Ž›„‡‡ˆ‹–ˆ”‘•— Šˆ‹†‹‰•ǤŽ‡ƒ•‡•‡‡Dz–Š‹ ƒŽ ‘•‹†‡”ƒ–‹‘•dzǤ

Strengths: ͳȌ”‘•’‡ –‹˜‡†‡•‹‰ǡʹȌ‘ˆˆ‡”•ƒ„‡––‡”‘†ƒŽ‹–›–‘‡˜ƒŽ—ƒ–‡†‘‘”Ǧ•‹–‡ ‘”„‹†‹–›ȋ‡Ǥ‰Ǥˆ‘”Š‡”‹ƒƒ†•‡”‘ƒ•Ȍ–Šƒ—Ž–”ƒ•‘‘‰”ƒ’Š›ǡ͵Ȍ‹•ƒƒ —”ƒ–‡ ‘†ƒŽ‹–›‡ƒ•—”‹‰—• Ž‡†‹‡•‹‘•†—‡–‘–Š‡Š‹‰Šƒ––‡—ƒ–‹‘†‹ˆˆ‡”‡ ‡ ȋ ‘—•ˆ‹‡Ž†—‹–•Ȍ„‡–™‡‡—• Ž‡ƒ†ˆƒ–ǡͶȌ‘’ƒ”‡†—Ž–‹’Ž‡œ‘‡•‘ˆ–Š‡ ƒ„†‘‹ƒŽ™ƒŽŽȋ‡–Š‘†‘Ž‘‰‹ ƒŽŽ›•—’‡”‹‘”–‘’”‡˜‹‘—•Ž›’—„Ž‹•Š‡†ƒ”–‹ Ž‡•–Šƒ–Šƒ˜‡ —•‡†‘‡œ‘‡ȌȋͶͻǡͳͲͲǡͳʹ͵ȌǡͷȌ–‹Ž‹œ‡†–Š‡’”‡‘’‡”ƒ–‹˜‡–‘’‡”ˆ‘”‡˜ƒŽ—ƒ–‹‘• ‘–Š‡”–Šƒ’‡”ˆ‘”ƒ–‘”ƒ’’‹‰ǡ͸Ȍ‘‰ˆ‘ŽŽ‘™Ǧ—’–‹‡ȋ–™‘›‡ƒ”•ȌȂ‡Ž‹‹ƒ–‹‰ ’‘•–•—”‰‹ ƒŽ‡†‡ƒƒ†ƒ”–‡ˆƒ –••‡‡–Š‡ˆ‹”•–™‡‡•Ȁ‘–Š•ƒˆ–‡”•—”‰‡”›ǡƒ†͹Ȍ ˜‡”›’ƒ–‹‡–™ƒ•Š‡”‘™ ‘–”‘Žȋ‡Ǥ‰Ǥ–Š‡‡ƒ•—”‡‡–•‘ˆ‘‡”‡ –—•„‡ŽŽ›™‡”‡ ‘’ƒ”‡†™‹–Š–Šƒ–‘ˆƒ‘–Š‡””‡ –—•„‡ŽŽ›Ȃ–Š‡”‡„›”‡†— ‹‰–Š‡‹’ƒ –‘ˆ — ‘–”‘ŽŽ‡†˜ƒ”‹ƒ„Ž‡•Ȍ

62 62 Paper III Study design 1) Comparing two considerably different patient populations: ’ƒ’‡” ǡ–Š‡ •„‡–™‡‡ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‡†’ƒ–‹‡–•ȋ ‰”‘—’Ȍƒ† ƒ„†‘‹‘’Žƒ•–›’ƒ–‹‡–•ȋ‰”‘—’Ȍ™‡”‡ ‘’ƒ”‡†ǤŠ‡•‡‰”‘—’•”‡’”‡•‡––™‘ ”ƒ–Š‡”†‹ˆˆ‡”‡–’ƒ–‹‡–’‘’—Žƒ–‹‘•‹–‡”•‘ˆǣͳȌ‰‡ȋ‡ƒƒ‰‡ ‰”‘—’ǣͷͳǤͺǡ ‡ƒƒ‰‡‰”‘—’ǣͶͳǤͺǡδͲǤͲͲͳȌǡʹȌ‘–‹˜ƒ–‹‘ǡ͵Ȍš’‡ –ƒ–‹‘ǡƒ†ͶȌ—”‰‹ ƒŽ –‡ Š‹“—‡ȋŽ‹’‘•— –‹‘ǡ–‘–ƒŽˆŽƒ’™‡‹‰Š–ǡ—„‹Ž‹ ƒŽ•—”‰‡”›ǡ”‡ –—•’Ž‹ ƒ–‹‘ǡ‡– ǤȌǤ‡ ƒŽ•‘Š›’‘–Š‡•‹œ‡–Šƒ–„‘†›‹ƒ‰‡†‹••ƒ–‹•ˆƒ –‹‘ƒ†’•› Š‹ƒ–”‹  ‘‘”„‹†‹–‹‡•ȋ‡Ǥ‰Ǥ „‘†›†›•‘”’Š‹ †‹•‘”†‡”Ȍƒ”‡‘”‡ˆ”‡“—‡–‹–Š‡‰”‘—’Ǥȋʹʹͻǡʹ͵ͲȌ ‘•‡“—‡–Ž›ǡ–Š‡•‡’ƒ–‹‡–’‘’—Žƒ–‹‘• ‘—Ž†„‡–‘‘†‹•–‹ –‹˜‡ƒ‹‰–Š‡ ‡–Š‘†‘Ž‘‰›‘ˆ‘—”•–—†›™‡ƒǤŠ‡ ‘–”ƒ•–‹‰’ƒ–‹‡–’‘’—Žƒ–‹‘•Šƒ˜‡–‘„‡ ƒ ‘—–‡†ˆ‘”™Š‡‹–‡”’”‡–‹‰–Š‡•–—†›Ǥ 2) Retrospective study: ‡–”‘•’‡ –‹˜‡•–—†‹‡•ƒ”‡’”‘‡–‘”‡ ƒŽŽ„‹ƒ•™Š‹ Š†‡• ”‹„‡• –Š‡–‡†‡ ›‘ˆ”‡•’‘†‡–•–‘’”‘˜‹†‡‡””‘‡‘—•”‡•’‘•‡•™Š‡”‡ ƒŽŽ‹‰’ƒ•– ‡˜‡–•Ǥȋʹ͵ͳȌ ’ƒ’‡” ǡˆ‘”‹•–ƒ ‡ǡ’ƒ–‹‡–•™‡”‡ƒ•‡†–‘†‡–‡”‹‡™Š‡–Š‡”–Š‡ ˆ‘ŽŽ‘™‹‰‘—– ‘‡•Šƒ† Šƒ‰‡†ƒˆ–‡”–Š‡’”‘ ‡†—”‡ǣͳȌ‡ŽˆǦ‹ƒ‰‡ǡʹȌ‘†›‹ƒ‰‡ǡ ͵Ȍ‘ ‹ƒŽ”‡Žƒ–‹‘•Š‹’ǡͶȌ‡‹‰ƒ‡†™‹–Š’ƒ”–‡”ǡͷȌ‡š—ƒŽ†‡•‹”‡ǡƒ†͸Ȍ‘””‹‡† ƒ„‘—–Š‡ƒŽ–ŠǤ•–Š‡‡ƒˆ‘ŽŽ‘™Ǧ—’–‹‡™ƒ•ʹǤͶ›‡ƒ”•‹–Š‡ ‰”‘—’ƒ†ʹǤʹ ›‡ƒ”•‹–Š‡‰”‘—’ǡ‹– ‘—Ž†„‡–Šƒ–’ƒ–‹‡–•ȋ‘˜‡”–Š‡ ‘—”•‡‘ˆ–™‘›‡ƒ”•ȌŠƒ† ˆ‘”‰‘––‡Š‘™–Š‡›ˆ‡Ž–’”‹‘”–‘•—”‰‡”›‘”–Šƒ––Š‡‹”ƒ•™‡”•™‡”‡‹ˆŽ—‡ ‡†„› Žƒ–‡”‡˜‡–•Ȃ„‡‹‰„‘–Š”‡Žƒ–‡†‘”‘Ǧ”‡Žƒ–‡†–‘–Š‡•—”‰‹ ƒŽ’”‘ ‡†—”‡Ǥ ˜‡” ‘‹‰•— Š”‡ ƒŽŽ„‹ƒ•‹”‡–”‘•’‡ –‹˜‡•–—†‹‡•‹•†‹ˆˆ‹ —Ž–Ǥ  ’”‘•’‡ –‹˜‡•–—†›†‡•‹‰ǡŠ‘™‡˜‡”ǡ™‘—Ž†Šƒ˜‡ƒŽŽ‘™‡†–Š‡’‘•–‘’‡”ƒ–‹˜‡ • ‘”‡•–‘„‡ƒ†Œ—•–‡†ˆ‘”–Š‡„ƒ•‡Ž‹‡• ‘”‡•ƒ•’‡”ˆ‘”‡†„› —ŠŽ‡–ƒŽǤȋʹ͵ʹȌŠ‹• ’”‘˜‹†‡•ƒ„‡––‡”‡–Š‘†‘Ž‘‰›ƒ†”‡†— ‡•„‹ƒ•Ǥ 3) No physical examination performed: Š‡•–—†›™‘—Ž†Šƒ˜‡–”—Ž›„‡‡ˆ‹––‡†ˆ”‘ ’‡”ˆ‘”‹‰ƒ’Š›•‹ ƒŽ‡šƒ‹ƒ–‹‘‹ƒ††‹–‹‘–‘–Š‡“—‡•–‹‘ƒ‹”‡•Ǥ’Š›•‹ ƒŽ ‡šƒ‹ƒ–‹‘ ‘—Ž†Šƒ˜‡ƒ••‡••‡†–Š‡ƒ„†‘‡ˆ‘”†‘‘”Ǧ•‹–‡‘”„‹†‹–‹‡•ǡ•— Šƒ•ǣͳȌ  ƒ””‹‰ȋ’‘•‹–‹‘ǡ• ƒ”†‹‡•‹‘ǡ‡– ǤȌǡʹȌ„†‘‹ƒŽ ‘–‘—” Šƒ‰‡•ȋ„—Ž‰‹‰ƒ† Š‡”‹ƒȌǡ͵Ȍ‘‰Ǧ‡ƒ”•ǡƒ†ͶȌ—„ƒ”Ȁ‡’‹‰ƒ•–”‹ ˆ—ŽŽ‡••ǤŠ‹• ‘—Ž†Šƒ˜‡ƒ –‡†ƒ•ƒ ˜ƒŽ‹†ƒ–‹‘‘ˆ–Š‡ƒ•™‡”•’”‘˜‹†‡†„›–Š‡”‡•’‘†‡–•Ǥ  ƒ††‹–‹‘ǡƒ•†‹• —••‡†—†‡”Dz •–”—‡–dzǡ‹– ‘—Ž†„‡–Šƒ–’ƒ–‹‡–•™‡”‡ ‘ˆ—•‡†‹–‡”•‘ˆ–Š‡‡†‹ ƒŽ–‡”‹‘Ž‘‰›Ǥ‡Šƒ˜‡–ƒ‡ˆ‘”‰”ƒ–‡†–Šƒ– ’ƒ–‹‡–•™‡”‡ƒ„Ž‡–‘†‹•–‹‰—‹•Š„—Ž‰‹‰ǡŠ‡”‹ƒ•ǡ†‘‰Ǧ‡ƒ”•ǡƒ†Ž—„ƒ”Ȁ‡’‹‰ƒ•–”‹  ˆ—ŽŽ‡••ǤŠ‡”‡‹•ǡŠ‘™‡˜‡”ǡƒŠ‹‰Š’”‘„ƒ„‹Ž‹–›–Šƒ–’ƒ–‹‡–•†‘‘–‘™™Šƒ–‹• ™Šƒ–ǡ™Š‹ Š‹•’”‘„ƒ„Ž›‹†‹ ƒ–‡†„›–Š‡„—Ž‰‹‰”ƒ–‡•”‡’‘”–‡†ǣ͵ͺΨ‹–Š‡  ‰”‘—’ƒ†͵ͲΨ‹–Š‡‰”‘—’”‡’‘”–‡†’‘•–‘’‡”ƒ–‹˜‡„—Ž‰‹‰ǤŠ‹•™ƒ•‘”‡–Šƒ ‡š’‡ –‡†Ǥ‘’ƒ–‹‡–†‹†ǡŠ‘™‡˜‡”ǡ”‡’‘”–Š‡”‹ƒǤ ”‡ƒŽ‹–›ǡ™‡„‡Ž‹‡˜‡–Šƒ–‘•–‘ˆ –Š‡•‡„—Ž‰‡•”‡’”‡•‡–†‘‰Ǧ‡ƒ”•ǡƒ„†‘‹ƒŽ‘˜‡”Šƒ‰ǡƒ†‘–Š‡”‹‘”ƒ„†‘‹ƒŽ ‘–‘—”ƒ„‘”ƒŽ‹–‹‡•Ǥ’Š›•‹ ƒŽ‡šƒ‹ƒ–‹‘ ‘—Ž†Šƒ˜‡ Žƒ”‹ˆ‹‡†–Š‡•‡ƒ––‡”•Ǥ

Patients 1) No a priori power or sample size calculation performed: •†‹• —••‡†ˆ‘”’ƒ’‡” Ǥ –‹•’ƒ”–‹ —Žƒ”Ž›†‹ˆˆ‹ —Ž––‘’‡”ˆ‘”•— Š ƒŽ —Žƒ–‹‘•ˆ‘”’ƒ’‡” ƒ•–Š‡–™‘

63 63 “—‡•–‹‘ƒ‹”‡•—•‡† ‘’ƒ”‡†–Š‡ ƒ†‰”‘—’•„›˜ƒ”›‹‰‡ƒ•—”‡• ȋ†‹ Š‘–‘‘—•ǡ‘”†‹ƒŽǡƒ†—‡”‹ ƒŽƒ•™‡”ƒŽ–‡”ƒ–‹˜‡•ȌǤ‡Šƒ˜‡ǡ–Š‡”‡ˆ‘”‡ǡ‘– ’‡”ˆ‘”‡†ƒ›’‘•–ǦŠ‘  ƒŽ —Žƒ–‹‘•Ǥ  Š‡ ‰”‘—’‹’ƒ’‡” ™ƒ•–Š‡•ƒ‡ƒ••–—†‹‡†‹ƒ’”‡˜‹‘—•’—„Ž‹ ƒ–‹‘ „›•—’‡”˜‹•‘”•ƒ† ‘Ǧƒ—–Š‘”•ǤȋͳͻȌŠ‡‰”‘—’™ƒ•ƒ‡™ǡ•–—†›Ǧ•’‡ ‹ˆ‹  ‘Š‘”–Ǥ 2) Small sample size: •†‹• —••‡†ˆ‘”’ƒ’‡” Ǥ 3) Patients operated in 2000-2004 (DIEAP group) and 2002-2003 (AP group): • †‹• —••‡†ˆ‘”’ƒ’‡” Ǥ  Š‡’ƒ–‹‡–•‹’ƒ’‡” ™‡”‡‹ˆƒ –‘’‡”ƒ–‡†ƒŽŽ–Š‡™ƒ›„ƒ ‹ʹͲͲͲǡƒ†–Š‡  ‰”‘—’‹ Ž—†‡†–Š‡˜‡”›ˆ‹”•– ˆŽƒ’‡˜‡” ‘’Ž‡–‡†‹‘—”‡’ƒ”–‡– ȋ™‹–Š•—’‡”˜‹•‹‘ˆ”‘™‡†‹•Š’Žƒ•–‹ •—”‰‡‘•Ǣ”Ǥچ‡”•–”ޏƒ†”Ǥ”ŽŒ‘– ˆ”‘ƒŽÚŽŽ¡ƒŒ—Š—•ȌǤ  ‡„‡Ž‹‡˜‡–Šƒ– —””‡– ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘•ƒ”‡„‡––‡”ȋŽ‡ƒ”‹‰Ǧ —”˜‡ǡ–‡ Š‹ ƒŽƒ†˜ƒ ‡•ǡ”‡•‡ƒ” Šǡ‡– ǤȌ–Šƒ–Š‡‘‡•’‡”ˆ‘”‡†ʹͲ›‡ƒ”•ƒ‰‘ǡƒ† –Šƒ––Š‡•‹‰Š–Šƒ˜‡„‡‡†‹ˆˆ‡”‡–‹ˆ‡˜ƒŽ—ƒ–‡†–‘†ƒ›ǤŠ‹•”‡’”‡•‡–•ƒŒ‘” „‹ƒ•Ǥ 4) Non-consecutive patient enrollment in the AP group: •†‹• —••‡†ˆ‘”’ƒ’‡” Ǥ 5) Only secondary, unilateral DIEAP flap breast reconstructions: •†‹• —••‡†ˆ‘” ’ƒ’‡” Ǣ’”‹ƒ”›„”‡ƒ•–”‡ ‘•–”— –‹‘•ǡ„‹Žƒ–‡”ƒŽ ˆŽƒ’•ǡƒ†Ȁ‘”„‹’‡†‹ Ž‡†  ˆŽƒ’• ‘—Ž††‹ˆˆ‡”ˆ”‘–Š‡‘„•‡”˜ƒ–‹‘••‡‡‹’ƒ’‡” Ǥ‘”‡‘˜‡”ǡ‹–‡”• ‘ˆ„”‡ƒ•–”‡ ‘•–”— –‹‘–‹‹‰ǡŠ‘‰‡–ƒŽǤŠƒ˜‡•’‡ ‹ˆ‹ ƒŽŽ›”‡’‘”–‡†–Šƒ–’ƒ–‹‡–• ƒ™ƒ‹–‹‰•‡ ‘†ƒ”›„”‡ƒ•–”‡ ‘•–”— –‹‘Šƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž›™‘”•‡„‘†›‹ƒ‰‡ǡ •‡š—ƒŽ‹–›ǡƒ†“—ƒŽ‹–›Ǧ‘ˆǦŽ‹ˆ‡†‘ƒ‹•ȋ’•› Š‘•‘ ‹ƒŽƒ†•‡š—ƒŽ™‡ŽŽǦ„‡‹‰Ȍ ‘’ƒ”‡† ™‹–Š’”‹ƒ”›„”‡ƒ•–”‡ ‘•–”— –‹‘’ƒ–‹‡–•ǤȋͳͺͲȌŠ‹•‹•‘‡ǡ‘—–‘ˆƒ›‡šƒ’Ž‡•ǡ –Šƒ–‡š‡’Ž‹ˆ›–Š‡’•› Š‘•‘ ‹ƒŽ†‹•–”‡•••‡‡ƒ‘‰’ƒ–‹‡–•™ƒ‹–‹‰ˆ‘”„”‡ƒ•– ”‡ ‘•–”— –‹‘ǤŠ‡ ‘–‡š–‘ˆ•‡ ‘†ƒ”›„”‡ƒ•–”‡ ‘•–”— –‹‘‹•‹’‘”–ƒ––‘‡‡’ ‹‹†ȋƒ†‹†‡ƒŽŽ›ƒ†Œ—•–ˆ‘”Ȍƒ•–Š‡”‡ƒ”‡”‡ƒ•‘•–‘„‡Ž‹‡˜‡–Šƒ–„‘–Š„ƒ•‡Ž‹‡• • ‘”‡•ƒ†”‡ ‘•–”— –‹‘‡ˆˆ‡ –•ƒ”‡†‡’‡†‡–‘„”‡ƒ•–”‡ ‘•–”— –‹‘ –‹‹‰ǤȋͳͺͲǡʹ͵ʹȌ 6) Demographic and clinical characteristics of respondents and non-respondents were not compared: ’ƒ’‡” ǡ†‡‘‰”ƒ’Š‹ ƒ† Ž‹‹ ƒŽ Šƒ”ƒ –‡”‹•–‹ •‘ˆ ”‡•’‘†‡–•ƒ†‘Ǧ”‡•’‘†‡–•™‡”‡‘– ‘’ƒ”‡†Ǥ –Š‡ ’—„Ž‹ ƒ–‹‘ Dz—ƒŽ‹–›‘ˆŽ‹ˆ‡ǡ’ƒ–‹‡–•ƒ–‹•ˆƒ –‹‘ƒ† ‘•‡–‹ ‘—– ‘‡ƒˆ–‡”„”‡ƒ•–”‡ ‘•–”— –‹‰ —•‹‰ ˆŽƒ’‘”‡š’ƒ†ƒ„Ž‡„”‡ƒ•–‹’Žƒ–dz™”‹––‡„›•—’‡”˜‹•‘”•ƒ† ‘Ǧ ƒ—–Š‘”•ǡŠ‘™‡˜‡”ǡ–Š‡•ƒ‡ ‰”‘—’™ƒ••–—†‹‡†ǤȋͳͻȌ ‡”‡ǡ–Š‡›†‹†‘–ˆ‹† ƒ›•‹‰‹ˆ‹ ƒ–†‹ˆˆ‡”‡ ‡•‹†‡‘‰”ƒ’Š‹ ‘” Ž‹‹ ƒŽ Šƒ”ƒ –‡”‹•–‹ •„‡–™‡‡ ”‡•’‘†‡–•ȋαʹͻȌƒ†‘Ǧ”‡•’‘†‡–•ȋαͷȌǤŽ‡ƒ•‡•‡‡ƒ„Ž‡ʹ„‡Ž‘™Ǥ  •‹‹Žƒ” ‘’ƒ”‹•‘‘ˆ–Š‡”‡•’‘†‡–•ȋαʹͲȌƒ†‘Ǧ”‡•’‘†‡–•ȋαͳͲȌ‹ –Š‡‰”‘—’™ƒ•‘–”‡’‘”–‡†‹’ƒ’‡” Ǥ”‰‘ǡ’ƒ”–‹ ‹’ƒ–‹‘„‹ƒ•ƒ†‘Ǧ ”‡•’‘•‡„‹ƒ•ȋ‘Ǧ”‡•’‘†‡–•†‹ˆˆ‡”‹‰ˆ”‘–Š‡”‡•’‘†‡–•Ȍ—•–„‡‡š–‡•‹˜‡Ž› ‘•‹†‡”‡†Ǥ‡Šƒ˜‡ǡŠ‘™‡˜‡”ǡ ‘’ƒ”‡†–Š‡”‡‰‹•–‡”‡††‡‘‰”ƒ’Š‹ ƒ† Ž‹‹ ƒŽ Šƒ”ƒ –‡”‹•–‹ •‘ˆ”‡•’‘†‡–•ƒ†‘Ǧ”‡•’‘†‡–•’‘•–ǦŠ‘ Ǥ‘•‹‰‹ˆ‹ ƒ– †‹ˆˆ‡”‡ ‡•™‡”‡ˆ‘—†ǤŽ‡ƒ•‡•‡‡Dz‘•–ǦŠ‘  ‘’ƒ”‹•‘‘ˆ”‡•’‘†‡–•ƒ†‘Ǧ ”‡•’‘†‡–•dzǤ

64 64

Table 2 Comparisons of clinical and demographic characteristics within the DIEAP group. Used with kind permission from Prof. Tønseth and Dr. Tindholdt (Department of Plastic and Reconstructive Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway).

7) Did not screen for psychiatric comorbidities: –‡”•‘ˆ’ƒ–‹‡– ‘‘”„‹†‹–‹‡•ǡ ™‡• ”‡‡‡†ˆ‘”Dz‹ƒ„‡–‡•‡ŽŽ‹–—•dzǡDz ‡ƒ”–‘”˜ƒ• —Žƒ”†‹•‡ƒ•‡dzǡDz ›’‡”–‡•‹‘dzǡƒ† Dz–Š‡”dzǤŠ‡Žƒ––‡”™ƒ•‘–•’‡ ‹ˆ‹‡†Ǥ  •’•› Š‹ƒ–”‹  ‘‘”„‹†‹–‹‡•ƒ”‡‘”‡ˆ”‡“—‡–ƒ‘‰ ˆŽƒ’ƒ† ’ƒ–‹‡–•ǡƒ† ‘—Ž†’‘–‡–‹ƒŽŽ›‹ˆŽ—‡ ‡–Š‡•ǡ™‡•Š‘—Ž†Šƒ˜‡• ”‡‡‡†ˆ‘” •— Š†‹•‘”†‡”•Ȃ‡‹–Š‡”‰‡‡”ƒŽŽ›ƒ•Dz•› Š‹ƒ–”‹ †‹•‘”†‡”dz‘”‘”‡•’‡ ‹ˆ‹ ƒŽŽ›ƒ• Dz‡’”‡••‹‘dzǡDzš‹‡–›dzǡDzƒ–‹‰†‹•‘”†‡”dzǡDz‘†›†›•‘”’Š‹ †‹•‘”†‡”dzǡ‡– Ǥȋʹʹͻǡ ʹ͵Ͳǡʹ͵͵Ǧʹ͵ͺȌ 8) Personality traits not recorded: —ŠŽ‡–ƒŽǤ†‡‘•–”ƒ–‡†–Šƒ– ‡”–ƒ‹’‡”•‘ƒŽ‹–› –”ƒ‹–•ǡ•— Šƒ•‡—”‘–‹ ‹•ǡƒ”‡•‹‰‹ˆ‹ ƒ–‹†‡’‡†‡–’”‡†‹ –‘”•™Š‡ ‘’ƒ”‹‰ ’”‡Ǧƒ†’‘•–‘’‡”ƒ–‹˜‡•Ǥȋ͵ͶȌŠ‡•–—†›•Š‘™‡†ǡˆ‘”‹•–ƒ ‡ǡ–Šƒ–’ƒ–‹‡–• • ‘”‹‰Š‹‰Š‘–Š‡‡—”‘–‹ ‹•–”ƒ‹–ƒ›„‡’”‡†‹•’‘•‡†–‘‡š’‡”‹‡ ‡Ž‡••„‡‡ˆ‹– ƒˆ–‡”„”‡ƒ•–”‡ ‘•–”— –‹‘‹–‡”•‘ˆ„‘†›‹ƒ‰‡ƒ†“—ƒŽ‹–›‘ˆŽ‹ˆ‡Ǥ‹‹Žƒ”—•‡‘ˆ

65 65 Ǧ ȋ‡—”‘–‹ ‹•Ǧš–”ƒ˜‡”•‹‘Ǧ’‡‡•• ‹˜‡ ƒ –‘” ˜‡–‘”›Ȍǡƒ͸ͲǦ‹–‡ “—‡•–‹‘ƒ‹”‡ǡ ‘—Ž†Šƒ˜‡’”‘˜‹†‡†˜ƒŽ—ƒ„Ž‡†ƒ–ƒˆ”‘‘—”–™‘ ‘Š‘”–•ƒ†’‘••‹„Ž› Šƒ˜‡Ž‹‹–‡†’‡”•‘ƒŽ‹–›Ǧƒ••‘ ‹ƒ–‡†„‹ƒ•Ǥ 9) Ethnicity was not recorded: ‡•’‹–‡ˆ‹†‹‰ ‘’ƒ”ƒ„Ž‡”ƒ–‡•‘ˆ†‘‘”Ǧ•‹–‡ ‘’Ž‹ ƒ–‹‘•„‡–™‡‡•‹ƒƒ†‡•–‡”’ƒ–‹‡–•ǡƒ‹‡–ƒŽǤ•’‡ —Žƒ–‡†™Š‡–Š‡” †‘‘”Ǧ•‹–‡‘”„‹†‹–› ƒ„‡†‹ˆˆ‡”‡–„‡–™‡‡‡–Š‹ ‹–‹‡•‹–Š‡‹”ʹͲͳͷ’—„Ž‹ ƒ–‹‘ ‹‹ ”‘•—”‰‡”›Ǥȋͳ͸ͶȌ –‡”•‘ˆ•‹ƒ’ƒ–‹‡–•ǡ–Š‡›‡–‹‘‡†Ž‘™‡” ™‹–Š Ž‡••”‡†—†ƒ––‹••—‡ƒ†ƒ–‡†‡ ›ˆ‘”’‘‘”• ƒ””‹‰Ǥ  ƒ–‡”ǡ‹ʹͲͳͻǡ–‘‡‡–ƒŽǤ ‘’ƒ”‡†–Š‡’Š›•‹ ƒŽ™‡ŽŽǦ„‡‹‰‘ˆ–Š‡ƒ„†‘‡ „‡ˆ‘”‡ƒ†ƒˆ–‡”ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘–‘†‡–‡”‹‡’‘–‡–‹ƒŽ’”‡†‹ –‘”• ˆ‘” Ž‹‹ ƒŽŽ›Ǧ‹’‘”–ƒ–™‘”•‡‹‰‘ˆ–Š‹•‘—– ‘‡Ǥȋʹ͵ͻȌŠ‡†ƒ–ƒ•Š‘™‡†ƒ ƒ••‘ ‹ƒ–‹‘„‡–™‡‡•’‡ ‹ˆ‹ ‡–Š‹ ‹–‹‡•ƒ††‡ ”‡ƒ•‡†’Š›•‹ ƒŽ™‡ŽŽǦ„‡‹‰‘ˆ–Š‡ ƒ„†‘‡’‘•–‘’‡”ƒ–‹˜‡Ž›Ǥ‘™‡” †‡‘•–”ƒ–‡†ƒ–”‡†Ǥ  ƒ•‡†‘–Š‡•‡–™‘’—„Ž‹ ƒ–‹‘•ǡ™‡•Š‘—Ž†Šƒ˜‡”‡ ‘”†‡†‡–Š‹ ‹–›ƒ† ’‡”ˆ‘”‡†ƒ†Œ—•–‡†ƒƒŽ›•‡•Ǥ

Instruments 1) Response bias in questionnaire-based research: Š‡”‡‹•ƒ ‘•‹†‡”ƒ„Ž‡ƒ‘—– ‘ˆ‹Š‡”‡–”‡•’‘•‡„‹ƒ•”‡Žƒ–‡†–‘“—‡•–‹‘ƒ‹”‡Ǧ„ƒ•‡†”‡•‡ƒ” Šǡ•— Šƒ•„‹ƒ• ƒ”‹•‹‰ˆ”‘–Š‡™ƒ›‹†‹˜‹†—ƒŽ“—‡•–‹‘•ƒ”‡†‡•‹‰‡†ǡ–Š‡™ƒ›–Š‡“—‡•–‹‘ƒ‹”‡ƒ• ƒ™Š‘Ž‡‹•†‡•‹‰‡†ǡƒ†Š‘™–Š‡“—‡•–‹‘ƒ‹”‡‹•ƒ†‹‹•–‡”‡†‘” ‘’Ž‡–‡†ǤȋʹͶͲȌ  šƒ’Ž‡•‘ˆ”‡•’‘•‡„‹ƒ•ƒ”‡ǣͳȌDz†ƒ˜‡”•‹‘dzȋƒŽ•‘‘™ƒ• ‡–”ƒŽ –‡†‡ ›Ȍ™Š‹ Š†‡• ”‹„‡•–Š‡’Š‡‘‡‘™Š‡”‡”‡•’‘†‡–•™‹•Š–‘„‡‹–Š‡ ‹††Ž‡ƒ†—•—ƒŽŽ›ƒ˜‘‹†‡†•‘ˆ• ƒŽ‡•‹–Š‡‹”ƒ•™‡”•ǡʹȌDz‘•‹–‹˜‡•ƒ–‹•ˆƒ –‹‘dz ȋƒŽ•‘‘™ƒ•’‘•‹–‹˜‡•‡™Ȍ™Š‹ Š†‡• ”‹„‡•–Š‡–‡†‡ ›‘ˆ”‡•’‘†‡–•‰‹˜‹‰ ’‘•‹–‹˜‡ƒ•™‡”•™Š‡ƒ•™‡”‹‰“—‡•–‹‘•‘•ƒ–‹•ˆƒ –‹‘ǡƒ†͵ȌDzš–”‡‡ ”‡•’‘†‹‰dz†‡• ”‹„‡•–Š‡’Š‡‘‡‘™Š‡”‡•‘‡”‡•’‘†‡–••›•–‡ƒ–‹ ƒŽŽ› ƒ•™‡”Š‹‰Š‘”Ž‘™‘“—‡•–‹‘•ǤȋʹͶͲǡʹͶͳȌ ‡•’‘•‡„‹ƒ• ƒŠƒ˜‡ƒŽƒ”‰‡‹’ƒ –‘–Š‡˜ƒŽ‹†‹–›‘ˆ–Š‡•–—†›ǡƒ†‹–‹• ’‘••‹„Ž‡–Šƒ––Š‡•‹‰‹ˆ‹ ƒ–†ƒ–ƒ”‡’”‡•‡–•›•–‡ƒ–‹ ”‡•’‘•‡„‹ƒ•”ƒ–Š‡”–Šƒ–Š‡ Š›’‘–Š‡•‹œ‡†‡ˆˆ‡ –ǤȋʹͶʹȌ 2) Non-validated, study-specific questionnaires: Š‡–™‘“—‡•–‹‘ƒ‹”‡•—•‡†ǡ‘‡ ™‹–Šƒ„†‘‹ƒŽ•ƒ†‘‡™‹–Š‰‡‡”ƒŽ•ǡƒ”‡•–—†›Ǧ•’‡ ‹ˆ‹ Ǥƒ’‡”  ™ƒ•ǡƒ•’”‡˜‹‘—•Ž›‡–‹‘‡†ǡƒ‡š–‡•‹‘‘ˆƒ’”‡˜‹‘—•Ž›’—„Ž‹•Š‡†™‘” ’‡”ˆ‘”‡†„›•—’‡”˜‹•‘”•ƒ† ‘Ǧƒ—–Š‘”•ǤȋͳͻȌŽŽ†ƒ–ƒ”‡‰ƒ”†‹‰‰‡‡”ƒŽ•‹ –Š‡ ‰”‘—’Šƒ˜‡„‡‡’”‡˜‹‘—•Ž›’—„Ž‹•Š‡†‹–Š‹•ƒ”–‹ Ž‡Ǥ‹“—‡ˆ‘”’ƒ’‡” ǡ Š‘™‡˜‡”ǡ™ƒ•–Š‡ƒ„†‘‹ƒŽ•‡ƒ•—”‡†ǡƒ†–Š‡‹ Ž—•‹‘‘ˆƒ‰”‘—’–Šƒ– ƒ•™‡”‡†„‘–Š“—‡•–‹‘ƒ‹”‡•Ǥ  ”‘ˆǤސ•‡–Šǡ”Ǥ‹†Š‘Ž†–ǡƒ† ‘Ǧƒ—–Š‘”•‹ Ž—†‡†“—‡•–‹‘•ȋ†‹”‡ –Ž›ƒ’’Ž‹‡† ‘”ƒ†ƒ’–‡†Ȍˆ”‘–™‘’”‡˜‹‘—•’—„Ž‹ ƒ–‹‘•ǢͳȌ‘ “—‡–‡–ƒŽǤȋ”‹–‹•Š ‘—”ƒŽ‘ˆ Žƒ•–‹ —”‰‡”›ȌȋʹͶ͵Ȍƒ†ʹȌŽ†‡”ƒ‡–ƒŽǤȋȌȋʹͶͶȌǤŠ‡ˆ‹”•–’—„Ž‹ ƒ–‹‘Šƒ†ƒ •–—†›Ǧ•’‡ ‹ˆ‹ “—‡•–‹‘ƒ‹”‡‹˜‡•–‹‰ƒ–‹‰•Ž‹‡„‘†›‹ƒ‰‡ǡ•‘ ‹ƒŽ ”‡Žƒ–‹‘•Š‹’•ǡ‹–‹ƒ–‡”‡Žƒ–‹‘•Š‹’•ǡƒ†‰‡‡”ƒŽŠ‡ƒŽ–ŠǡŠ‘™‡˜‡”ǡ‘’•› Š‘‡–”‹  ƒ••‡••‡–™ƒ•”‡’‘”–‡†Ǥ••— Šǡ™‡†‘‘–‘™ƒ›–Š‹‰ƒ„‘—–“—‡•–‹‘ƒ‹”‡ǯ• ˜ƒŽ‹†‹–›ȋ–Š‡ƒ„‹Ž‹–›‘ˆƒ‹•–”—‡––‘‡ƒ•—”‡‡šƒ –Ž›™Šƒ–‹–’”‘’‘•‡•Ȍǡ”‡Ž‹ƒ„‹Ž‹–›

66 66 ȋ–Š‡ƒ„‹Ž‹–›‘ˆƒ‹•–”—‡––‘”‡’”‘†— ‡ƒ”‡•—Ž–ȋ„›ƒ‘–Š‡”‘„•‡”˜‡”ȌȌǡƒ† ”‡•’‘•‹˜‡‡••ȋ–Š‡ƒ„‹Ž‹–›–‘†‡–‡ – Ž‹‹ ƒŽ Šƒ‰‡•‹‘—– ‘‡ȌǤȋʹͶͷǡʹͶ͸ȌŠ‡ •‡ ‘†’—„Ž‹ ƒ–‹‘ǡ‘–Š‡‘–Š‡”Šƒ†ǡ™ƒ•„ƒ•‡†‘˜ƒŽ‹†ƒ–‡†‹•–”—‡–•™‹–Š ‰‘‘†’•› Š‘‡–”‹ ’”‘’‡”–‹‡•ȋ„‡‹‰’ƒ”–‘ˆ–Š‡‹ Š‹‰ƒ”‡ƒ•–‡ ‘•–”— –‹‘ —– ‘‡–—†›ȌǤ—‡•–‹‘•‘‰‡‡”ƒŽ•ƒ–‹•ˆƒ –‹‘™‡”‡ƒ†ƒ’–‡†ˆ”‘–Š‹••–—†›Ǥ  ‡Šƒ˜‡ǡ‹‘–Š‡”™‘”†•ǡ ‘•–”— –‡†‡™“—‡•–‹‘ƒ‹”‡‹•–”—‡–•„ƒ•‡†‘ „‘–Š‘Ǧ˜ƒŽ‹†ƒ–‡†ƒ†˜ƒŽ‹†ƒ–‡†‹•–”—‡–•ǤŠ‹•Ž‡ƒ†•–‘–Š‡ˆ‘ŽŽ‘™‹‰“—‡•–‹‘ǣ ”‡–Š‡‹•–”—‡–•—•‡†–‘‡ƒ•—”‡•• ‹‡–‹ˆ‹ ƒŽŽ›•‘—†ǫŽ–Š‘—‰Š Ž†‡”ƒ‡–ƒŽǤ†‡‘•–”ƒ–‡†•ƒ–‹•ˆ›‹‰’•› Š‘‡–”‹ ’”‘’‡”–‹‡•ǡ‹–†‘‡•‘– ‡ ‡••ƒ”‹Ž›‡ƒ–Šƒ–‘—”“—‡•–‹‘ƒ‹”‡•™‡”‡•‹‹Žƒ”Ž›‰‘‘†Ǥ ’ƒ’‡” ǡ ƒ††‹–‹‘ƒŽ“—‡•–‹‘•Šƒ˜‡„‡‡„”‘—‰Š–‹–‘–Š‡‹šǡƒ†–Š‡–‹‡ǡ ‘–‡š–ǡƒ† ’ƒ–‹‡–’‘’—Žƒ–‹‘•ƒ”‡†‹ˆˆ‡”‡–ǤŠ‡‡ƒ•—”‡††‘ƒ‹•‹‰Š–‘–‡˜‡„‡”‡Ž‡˜ƒ– –‘–Š‡”‡•‡ƒ” Š“—‡•–‹‘•ƒ‹‰–Š‡”‡•—Ž–•Ž‡••‡ƒ‹‰ˆ—ŽǤȋʹͶ͸Ȍ  †‡ƒŽŽ›ǡ™‡•Š‘—Ž†Šƒ˜‡ƒ••‡••‡†–Š‡’•› Š‘‡–”‹ ’”‘’‡”–‹‡•‘ˆ–Š‡–™‘ “—‡•–‹‘ƒ‹”‡•—•‡†‘‘—”‘™’‘’—Žƒ–‹‘•ȋDzˆ‹‡Ž†–‡•–‹‰dzȌǤŽ›–Š‡ ‘—Ž†™‡ Šƒ˜‡•ƒ‹†•‘‡–Š‹‰˜ƒŽ—ƒ„Ž‡‹–‡”•‘ˆ‘—”“—‡•–‹‘ƒ‹”‡•ǯ˜ƒŽ‹†‹–›ƒ†”‡Ž‹ƒ„‹Ž‹–›Ǥ Š‡“—‡•–‹‘ƒ‹”‡• ‘—Ž†Šƒ˜‡„‡‡‹’”‘˜‡†„›“—‡•–‹‘”‡’Š”ƒ•‹‰ǡ ‹ ”‡ƒ•‹‰Ȁ”‡†— ‹‰–Š‡—„‡”‘ˆ“—‡•–‹‘•ǡƒ†Œ—•–‹‰• ƒŽ‡•ǡ‡– ǤȋʹͶͷȌ‡–ƒ‹Ž• ‘ ‡”‹‰•— Š‹•–”—‡–†‡˜‡Ž‘’‡–•Š‘—Ž†Šƒ˜‡„‡‡‡Ž— ‹†ƒ–‡†‹–Š‡ƒ”–‹ Ž‡Ǥ ‹–Š–Šƒ–„‡‹‰•ƒ‹†ǡŠ‘™‡˜‡”ǡˆ‘”ƒŽ†‡˜‡Ž‘’‡–‘ˆ‹•–”—‡–•‹•‘––Šƒ– ‡•–ƒ„Ž‹•Š‡†‹’Žƒ•–‹ •—”‰‡”›”‡•‡ƒ” Šǣ ƒ•›•–‡ƒ–‹ ”‡˜‹‡™‘ˆ’ƒ–‹‡–•ƒ–‹•ˆƒ –‹‘ •–—†‹‡•‹’Žƒ•–‹ •—”‰‡”›ǡŽƒ’Šƒǡ—•Šƒǡƒ†Š—‰”‡’‘”–‡†–Šƒ–͸ͺΨ‘ˆ–Š‡ ƒ”–‹ Ž‡•†‹†‘–—†‡”‰‘–Š‡ƒˆ‘”‡‡–‹‘‡†•–‡’•‘ˆ‹•–”—‡–†‡˜‡Ž‘’‡–ǤȋʹͶ͹Ȍ 3) No outcomes concerning dog-ears: Dz ˆŽƒ’ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘ǣ ‡–”‘•’‡ –‹˜‡‡˜ƒŽ—ƒ–‹‘‘ˆ’ƒ–‹‡–•ƒ–‹•ˆƒ –‹‘‘ƒ„†‘‹ƒŽ”‡•—Ž–•dz‹††ƒ‡–ƒŽǤ ”‡’‘”–‡†–Šƒ–†‘‰Ǧ‡ƒ”•™‡”‡–Š‡‘•–ˆ”‡“—‡–Ž› ‹–‡†ƒ”‡ƒ‘ˆ†‹••ƒ–‹•ˆƒ –‹‘ȋͷͲ ΨȌǤȋͷʹȌ‡„‡Ž‹‡˜‡–Šƒ––Š‹•‹•ƒ ‘‘•‘—” ‡‘ˆ†‹••ƒ–‹•ˆƒ –‹‘ƒ‘‰‘—”  ˆŽƒ’’ƒ–‹‡–•ƒ•™‡ŽŽǡƒ†’”‘„ƒ„Ž›’ƒ”–‘ˆ–Š‡‡š’Žƒƒ–‹‘ˆ‘”–Š‡Š‹‰Š”ƒ–‡•‘ˆ „—Ž‰‹‰†‹• —••‡†ƒ„‘˜‡ȋ’Ž‡ƒ•‡•‡‡Dz‘’Š›•‹ ƒŽ‡šƒ‹ƒ–‹‘’‡”ˆ‘”‡†dzȌǤ —‡•–‹‘• ‘ ‡”‹‰†‘‰Ǧ‡ƒ”•ȋ’”‡ˆ‡”ƒ„Ž›™‹–Šƒ‹ŽŽ—•–”ƒ–‹˜‡’‹ –—”‡Ȍ•Š‘—Ž†Šƒ˜‡ „‡‡‹ Ž—†‡†‹–Š‡“—‡•–‹‘ƒ‹”‡Ǥ 4) Use of medical terms (hernia and bulging): Š‡‡†‹ ƒŽ–‡”•DzŠ‡”‹ƒdzƒ† Dz„—Ž‰‹‰dz™‡”‡—•‡†‹–Š‡“—‡•–‹‘ƒ‹”‡Ǥ‡„‡Ž‹‡˜‡–Šƒ––Š‹• ‘—Ž†Šƒ˜‡ ƒ—•‡† •‘‡ ‘ˆ—•‹‘ǡ™Š‡”‡’ƒ–‹‡–••‡Ž‡ –‡†–Š‡™”‘‰ƒ•™‡”ƒŽ–‡”ƒ–‹˜‡•ȋ‘”‹š‡†—’ ™‹–Š†‘‰Ǧ‡ƒ”•ȌǤ  ›‹ Ž—†‹‰†‡• ”‹’–‹‘•ƒ†Ȁ‘”‹ŽŽ—•–”ƒ–‹˜‡’‹ –—”‡•ǡ™‡ ‘—Ž†Šƒ˜‡‰—‹†‡†–Š‡ ’ƒ–‹‡–•‹ƒ•™‡”‹‰ ‘””‡ –Ž›Ǥ’Š›•‹ ƒŽ‡šƒ‹ƒ–‹‘’‡”ˆ‘”‡†„›ƒ’Žƒ•–‹  •—”‰‡‘™‘—Ž†Šƒ˜‡„‡‡‡˜‡„‡––‡”Ǥ 5) Difference between self-image and body image: Š‡†‹ˆˆ‡”‡ ‡„‡–™‡‡•‡ŽˆǦ ‹ƒ‰‡ƒ†„‘†›‹ƒ‰‡‹‰Š–‘–„‡ Ž‡ƒ”–‘ƒŽŽȂ”‡†— ‹‰–Š‡˜ƒŽ‹†‹–›‘ˆ–Š‡ “—‡•–‹‘ƒ‹”‡ǤŽ‡˜‡Žƒ†Ž‹‹ Šƒ˜‡•Šƒ”‡†–Š‡ˆ‘ŽŽ‘™‹‰†‡ˆ‹‹–‹‘•ǣDz‡ŽˆǦ‹ƒ‰‡‹• –Š‡’‡”•‘ƒŽ˜‹‡™ǡ‘”‡–ƒŽ’‹ –—”‡ǡ–Šƒ–™‡Šƒ˜‡‘ˆ‘—”•‡Ž˜‡•Ǥ‡ŽˆǦ‹ƒ‰‡‹ƒ Dz‹–‡”ƒŽ†‹ –‹‘ƒ”›dz–Šƒ–†‡• ”‹„‡•–Š‡ Šƒ”ƒ –‡”‹•–‹ •‘ˆ–Š‡•‡Žˆǡ‹ Ž—†‹‰•— Š –Š‹‰•ƒ•‹–‡ŽŽ‹‰‡–ǡ„‡ƒ—–‹ˆ—Žǡ—‰Ž›ǡ–ƒŽ‡–‡†ǡ•‡Žˆ‹•Šǡƒ†‹†ǤŠ‡•‡ Šƒ”ƒ –‡”‹•–‹ • ˆ‘”ƒ ‘ŽŽ‡ –‹˜‡”‡’”‡•‡–ƒ–‹‘‘ˆ‘—”ƒ••‡–•ȋ•–”‡‰–Š•Ȍƒ†Ž‹ƒ„‹Ž‹–‹‡• ȋ™‡ƒ‡••‡•Ȍƒ•™‡•‡‡–Š‡dzƒ†Dz‘†›‹ƒ‰‡‹•’ƒ”–‘ˆ•‡ŽˆǦ‹ƒ‰‡Ǥ—”„‘†›‹ƒ‰‡

67 67 ‹ Ž—†‡•‘”‡–Šƒ™Šƒ–™‡Ž‘‘Ž‹‡‘”Š‘™‘–Š‡”••‡‡—•Ǥ –ƒŽ•‘”‡ˆ‡”•–‘Š‘™™‡ –Š‹ǡˆ‡‡Žǡƒ†”‡ƒ ––‘‘—”‘™’‡” ‡’–‹‘‘ˆ‘—”’Š›•‹ ƒŽƒ––”‹„—–‡•dzǤȋʹͶͺȌ ‘–Š‡” ™‘”†•ǡ„‘†›‹ƒ‰‡”‡ˆ‡”•–‘ƒ’‡”•‘ǯ•’‡” ‡’–‹‘‘ˆŠ‹•‘”Š‡”‘—–™ƒ”†ƒ’’‡ƒ”ƒ ‡ǡ ™Š‹Ž‡•‡ŽˆǦ‹ƒ‰‡‹•ƒ™‹†‡”–‡”–Šƒ–”‡ˆ‡”•–‘ƒ’‡”•‘ǯ•’‡” ‡’–‹‘‘ˆ•‡˜‡”ƒŽ ƒ•’‡ –•‘ˆ–Š‡‹”„‡‹‰‹ƒ††‹–‹‘–‘„‘†›Ǧ‹ƒ‰‡Ǥ  ›ƒ††‹‰ƒ‡š’Žƒƒ–‹‘‘ˆ‡ƒ Š–‡”ƒ†–Š‡‹”†‹ˆˆ‡”‡ ‡•ǡ‘”„›‘Ž›‹ Ž—†‹‰ „‘†›‹ƒ‰‡‡ƒ•—”‡•ǡ™‡ ‘—Ž†Šƒ˜‡Ž‹‹–‡†”‡•’‘•‡„‹ƒ• ƒ—•‡†„› ‘ˆ—•‹‘ƒ† ‹ ”‡ƒ•‡†–Š‡’•› Š‘‡–”‹ ’”‘’‡”–‹‡•Ǥ 6) Did not specifically investigate the main reason of dissatisfaction: Š‡”‡™ƒ• •‘‡’‘•–‘’‡”ƒ–‹˜‡†‹••ƒ–‹•ˆƒ –‹‘”‡ ‘”†‡†‹‘—”•–—†›ǣ͵ͷΨȋ͹ȀʹͲȌ‘ˆ–Š‡ ’ƒ–‹‡–•™‡”‡†‹••ƒ–‹•ˆ‹‡†™‹–Š–Š‡‹”„‘†›™Š‡†”‡••‡†ǤͳͲΨ‘ˆ„‘–Š–Š‡  ‰”‘—’ȋ͵ȀʹͻȌƒ†–Š‡‰”‘—’ȋʹȀʹͲȌˆ‡Ž–‹–™ƒ•‘”‡†‹ˆˆ‹ —Ž––‘„‡ƒ‡†™‹–Š ’ƒ”–‡”Ǥͳ͹ΨȋͷȀʹͻȌ‘ˆ–Š‡ ‰”‘—’Šƒ†ƒ†‡ ”‡ƒ•‡‘ˆ•‡š—ƒŽ†‡•‹”‡Ǥͳ͹Ψ ȋͷȀʹͻȌ‘ˆ–Š‡ ‰”‘—’ƒ†ͷΨȋͳȀʹͲȌ‘ˆ–Š‡‰”‘—’™‡”‡‘”‡™‘””‹‡†ƒ„‘—– –Š‡‹”Š‡ƒŽ–ŠǤͳͷΨȋ͵ȀʹͲȌ‘ˆ–Š‡‰”‘—’™‡”‡‘–‘˜‡”ƒŽŽ•ƒ–‹•ˆ‹‡†™‹–Š–Š‡ ‘’‡”ƒ–‹‘ǤͳͲΨȋ͵ȀʹͻȌ‘ˆ–Š‡ ‰”‘—’ƒ†ʹͳΨȋͷȀʹͲȌ‘ˆ‰”‘—’™‡”‡‘– •ƒ–‹•ˆ‹‡†™‹–Š–Š‡’”‡‘’‡”ƒ–‹˜‡ ‘—•‡Ž‹‰Ǥ  Ž–Š‘—‰Š•— Š†‹••ƒ–‹•ˆƒ –‹‘™ƒ•‘–‡†ǡ™‡™‡”‡‘–ƒ„Ž‡–‘ˆ‘ŽŽ‘™—’ƒ† Žƒ”‹ˆ›–Š‡ ƒ—•‡•‘ˆ†‹••ƒ–‹•ˆƒ –‹‘†—‡–‘–Š‡‡–Š‘†‘Ž‘‰›—•‡†Ǥ›‹ Ž—†‹‰ “—ƒŽ‹–ƒ–‹˜‡”‡•‡ƒ” Š‡–Š‘†•ǡ•— Šƒ••‡‹Ǧ•–”— –—”‡†‹–‡”˜‹‡™•ǡ™‡ ‘—Ž†Šƒ˜‡ –Š”‘™Ž‹‰Š–‘†‹••ƒ–‹•ˆƒ –‹‘ ƒ—•‡•–Š”‘—‰Šƒ†‹• —••‹‘Ǥ ‘”‡šƒ’Ž‡ǡ™Š›™‡”‡ ͳͲΨ‘ˆ–Š‡ ‰”‘—’ƒ†ʹͳΨ‘ˆ–Š‡‰”‘—’†‹••ƒ–‹•ˆ‹‡†™‹–Š–Š‡’”‡‘’‡”ƒ–‹˜‡ ‘—•‡Ž‹‰ǫ–Š‡”’‘••‹„‹Ž‹–‹‡•™‘—Ž†Šƒ˜‡„‡‡–‘‹ Ž—†‡‘”‡“—‡•–‹‘•‘‡ƒ Š ƒ•’‡ –ǡ‘”ƒŽŽ‘™’ƒ–‹‡–•–‘™”‹–‡ˆ”‡‡–‡š–Ǥ 7) Insensitive measures: – ‘—Ž†„‡–Šƒ––Š‡“—‡•–‹‘•™‹–Š‘”†‹ƒŽƒ•™‡” ƒŽ–‡”ƒ–‹˜‡•ȋ‡Ǥ‰ǤDzŽ‡••dzǡDz— Šƒ‰‡†dzǡDz‘”‡dzȌ†‹†‘–Šƒ˜‡•—ˆˆ‹ ‹‡–†‹• ”‹‹ƒ–‹‰ ’‘™‡”–‘†‹ˆˆ‡”‡–‹ƒ–‡–Š‡”‡•’‘†‡–•„‡ ƒ—•‡‘ˆ–Š‡Ž‹‹–‡† ƒ–‡‰‘”‹‡•ǤȋʹͶͲȌ ‘”‡‘˜‡”ǡŠƒ˜‹‰ˆ‡™ƒ•™‡”ƒŽ–‡”ƒ–‹˜‡•‹‰Š–ˆ‘” ‡”‡•’‘†‡–•–‘ Š‘‘•‡ ‹’”‡ ‹•‡Ž›ǤȋʹͶͲȌŠ‡“—‡•–‹‘•™‹–Š—‡”‹ ƒŽƒ•™‡”ƒŽ–‡”ƒ–‹˜‡•ȋ‡Ǥ‰ǤͳǦͳͲȌ™‡”‡ ’”‘„ƒ„Ž›‘”‡ƒ†‡“—ƒ–‡”‡‰ƒ”†‹‰–Š‡•‡ƒ––‡”•Ǥ

Statistical analysis 1) Multiple comparisons: •†‹• —••‡†ˆ‘”’ƒ’‡” Ǥ‘ˆ‡””‘‹ ‘””‡ –‹‘™ƒ•‘–—•‡† ‹’ƒ’‡” Ǥ 2) Ordinal test (Gamma): ”†‹ƒŽ–‡•–ȋ ƒƒȌ”‡ˆ‡”•–‘–Š‡ ‘‘†ƒƒ†”—•ƒŽǯ• ‰ƒƒǤȋʹͶͻȌ –‹•ƒ‘Ǧ’ƒ”ƒ‡–”‹ –‡•––Šƒ–‡ƒ•—”‡•–Š‡ƒ••‘ ‹ƒ–‹‘ȋ†‹”‡ –‹‘ƒ† •–”‡‰–ŠȌ„‡–™‡‡˜ƒ”‹ƒ„Ž‡•‡ƒ•—”‡†‘ƒ‘”†‹ƒŽ• ƒŽ‡Ǥ ’ƒ’‡” ǡˆ‘”‹•–ƒ ‡ǡ •— Š˜ƒ”‹ƒ„Ž‡•ƒ”‡DzŽ‡••–Šƒ‡š’‡ –‡†dzȀdzƒ•‡š’‡ –‡†dzȀdz‘”‡–Šƒ‡š’‡ –‡†dzƒ† DzŽ‡••dzȀdz— Šƒ‰‡†dzȀdz‘”‡dzǤŠ‡‰ƒƒ ‘‡ˆˆ‹ ‹‡–•Šƒ˜‡‘–„‡‡Ž‹•–‡†ǡŠ‘™‡˜‡”ǡ –Š‡•–ƒ–‹•–‹ ƒŽ•‹‰‹ˆ‹ ƒ ‡‘ˆ–Š‡–‡•–•ȋP-˜ƒŽ—‡ȌŠƒ˜‡„‡‡’”‘˜‹†‡†Ǥ‡™‘—Ž†Šƒ˜‡ ‹’”‘˜‡†–Š‡”‡’‘”–‹‰‘ˆ–Š‡•–ƒ–‹•–‹ ƒŽƒƒŽ›•‡•„›’”‡•‡–‹‰„‘–Š–Š‡‰ƒƒ ‘‡ˆˆ‹ ‹‡–ƒ†–Š‡P-˜ƒŽ—‡. Š‡Ž‹‹–ƒ–‹‘•‘ˆ‘Ǧ’ƒ”ƒ‡–”‹ –‡•–•Šƒ˜‡„‡‡ †‹• —••‡†ˆ‘”’ƒ’‡” Ǥ 3) Fisher’s exact test (with Freeman-Halton extension): ”‘••Ǧ–ƒ„—Žƒ–‹‘ȋʹšʹȌƒ† ‹• Š‡”ǯ•‡šƒ ––‡•– ƒ„‡ ƒ””‹‡†‘—––‘†‡–‡”‹‡‹ˆ–Š‡”‡‹•ƒ•‹‰‹ˆ‹ ƒ–

68 68 ƒ••‘ ‹ƒ–‹‘„‡–™‡‡ ƒ–‡‰‘”‹ ƒŽ†ƒ–ƒ‹–™‘‹†‡’‡†‡–‰”‘—’•ǤȋʹͷͲȌŠ‡—ŽŽ Š›’‘–Š‡•‹••–ƒ–‡•–Š‡”‡‹•‘ƒ••‘ ‹ƒ–‹‘Ǥ –‹• ‘‘Ž›—•‡†‹•ƒŽŽ•ƒ’Ž‡•‹œ‡ •–—†‹‡•Ȃ”‡’Žƒ ‹‰–Š‡ Š‹•“—ƒ”‡–‡•–ǤȋʹͷͳǡʹͷʹȌŠ‡Šƒ˜‹‰–Š”‡‡ ƒ–‡‰‘”‹‡• ȋʹš͵Ȍǡ•— Šƒ•Dz‘‡dzǡDzŠ‡”‹ƒdzǡƒ†Dz„—Ž‰‹‰dz‹’ƒ’‡” ǡƒ‡š–‡•‹‘ȋ ”‡‡ƒǦ ƒŽ–‘‘” ‹•Š‡”Ǧ ”‡‡ƒǦ ƒŽ–‘ȌŠƒ•–‘„‡ƒ’’Ž‹‡†Ǥȋʹͷ͵Ȍ  Š‡”‡ƒ”‡•‘‡ ‘•‹†‡”ƒ–‹‘•™‹–Š–Š‡ ‹•Š‡”ǯ•‡šƒ ––‡•–ȋʹͷͲȌǣͳȌŠ‡–‡•–‹• ‘–†‡•‹‰‡†ˆ‘”‘”†‹ƒŽ†ƒ–ƒȋƒ† ‘—Ž†‘–„‡—•‡†ˆ‘”‡Ǥ‰ǤDzŽ‡••dzǡDz— Šƒ‰‡†dzǡƒ† Dz‘”‡dzȌǡʹȌŠ‡–‡•–’”‘˜‹†‡•ƒƒ’’”‘š‹ƒ–‡ǡ—’’‡”ǦŽ‹‹–PǦ˜ƒŽ—‡ƒ†‹•„›–Šƒ– ”ƒ–Š‡” ‘•‡”˜ƒ–‹˜‡ȋ”‹•‘ˆˆƒŽ•‡‡‰ƒ–‹˜‡ƒ••‘ ‹ƒ–‹‘•Ǣ–›’‡ ‡””‘”Ȍǡƒ†͵ȌŠ‡–‡•– ‹••‘Ž‡Ž›ƒ•‹‰‹ˆ‹ ƒ ‡–‡•–ƒ†’”‘˜‹†‡•‘“—ƒ–‹ˆ‹ ƒ–‹‘‘ˆ–Š‡‡ˆˆ‡ –•‹œ‡ȂƒP- ˜ƒŽ—‡‘ˆͲǤͲͲͳ†‘‡•‘–‹†‹ ƒ–‡ƒ•–”‘‰‡”ƒ••‘ ‹ƒ–‹‘–ŠƒƒPǦ˜ƒŽ—‡‘ˆͲǤͲͷǤȋʹͷͳȌ 4) Non-parametric tests: ƒǦŠ‹–‡›UǦ–‡•–™ƒ•—•‡†ˆ‘”„‘–Š†‹ Š‘–‘‘—•ƒ† —‡”‹ ƒŽ†ƒ–ƒ–Šƒ–†‹†‘–‡‡––Š‡‘”ƒŽ‹–›ƒ••—’–‹‘ǤŠ‡Ž‹‹–ƒ–‹‘•‘ˆ‘Ǧ ’ƒ”ƒ‡–”‹ –‡•–•Šƒ˜‡„‡‡†‹• —••‡†ˆ‘”’ƒ’‡” Ǥ

Miscellaneous 1) Response rate: ͺͷΨȋʹͻȀ͵ͶȌ‘ˆ–Š‡ ‰”‘—’ƒ†͸͸ΨȋʹͲȀ͵ͲȌ‘ˆ–Š‡‰”‘—’ ƒ•™‡”‡†–Š‡“—‡•–‹‘ƒ‹”‡•Ǥ‘Ǧ”‡•’‘†‡–•™‡”‡•‡–‘‡”‡‹†‡”Ǥ  ‘‹ ”‡ƒ•‡–Š‡”‡•’‘•‡”ƒ–‡ǡ™‡ ‘—Ž†Šƒ˜‡‹’Ž‡‡–‡†•—”˜‡›‡–Š‘†•ƒ• ’”‘’‘•‡†„›‹ŽŽƒǤȋʹͷͶȌŠ‡‹ŽŽƒ‘–ƒŽ‡•‹‰—”˜‡›‡–Š‘† ‘•‹•–•‘ˆƒ •‡”‹‡•‘ˆ’”‡ ‹•‡Ž›Žƒ‹†Ǧ‘—–•–‡’•ȋ“—‡•–‹‘ƒ‹”‡Ž‡‰–Šǡˆ‘”ƒ––‡† ‘˜‡”ƒ†ˆ‘ŽŽ‘™Ǧ —’Ž‡––‡”•ǡ—„‡”‘ˆ”‡‹†‡”•ǡ‡– ǤȌ–Šƒ–Dz‰—ƒ”ƒ–‡‡•dz͹ͷǦͺͲΨ”‡•’‘•‡”ƒ–‡•Ǥ – ‘ˆ‹”•–Šƒ–Š‹‰Š”‡•’‘•‡”ƒ–‡•ƒ”‡ƒ Š‹‡˜‡†™Š‡ƒ––‡–‹‘‹•’ƒ‹†–‘ ƒ†‹‹•–”ƒ–‹˜‡†‡–ƒ‹Ž•Ǥ –Š‹•†‡•‹‰ǡ–™‘”‡‹†‡”•ȋ–Š”‡‡ƒ†•‡˜‡™‡‡•Ȍƒ”‡ •‡–Ǥ  ƒ–—”ƒŽŽ›ǡƒŠ‹‰Š‡””‡•’‘•‡”ƒ–‡™‘—Ž†Šƒ˜‡„‡‡ƒ’’”‡ ‹ƒ–‡†ƒ•ƒŽ‘™”‡•’‘•‡ ”ƒ–‡‹ ”‡ƒ•‡•–Š‡Ž‹‡Ž‹Š‘‘†‘ˆ„‹ƒ•ƒ†ƒ‡•–Š‡”‡•—Ž–•Ž‡•• ”‡†‹„Ž‡ǤŠ‡”‡‹•ǡ Š‘™‡˜‡”ǡ‘ƒ‰”‡‡†Ǧ—’‘•–ƒ†ƒ”†ˆ‘”ƒ ‡’–ƒ„Ž‡”‡•’‘•‡”ƒ–‡•ǤͷͲǦ͸ͲΨŠƒ˜‡ „‡‡•—‰‰‡•–‡†ǤȋʹͷͷȌ  Š‡’‘–‡–‹ƒŽ„‹ƒ•‘ˆ”‡•’‘†‡–•‘–”‡’”‡•‡–‹‰–Š‡’ƒ–‹‡–‰”‘—’ƒ†Ȁ‘”–Š‡ ‘Ǧ”‡•’‘†‡–•†‹ˆˆ‡”‹‰ˆ”‘–Š‡”‡•’‘†‡–•Šƒ˜‡„‡‡†‹• —••‡†ƒ„‘˜‡ȋ’Ž‡ƒ•‡ •‡‡Dz‡‘‰”ƒ’Š‹ ƒ† Ž‹‹ ƒŽ Šƒ”ƒ –‡”‹•–‹ •‘ˆ”‡•’‘†‡–•ƒ†‘Ǧ”‡•’‘†‡–• ™‡”‡‘– ‘’ƒ”‡†dzȌǤŠ‡•‡ƒ”‡‹’‘”–ƒ– ‘•‹†‡”ƒ–‹‘•Ǥ 2) Varying volume of liposuctioned fat and flap weight:Š‡”‡™ƒ•ƒ ‘•‹†‡”ƒ„Ž‡ ˜ƒ”‹ƒ–‹‘‹–Š‡ƒ‘—–‘ˆŽ‹’‘•— –‹‘‡†ˆƒ–ƒ†ˆŽƒ’™‡‹‰Š–ǣ‡ƒǡȋ‹ǦƒšȌ Ž‹’‘•— –‹‘‡†ˆƒ–™ƒ•͸Ͳͳ ǡʹͺ͹ ȋͳͲͲǦͳͲͲͲ ȌǤ‡ƒǡȋ‹ǦƒšȌ–‘–ƒŽˆŽƒ’ ™‡‹‰Š–™ƒ•ͳͶͲͲ‰ǡ͹ͷ͸‰ȋ͸͹ͲǦ͵ͷͲͲ‰ȌǤ‡ƒǡȋ‹ǦƒšȌ–‘–ƒŽ ˆŽƒ’™‡‹‰Š– ™ƒ•ͳͲ͵ͺ‰ǡ͵Ͳͺ‰ȋͶͳͲǦͳͷͺͲ‰ȌǤ— Š˜ƒ”‹ƒ–‹‘•ƒ††–‘–Š‡Š‡–‡”‘‰‡‡‹–›™‹–Š‹ƒ† „‡–™‡‡’ƒ–‹‡–‰”‘—’•ƒ†“—‡•–‹‘–Š‡‡–Š‘†‘Ž‘‰›‘ˆ‘—”•–—†›Ǥ 3) Complication and reoperation rates were too small for statistical analysis:  Ž‹‹–‡†—„‡”‘ˆƒ„†‘‹ƒŽ ‘’Ž‹ ƒ–‹‘•ƒ†‘Ž›‘‡”‡‘’‡”ƒ–‹‘ȋ†—‡–‘ ’‘•–‘’‡”ƒ–‹˜‡‹ˆ‡ –‹‘‹’ƒ–‹‡–Ȍ™‡”‡”‡ ‘”†‡†ǤŠ‡•‡†ƒ–ƒ™‡”‡–‘‘•ƒŽŽˆ‘” •–ƒ–‹•–‹ ƒŽƒƒŽ›•‹•ǡƒ†‡š‡’Ž‹ˆ‹‡•–Š‡‡–Š‘†‘Ž‘‰‹ ƒŽˆŽƒ™•‹–”‘†— ‡†„›•ƒŽŽ ‘Š‘”–•Ǥ›”‡ ”—‹–‹‰‘”‡’ƒ–‹‡–•‹‡ƒ Š‰”‘—’ǡ™‡ ‘—Ž†Šƒ˜‡•–ƒ–‹•–‹ ƒŽŽ› ‘’ƒ”‡†–Š‡’ƒ–‹‡–‰”‘—’•ƒ†’‡”ˆ‘”‡†ƒ†Œ—•–‡†ƒƒŽ›•‡•„ƒ•‡†‘

69 69 ‘’Ž‹ ƒ–‹‘–›’‡ƒ†—„‡”‘ˆ”‡‘’‡”ƒ–‹‘•Ǥƒ–—”ƒŽŽ›ǡ–Š‡•–”‡•• ƒ—•‡†„›„‘–Š ‘’Ž‹ ƒ–‹‘•ƒ†Ȁ‘””‡‘’‡”ƒ–‹‘•’Žƒ›ƒ‹’‘”–ƒ–”‘Ž‡‹’‘•–‘’‡”ƒ–‹˜‡ •ƒ–‹•ˆƒ –‹‘Ž‡˜‡Ž•Ǥ – ƒƒŽ•‘ƒˆˆ‡ ––Š‡ƒ‡•–Š‡–‹ ƒ„†‘‹‘’Žƒ•–›‘—– ‘‡• •‹‰‹ˆ‹ ƒ–Ž›Ǥ

Strengths: ͳȌŽŽ’ƒ–‹‡–•‘’‡”ƒ–‡†‹–Š‡•ƒ‡•—”‰‹ ƒŽ†‡’ƒ”–‡–ȋ™‹–Š•–ƒ†ƒ”†‹œ‡† Šƒ”˜‡•–‹‰ƒ† Ž‘•—”‹‰–‡ Š‹“—‡•ǡƒ†’‘•–‘’‡”ƒ–‹˜‡ ƒ”‡ȌǡʹȌ‘•‡ —–‹˜‡ ˆŽƒ’ ’ƒ–‹‡–•ȋ‡Ž‹‹ƒ–‹‰‡”‘ŽŽ‡–„‹ƒ•Ȍǡ͵Ȍ‘‰ˆ‘ŽŽ‘™Ǧ—’–‹‡ȋεʹ›‡ƒ”•Ȍȋ’ƒ–‹‡–•Šƒ˜‡ ”‡–—”‡†–‘Dz‘”ƒŽŽ‹ˆ‡dzǡͶȌƒ”–•‘ˆ–Š‡“—‡•–‹‘ƒ‹”‡•ƒ”‡„ƒ•‡†‘’•› Š‘‡–”‹ ƒŽŽ› ƒ’’”‘˜‡†‹•–”—‡–•ǡͷȌ•‡†‘”ƒ†ƒ’–‡†“—‡•–‹‘•ˆ”‘’”‡˜‹‘—•“—‡•–‹‘ƒ‹”‡•™‡”‡ –”ƒ•Žƒ–‡†ˆ”‘‰Ž‹•Š–‘‘”™‡‰‹ƒȋ„›„‘–Š•—’‡”˜‹•‘”•Ȍǡƒ†–Š‡„ƒ Ǧ–”ƒ•Žƒ–‡†–‘ ‰Ž‹•Š„›ƒ–Š‹”†’Š›•‹ ‹ƒǤŠ‡„ƒ Ǧ–”ƒ•Žƒ–‡†˜‡”•‹‘™ƒ• ‘’ƒ”‡†™‹–Š–Š‡ ‘”‹‰‹ƒŽ˜‡”•‹‘ƒ†ˆ‘—† ‘•‹•–‡–ǡ͸Ȍ—‡•–‹‘ƒ‹”‡•™‡”‡’‹Ž‘–‡†ǡ͹Ȍ•ƒ”‡ Š‹‰ŠŽ›”‡Ž‡˜ƒ–ƒ•–Š‡ƒŒ‘”‹–›‘ˆ’Žƒ•–‹ •—”‰‡”›’”‘ ‡†—”‡•ȋ‡Ǥ‰Ǥƒ„†‘‹‘’Žƒ•–›Ȍƒ‹ ƒ–‹’”‘˜‹‰’Š›•‹ ƒŽƒ’’‡ƒ”ƒ ‡ǡ„‘†›‹ƒ‰‡ǡ•‡ŽˆǦ‹ƒ‰‡ǡ’•› Š‘•‘ ‹ƒŽˆ— –‹‘ǡƒ† “—ƒŽ‹–›‘ˆŽ‹ˆ‡ȋʹͶ͸ȌǡͺȌ ‡‡”ƒŽ‘—– ‘‡•ƒ†•ƒ–‹•ˆƒ –‹‘Ž‡˜‡Ž•ƒ”‡ ‘’ƒ”ƒ„Ž‡™‹–Š •‹‹Žƒ”’—„Ž‹ ƒ–‹‘•ȋͷʹǡ͹͸ǡͳͺʹǡͳͺ͵Ȍǡƒ†ͻȌ–ƒ–‹•–‹ ‹ƒȋ”‹’’ Ȍ™ƒ• ‘•—Ž–‡†Ǥ  Post-hoc power and sample size calculations –Š‡ˆ‘ŽŽ‘™‹‰–‡š–ǡ’‘•–ǦŠ‘ ’‘™‡”ƒ†•ƒ’Ž‡•‹œ‡ ƒŽ —Žƒ–‹‘•ˆ‘”„‘–Š’ƒ’‡” ƒ†  ƒ”‡’”‡•‡–‡†ǤŠ‡›™‡”‡’‡”ˆ‘”‡†–‘ƒ••‡••–Š‡•–ƒ–‹•–‹ ƒŽ•–”‡‰–Š‘ˆ‘—”–™‘ ƒˆ‘”‡‡–‹‘‡†•–—†‹‡•ǡ•‹ ‡’ƒ’‡” ™ƒ•„ƒ•‡†‘•—„‘’–‹ƒŽ‡ˆˆ‡ –•‹œ‡•ƒ†’ƒ’‡”  †‹†‘–Šƒ˜‡ƒ›ƒ’”‹‘”‹ ƒŽ —Žƒ–‹‘•Ǥ  –Š‡•‡’‘•–ǦŠ‘  ƒŽ —Žƒ–‹‘•ǡ–Š‡‘„•‡”˜‡††ƒ–ƒŠƒ˜‡„‡‡—•‡†–‘ ‘’—–‡–Š‡ ‡š’‡ –‡†‡ƒ†‹ˆˆ‡”‡ ‡•ƒ†•ȋ‡Ǥ‰Ǥ„›—•‹‰‡ƒ’”‡‘’‡”ƒ–‹˜‡˜‡”•—•‡ƒ ’‘•–‘’‡”ƒ–‹˜‡ȌǤ  Š‡”‡ƒ”‡Ž‹‹–ƒ–‹‘•ˆ‘”•— Š’‘•–ǦŠ‘  ƒŽ —Žƒ–‹‘•‹–‡”•‘ˆ‹†‹ ƒ–‹‰’‘™‡” –‘†‡–‡ –•‹‰‹ˆ‹ ƒ–†‹ˆˆ‡”‡ ‡•–Šƒ–ƒ”‡ƒŽ”‡ƒ†›‘„•‡”˜‡†Ǥȋʹͷ͸Ȍ  Paper I Power calculation: › ‘’ƒ”‹‰–Š‡‡ƒ†‹ˆˆ‡”‡ ‡•‘ˆ•‹œ‘‡•ͳǦͶ ȋ—†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’ ƒŽ —Žƒ–‡†ƒ•ƒ™Š‘Ž‡Ȍ„‡–™‡‡’”‡Ǧƒ†’‘•–‘’‡”ƒ–‹˜‡ ‡ƒ•—”‡‡–•ǡ™‡ˆ‘—†ƒ‡ƒ’”‡‘’‡”ƒ–‹˜‡‘ˆͶͲǤͷǡƒ‡ƒ’‘•–‘’‡”ƒ–‹˜‡‘ˆ ͸͵Ǥͷǡƒ‡ƒ†‹ˆˆ‡”‡ ‡‘ˆʹ͵ǤͲǡƒ†‡ƒȋ„ƒ•‡†‘–Š‡‡ƒ†‹ˆˆ‡”‡ ‡•Ȍ‘ˆͳ͵ǤͷǤ Š‡•‡‡•–‹ƒ–‡•ǡƒ†ƒ Š‘•‡•‹‰‹ˆ‹ ƒ ‡Ž‡˜‡Ž‘ˆͲǤͲͷǡ‰‹˜‡ƒ‡•–‹ƒ–‡†’‘™‡”ȋ–™‘Ǧ •ƒ’Ž‡’ƒ‹”‡†Ǧ‡ƒ•–‡•–Ȍ‘ˆͻͻΨǤ‡ƒ••—‡–Šƒ––Š‹•‹•”‡’”‡•‡–ƒ–‹˜‡ˆ‘”–Š‡ ”‡ƒ‹‹‰ ‘’ƒ”‹•‘•Ǥ  Sample size calculation: •†‡• ”‹„‡†‡ƒ”Ž‹‡”ǡ–Š‡”‡‹•‘ ‘•‡•—•‹–‡”•‘ˆƒŽ‘™‡” Ž‹‹–‘ˆ•–Šƒ–‹•ƒ••‘ ‹ƒ–‡†™‹–Š‡ ”‘•‹•Ǥ‡Š›’‘–Š‡•‹œ‡–Šƒ–ƒͷͲΨ”‡†— –‹‘‘ˆ „Ž‘‘†’‡”ˆ—•‹‘ȋ•Ȍ‹• Ž‹‹ ƒŽ‡ƒ‹‰ˆ—ŽǤŠ‹•‹• Š‘•‡ƒ•‘—”‡ˆˆ‡ –•‹œ‡Ǥ  ‹–ŠƒͷΨ•‹‰‹ˆ‹ ƒ ‡Ž‡˜‡ŽǡͺͲΨ’‘™‡”ǡͷͲΨ•”‡†— –‹‘ȋ‡ˆˆ‡ –•‹œ‡Ǣ’”‡Ǧ –”‡ƒ–‡–ͶͲǤͷ•ƒ†’‘•–Ǧ–”‡ƒ–‡–ʹͲǤʹͷ•Ȍǡƒ†‘ˆͳ͵Ǥͷǡƒ•ƒ’Ž‡•‹œ‡‘ˆ•‹š

70 70 ’ƒ–‹‡–•‹•‡‡†‡†Ǥ—”•ƒ’Ž‡•‹œ‡‹•‘”‡–Šƒ–™‹ ‡–Š‹••‹œ‡Ǥ  ›’‡”ˆ‘”‹‰–Š‹• ƒŽ —Žƒ–‹‘–Š‡‘–Š‡”™ƒ›ƒ”‘—†™‹–Š–Š‡•ƒ‡‡•–‹ƒ–‡•ƒ† –Š‡ƒ –—ƒŽ•ƒ’Ž‡•‹œ‡‘ˆͳͶ’ƒ–‹‡–•ǡ‘—”•–—†›•Š‘—Ž†„‡ƒ„Ž‡–‘†‡–‡ –ƒŠ›’‘–Š‡–‹ ƒŽ ͷͲΨ”‡†— –‹‘ȋ‡ˆˆ‡ –•‹œ‡Ȍ™‹–ŠͻͻΨ’‘™‡”Ǥ  Paper II Šƒ‰‡•‘ˆƒ†”‡ –—•—• Ž‡Šƒ˜‡‘–„‡‡ƒ••‡••‡†‹’”‡˜‹‘—•Ž‹–‡”ƒ–—”‡Ǥ ǡŠ‘™‡˜‡”ǡŠƒ•„‡‡•–—†‹‡†„›•‡˜‡”ƒŽ”‡•‡ƒ” Š‰”‘—’•Ȃ‹ Ž—†‹‰”‘ˆǤސ•‡–Š ƒ† ‘Ǧƒ—–Š‘”•Ǥȋͺ͵Ȍ –Š‹•’—„Ž‹ ƒ–‹‘ǡƒ•‹‰‹ˆ‹ ƒ–ͳͲΨ”‡†— –‹‘‘ˆ”‡ –—•—• Ž‡ ™ƒ•ˆ‘—†‘–Š‡‘’‡”ƒ–‡†•‹†‡™Š‡ ‘’ƒ”‡†–‘‘Ǧ‘’‡”ƒ–‡†•‹†‡ǤŽ–Š‘—‰Š ‘””‡Žƒ–‹‘•„‡–™‡‡•— Š”‡†— –‹‘•ƒ†ƒ„†‘‹ƒŽ™ƒŽŽ•–”‡‰–ŠȀˆ— –‹‘ƒŽ‹–› ™‡”‡‘–‡šƒ‹‡†ǡƒͳͲΨ”‡†— –‹‘ ‘—Ž†’‘–‡–‹ƒŽŽ›„‡•‡‡ƒ•ƒƒ’’”‘’”‹ƒ–‡ ‡ˆˆ‡ –•‹œ‡Ǥ

Power calculation: › ‘’ƒ”‹‰–Š‡‘„•‡”˜‡†‡ƒ•‘ˆœ‘‡•Ǧȋ ‘„‹‡†Ȍ‘ –Š‡‘’‡”ƒ–‡†•‹†‡’”‡Ǧƒ†’‘•–‘’‡”ƒ–‹˜‡Ž›ǡ‡•–‹ƒ–‡•ƒ•†‡• ”‹„‡†ˆ‘”’ƒ’‡” ™‡”‡ ƒŽ —Žƒ–‡†Ǥ‡ƒ’”‡‘’‡”ƒ–‹˜‡ȋœ‘‡•Ǧ ‘„‹‡†Ȍ™ƒ•ͻǤͶǡ‡ƒ ’‘•–‘’‡”ƒ–‹˜‡ȋœ‘‡•Ǧ ‘„‹‡†Ȍ™ƒ•ͻǤͻǡ‡ƒ†‹ˆˆ‡”‡ ‡™ƒ•ͲǤͷǡƒ† ‡ƒȋ„ƒ•‡†‘–Š‡‡ƒ†‹ˆˆ‡”‡ ‡•Ȍ™ƒ•ͳǤͷǤ•‹‰–Š‡•‡‡•–‹ƒ–‡•ǡƒ•ƒ’Ž‡•‹œ‡ ‘ˆʹͲ’ƒ–‹‡–•ǡƒ†ƒͷΨ•‹‰‹ˆ‹ ƒ ‡Ž‡˜‡Žǡ‰‹˜‡ƒ‡•–‹ƒ–‡†’‘™‡”ȋ–™‘Ǧ•ƒ’Ž‡ ’ƒ‹”‡†Ǧ‡ƒ•–‡•–Ȍ‘ˆƒ’’”‘š‹ƒ–‡Ž›͵ͲΨǤ ˆƒ‡ƒ†‹ˆˆ‡”‡ ‡‘ˆͲǤͷǡƒ• ƒŽ —Žƒ–‡†Š‡”‡ǡ‹• Ž‹‹ ƒŽŽ›•‹‰‹ˆ‹ ƒ–ǡ‘—”•–—†›™‘—Ž†Šƒ˜‡„‡‡—†‡”’‘™‡”‡†Ǥ  ‡„‡Ž‹‡˜‡ǡŠ‘™‡˜‡”ǡ–Šƒ–ƒ‡ƒ†‹ˆˆ‡”‡ ‡‘ˆͲǤͷȋ‡“—ƒŽ•̱ͷΨ Šƒ‰‡ ˆ”‘’”‡‘’‡”ƒ–‹˜‡‡ƒȌ‹•ǯ–‘ˆƒ› Ž‹‹ ƒŽ”‡Ž‡˜ƒ ‡ǤŠ‡•‡‘„•‡”˜‡††‹ˆˆ‡”‡ ‡• ™‡”‡‹†‡‡†•—”’”‹•‹‰Ž›•ƒŽŽǡ™Š‹ ŠŽ‡ƒ†—•–‘ƒƒŽ–‡”ƒ–‹˜‡‹–‡”’”‡–ƒ–‹‘‘ˆ–Š‡ •–—†›ǯ••–ƒ–‹•–‹ ƒŽ•Š‘”– ‘‹‰•ǣŠ‡ƒ‹†”ƒ™„ƒ ‹•‘– ‘ ‡”‡†™‹–ŠŽ‘™’‘™‡”‘” •ƒŽŽ•ƒ’Ž‡•‹œ‡ǡ„—––Š‡•ƒŽŽ‡ˆˆ‡ –•‹œ‡ȋ•Ȍȋ̱ͷΨ Šƒ‰‡Ȍ‘„•‡”˜‡†ǤƒŽŽ‡ˆˆ‡ –•‹œ‡• Šƒ˜‡ƒ†‹”‡ –‡ˆˆ‡ –‘„‘–Š’‘™‡”ƒ†•ƒ’Ž‡•‹œ‡Ǥ  ͳͲΨ”‡†— –‹‘ȋƒ•‘„•‡”˜‡†„›”‘ˆǤސ•‡–Šƒ† ‘Ǧƒ—–Š‘”•Ȍ‹‰Š–ǡ Š‘™‡˜‡”ǡ ‘•–‹–—–‡ƒ‘”‡ƒ’’”‘’”‹ƒ–‡‡ˆˆ‡ –•‹œ‡Ǥ›—•‹‰–Š‡•ƒ‡‡•–‹ƒ–‡•ǡ„—–„› Šƒ‰‹‰–Š‡‡ˆˆ‡ –•‹œ‡ˆ”‘ͷΨ–‘ͳͲΨǡ‘—”•–—†›ƒ Š‹‡˜‡•ƒ’‘™‡”‘ˆͺͲΨǤŠ‹•‹• ‘”‡ƒ†‡“—ƒ–‡Ǥ —”–Š‡”‘”‡ǡ‹˜‡•–‹‰ƒ–‹‰ƒʹͲΨ‹ ”‡ƒ•‡Ȁ†‡ ”‡ƒ•‡ȋ̱ʹȌ ‰‹˜‡•ƒ’‘™‡”‘ˆͻͻΨǤŠ‡’‘™‡”‘ˆ‘—”•–—†›‰‡–••–”‘‰‡”™‹–Š‹ ”‡ƒ•‹‰‡ˆˆ‡ –•‹œ‡Ǥ

Sample size calculation: ‹–ŠƒͷΨ•‹‰‹ˆ‹ ƒ ‡Ž‡˜‡ŽǡͺͲΨ’‘™‡”ǡͳͲ؏‡ƒ ”‡†— –‹‘ȋ‡ˆˆ‡ –•‹œ‡Ǣ’”‡‘’‡”ƒ–‹˜‡ͻǡͶǡ’‘•–‘’‡”ƒ–‹˜‡ͺǡͶȌǡƒ†‘ˆ ͳǤͷǡƒ•ƒ’Ž‡•‹œ‡‘ˆʹͲ’ƒ–‹‡–•‹•‡‡†‡†ǤŠ‹•‹•–Š‡‡šƒ –—„‡”‘ˆ’ƒ–‹‡–•‹ Ž—†‡† ‹’ƒ’‡” Ǥ 

71 71 Post-hoc comparison of respondents and non-respondents Paper III ‘•–ǦŠ‘  ‘’ƒ”‹•‘•‘ˆ†‡‘‰”ƒ’Š‹ ȋƒ‰‡ǡ ǡ ‘‘”„‹†‹–›ǡƒ†•‘‹‰Ȍƒ† Ž‹‹ ƒŽ ȋŽ‹’‘•— –‹‘ǡˆ‘ŽŽ‘™Ǧ—’–‹‡ǡ ‘’Ž‹ ƒ–‹‘•ǡƒ†”‡‘’‡”ƒ–‹‘Ȍ„‡–™‡‡”‡•’‘†‡–•ƒ† ‘Ǧ”‡•’‘†‡–•‹–Š‡‰”‘—’™‡”‡ƒŽŽ‹•‹‰‹ˆ‹ ƒ–Ǥ  ‘‘”„‹†‹–‹‡•ƒ† ‘’Ž‹ ƒ–‹‘•™‡”‡‘”‹‰‹ƒŽŽ›”‡‰‹•–‡”‡†‹•—„‰”‘—’•ȋ‡Ǥ‰Ǥ †‹ƒ„‡–‡•‡ŽŽ‹–—•ǡ ƒ”†‹‘˜ƒ• —Žƒ”†‹•‡ƒ•‡ǡŠ›’‡”–‡•‹‘ǡ‡– ǤȌǡŠ‘™‡˜‡”ǡ†—‡–‘Ž‘™ ‘—–•–Š‡†ƒ–ƒ™‡”‡†‹ Š‘–‘‹œ‡†ȋ›‡•Ȁ‘Ȍ„‡ˆ‘”‡”—‹‰–Š‡•‡•–ƒ–‹•–‹ ƒŽ–‡•–•Ǥ ‘–‹—‘—•†ƒ–ƒ™‡”‡ƒƒŽ›œ‡†—•‹‰ †‡’‡†‡–ƒ’Ž‡•tǦ–‡•–•ƒ†ƒǦŠ‹–‡› UǦ–‡•–ƒ•ƒ’’”‘’”‹ƒ–‡Ǥ‘‹ƒŽ†ƒ–ƒ™‡”‡ƒƒŽ›œ‡†—•‹‰Š‹Ǧ“—ƒ”‡–‡•–ƒ† ‹•Š‡”ǯ• ‡šƒ ––‡•–†‡’‡†‹‰‘—„‡”‘ˆ ‘—–•Ǥ   ‘ Ž—•‹‘ǡ–Š‡”‡™‡”‡‘•‹‰‹ˆ‹ ƒ–†‹ˆˆ‡”‡ ‡• ‘’ƒ”‹‰”‡‰‹•–‡”‡††ƒ–ƒ „‡–™‡‡”‡•’‘†‡–•ƒ†‘Ǧ”‡•’‘†‡–•‹–Š‡‰”‘—’Ǥ                   

72 72 7 Ethical considerations

ƒ’‡”• ƒ† ™‡”‡ƒ’’”‘˜‡†„›–Š‡Ž‘ ƒŽ–Š‹ ƒŽ‘‹––‡‡ǡƒ† ‘†— –‡†‹ ƒ ‘”†ƒ ‡™‹–Š–Š‡‘”Ž†‡†‹ ƒŽ••‘ ‹ƒ–‹‘ǯ•‡ Žƒ”ƒ–‹‘‘ˆ ‡Ž•‹‹Ǥȋʹͷ͹Ȍ‘ ƒ’’”‘˜ƒŽ™ƒ•‘„–ƒ‹‡†ˆ‘”’ƒ’‡” ȋ†—‡–‘–Š‡“—‡•–‹‘ƒ‹”‡Ǧ„ƒ•‡†‡–Š‘†‘Ž‘‰›—•‡†Ȍǡ ƒ†–Š‡•–—†›†‹† ‘•‡“—‡–Ž›‘–ƒ’’Ž›ƒŽŽ’”‹ ‹’Ž‡•‘ˆ–Š‡ƒˆ‘”‡‡–‹‘‡† †‡ Žƒ”ƒ–‹‘ǤŽŽ–Š”‡‡•–—†‹‡•™‡”‡”‡‰‹•–‡”‡†‹ƒ’—„Ž‹ Ž›ƒ ‡••‹„Ž‡†ƒ–ƒ„ƒ•‡ ȋŽ‹‹ ƒŽ”‹ƒŽ•Ǥ‰‘˜Ȍ„‡ˆ‘”‡”‡ ”—‹–‡–‘ˆ’ƒ–‹‡–•Ǥ‡’”‘˜‹†‡†‹ˆ‘”ƒ–‹‘”‡‰ƒ”†‹‰ –Š‡• ‘’‡‘ˆ–Š‡•–—†›ƒ†‘„–ƒ‹‡†™”‹––‡ ‘•‡–ˆ”‘ƒŽŽ’ƒ”–‹ ‹’ƒ–•Ǥ  ’‡ ‹ˆ‹ ‡–Š‹ ƒŽ ‘•‹†‡”ƒ–‹‘•‘ˆ–Š‡–Š”‡‡•–—†‹‡•™‡”‡ƒ•ˆ‘ŽŽ‘™•ǣ

Paper I –‡”•‘ˆ’ƒ’‡” ǡ–Š‡”‡™‡”‡ˆ‡™‡–Š‹ ƒŽ ‘•‹†‡”ƒ–‹‘•ǤŠ‡Žƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘ ‹ƒ‰‹‰ȋ Ȍ‹•ƒ‘Ǧ‹˜ƒ•‹˜‡–‡ Š‹“—‡‘ˆ‡ƒ•—”‹‰ —–ƒ‡‘—•„Ž‘‘†ˆŽ‘™ǡƒ†–Š‡ ’ƒ–‹‡–•™‡”‡‘–‡š’‘•‡†–‘ƒ›”‹••ȋƒ’ƒ”–ˆ”‘Ž‘‰‡”‘’‡”ƒ–‹˜‡–‹‡†—‡–‘ ‹–”ƒ‘’‡”ƒ–‹˜‡‡ƒ•—”‡‡–•ȌǤȋʹͷͺȌ 

Paper II ƒ’‡” Šƒ†‡–Š‹ ƒŽ ‘•‹†‡”ƒ–‹‘•†—‡–‘–Š‡—•‡‘ˆǤŠ‡• ƒ•–Šƒ–™‡”‡ ’‡”ˆ‘”‡†ƒ’’”‘š‹ƒ–‡Ž›–™‘›‡ƒ”•’‘•–‘’‡”ƒ–‹˜‡Ž›ƒ”‡‘–’ƒ”–‘ˆ‘—””‘—–‹‡ˆ‘ŽŽ‘™Ǧ —’ǤŠ‡”‡ˆ‘”‡ǡ–Š‡’ƒ–‹‡–•™‡”‡‡š’‘•‡†–‘‘”‡”ƒ†‹ƒ–‹‘–‘–Š‡ƒ„†‘‹ƒŽ”‡‰‹‘Ǥ ƒ”–‹ ‹’ƒ–•™‡”‡‹ˆ‘”‡†ƒ„‘—––Š‹•‹™”‹–‹‰ƒ†‰ƒ˜‡™”‹––‡ ‘•‡–„‡ˆ‘”‡Šƒ˜‹‰ –Š‡’‘•–‘’‡”ƒ–‹˜‡• ƒǤ‘Ž‹‹––Š‡”‹••ǡŠ‘™‡˜‡”ǡ‹‘†‹‡ ‘–”ƒ•–‡†‹ƒ‡Šƒ ‡‡– ™ƒ•ˆ‘—†ƒ˜‘‹†ƒ„Ž‡Ǥ  ‘‡‘ˆ–Š‡’‘•–‘’‡”ƒ–‹˜‡• ƒ•”‡’‘”–‡†—•—•’‡ –‡†ˆ‹†‹‰•Ǥ‘‰–Š‡ͳͶ ’ƒ–‹‡–•ǡ•‡Ž‡–ƒŽ‡–ƒ•–ƒ•‹•ǡȋ—•’‡ ‹ˆ‹‡†ȌŽ‹˜‡”Ž‡•‹‘•ǡƒ†ƒ•’Ž‡‹ ƒ‡—”›•™‡”‡ ˆ‘—†ƒ† ƒ”‡ˆ—ŽŽ›ˆ‘ŽŽ‘™‡†—’™‹–Šƒ’’Ž‹ ƒ„Ž‡–‡•–•ǤŠ‡ˆ‹†‹‰•™‡”‡ƒŽ•‘”‡’‘”–‡†–‘ –Š‡‹”‰‡‡”ƒŽ’Š›•‹ ‹ƒ•Ȁ‘ ‘Ž‘‰‹•–•ǤŠ‡•‡ˆ‹†‹‰• ƒ„‡˜‹‡™‡†ƒ•ƒƒ†˜ƒ–ƒ‰‡ ȋ‡ƒ”Ž›†‡–‡ –‹‘‘ˆ‡–ƒ•–ƒ•‹œ‹‰†‹•‡ƒ•‡Ȍƒ†ƒ†‹•ƒ†˜ƒ–ƒ‰‡ȋ†‡–‡ –‹‰ Dz‹ ‹†‡–ƒŽ‘ƒ•dz™Š‹ Š‹‰Š–‘–‡‡†ƒ›–›’‡‘ˆ–”‡ƒ–‡–‘”ˆ‘ŽŽ‘™Ǧ—’ǡ•— Šƒ• „‡‹‰Ž‹˜‡”Ž‡•‹‘•ǡƒ†™Š‹ Š ƒ—•‡’ƒ–‹‡–ƒš‹‡–›ƒ†—‡ ‡••ƒ”›—•‡‘ˆŠ‡ƒŽ–Š ”‡•‘—” ‡•ȌǤ  Paper III ‡†‹†‘–‘„–ƒ‹ƒƒ’’”‘˜ƒŽˆ”‘–Š‡Ž‘ ƒŽ–Š‹ ƒŽ‘‹––‡‡ˆ‘”’ƒ’‡” ƒ•–Š‡”‡ ™‡”‡‘ƒŒ‘”‡–Š‹ ƒŽ ‘•‹†‡”ƒ–‹‘•”‡ˆŽ‡ –‹‰–Š‡”‡–”‘•’‡ –‹˜‡ƒ†“—‡•–‹‘ƒ‹”‡Ǧ „ƒ•‡†‡–Š‘†—•‡†ǤŠ‹•†‡ ‹•‹‘”‡ˆŽ‡ –•‡ƒ”Ž‹‡”’”ƒ –‹ ‡ȋ„ƒ –‘–Š‡„‡‰‹‹‰‘ˆ–Š‡ ʹͲͲͲ•™Š‡–Š‡“—‡•–‹‘ƒ‹”‡•™‡”‡†‡•‹‰‡†ƒ††‹•–”‹„—–‡†Ȍǡƒ†‹•†‹ˆˆ‡”‡–ˆ”‘ –‘†ƒ›ǯ•’”ƒ –‹ ‡™Š‡”‡™‡ƒ’’Ž›ˆ‘”‡–Š‹ ƒŽƒ’’”‘˜ƒŽ‹ƒŽŽ”‡•‡ƒ” Š–Šƒ–‹ Ž—†‡• ’ƒ–‹‡–•Ǥ‘†ƒ›ǡ™‡™‘—Ž†Šƒ˜‡•‡–ƒˆ‘”ƒŽƒ’’Ž‹ ƒ–‹‘‹ˆ–Š‡•ƒ‡“—‡•–‹‘ƒ‹”‡•

73 73 ™‡”‡–‘„‡ ‘’Ž‡–‡†Ǥ ƒ††‹–‹‘ǡ™‡™‘—Ž†Šƒ˜‡ ‘–ƒ –‡†–Š‡ƒ–ƒ”‘–‡ –‹‘ˆˆ‹ ‡” ȋ‡”•‘˜‡”‘„—†Ȍƒ–‘—” ‘•’‹–ƒŽˆ‘”ƒƒ’’”‘˜ƒŽ–‘ ‘†— ––Š‡•–—†›Ǥ  ‡•’‹–‡—•‹‰ƒ‘Ǧ‹–‡”˜‡‹‰”‡•‡ƒ” Š‡–Š‘†™‹–Š‘ƒ••‘ ‹ƒ–‡†”‹••ǡ‹– ‘—Ž†„‡ƒ”‰—‡†–Šƒ––Š‡”‡ƒ”‡‡–Š‹ ƒŽ ŠƒŽŽ‡‰‡•Ȁ†‹•ƒ†˜ƒ–ƒ‰‡•‘ˆ’‡”ˆ‘”‹‰ƒ “—‡•–‹‘ƒ‹”‡Ǧ„ƒ•‡†•–—†›ǤȋʹͷͻȌ‘–Š†‹•ƒ†˜ƒ–ƒ‰‡•ƒ†ƒ†˜ƒ–ƒ‰‡•ƒ”‡†‹• —••‡†‹ –Š‡ˆ‘ŽŽ‘™‹‰ǣ  –Š‹ ƒŽ†‹•ƒ†˜ƒ–ƒ‰‡•ǣͳȌƒ•‡†‘–Š‡“—‡•–‹‘•ǯ ‘–‡–ȋ‡Ǥ‰Ǥ„‘†›‹ƒ‰‡ƒ† •‡š—ƒŽ‹–›Ȍƒ†–Š‡’ƒ–‹‡–•ǯ„ƒ ‰”‘—†ȋ„”‡ƒ•– ƒ ‡”’ƒ–‹‡–•ƒ†ƒ„†‘‹‘’Žƒ•–› ’ƒ–‹‡–•Ȍǡ‘—”“—‡•–‹‘ƒ‹”‡• ‘—Ž†„‡•‡‡ƒ•ƒƒ –‹˜‡‹–‡”˜‡–‹‘–Šƒ–‹‰Š–„”‹‰ ƒ„‘—–Šƒ”ˆ‘”–Š‡’ƒ”–‹ ‹’ƒ–ǡƒ†ʹȌŽ–Š‘—‰Š‹ Ž—†‹‰’ƒ–‹‡–•™Š‘Šƒ˜‡Šƒ†„”‡ƒ•– ”‡ ‘•–”— –‹‘†—‡–‘ ƒ ‡”ǡ†‡„”‹‡ˆ‹‰ȋƒˆ–‡”’ƒ”–‹ ‹’ƒ–‹‘Ȍ™ƒ•‘–’‡”ˆ‘”‡†Ǥ  –Š‹ ƒŽƒ†˜ƒ–ƒ‰‡•ǣͳȌ ˆ‘”‡† ‘•‡–’”‹‘”–‘’ƒ”–‹ ‹’ƒ–‹‘ǡʹȌ‘ˆ‹†‡–‹ƒŽ‹–› ™ƒ•ƒ‹–ƒ‹‡†ǡ͵Ȍƒ–‹‡–•Šƒ†–Š‡”‹‰Š––‘™‹–Š†”ƒ™‹ˆ‘”ƒ–‹‘ƒ–ƒ›–‹‡™‹–Š‘—– ‰‹˜‹‰”‡ƒ•‘ǡͶȌ‘‡’ƒ–‹‡–•‹‰Š–†‡”‹˜‡’‡”•‘ƒŽ„‡‡ˆ‹–ˆ”‘’ƒ”–‹ ‹’ƒ–‹‘ǡƒ†ͷȌ ƒ–‹‡–’‹ –—”‡†‹’—„Ž‹•Š‡†ƒ”–‹ Ž‡™ƒ• ‘–ƒ –‡†ˆ‘”™”‹––‡ ‘•‡–Ǥ                    

74 74 8 Conclusions

This thesis summarizes decades of research on donor-site morbidity after DIEAP flap breast reconstruction and provides new knowledge through three individual studies.

The main conclusion is that DIEAP flaps result in very limited donor-site morbidity which for most patients does not outweigh the benefits of free perforator flap breast reconstruction.

In addition to the overall low donor-site morbidity documented, the following conclusions can be made based on our observations: x  ‹•ƒ˜ƒŽ—ƒ„Ž‡‹•–”—‡–‹‘‹–‘”‹‰ —–ƒ‡‘—•„Ž‘‘†’‡”ˆ—•‹‘ x Š‡’‡”‹—„‹Ž‹ ƒŽ•‹‹•™‡ŽŽ’‡”ˆ—•‡† x †‡”‹‹‰ ƒ ƒ—•‡„‘–Šƒ‹ ”‡ƒ•‡‘ˆ’‡”ˆ—•‹‘ȋDz’‘•–Ǧ—†‡”‹‹‰ ”‡ƒ –‹˜‡Š›’‡”‡‹ƒdzȌƒ††‡ ”‡ƒ•‡‘ˆ’‡”ˆ—•‹‘ x ‡•‹‘”‡†— ‡•’‡”ˆ—•‹‘ x Š‡‘•–†‹•–ƒŽ’ƒ”–‘ˆ–Š‡—†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’Šƒ•–Š‡Š‹‰Š‡•– •—• ‡’–‹„‹Ž‹–›‘ˆ–‹••—‡‡ ”‘•‹•Ȃ‡•’‡ ‹ƒŽŽ›ƒˆ–‡”ƒ„†‘‹ƒŽ Ž‘•—”‡ x Š‡—†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’‡‡†•Ž‡••–Šƒ‘‡†ƒ›–‘•— ‡••ˆ—ŽŽ› ‹’Ž‡‡– ‘’‡•ƒ–‘”›‡ Šƒ‹••’”‡˜‡–‹‰–‹••—‡‹• Š‡‹ƒƒ† ’‘–‡–‹ƒŽŽ›‡ ”‘•‹•  λ  x  ˆŽƒ’Šƒ”˜‡•–‹‰ ƒ—•‡••ƒŽŽǡ›‡–•–ƒ–‹•–‹ ƒŽŽ›•‹‰‹ˆ‹ ƒ–ǡ Šƒ‰‡•–‘–Š‡ ”‡ –—•—• Ž‡ƒ–ƒ†‹ˆ‡”‹‘”Ž›–‘–Š‡‹–”ƒ—• —Žƒ”’‡”ˆ‘”ƒ–‘”†‹••‡ –‹‘ x  ˆŽƒ’Šƒ”˜‡•–‹‰ ƒ—•‡••‹‰‹ˆ‹ ƒ– Šƒ‰‡• x ‡”‹ƒ•ƒ”‡‘– ‘‘ ‘’Ž‹ ƒ–‹‘•ƒˆ–‡” ˆŽƒ’•—”‰‡”› x  ˆŽƒ’Šƒ”˜‡•–‹‰ ‘—Ž† ƒ—•‡’‡”•‹•–‡–•‡”‘ƒ•  λ  x  ˆŽƒ’’ƒ–‹‡–•ƒ”‡‘˜‡”ƒŽŽ•ƒ–‹•ˆ‹‡†™‹–Š–Š‡†‘‘”Ǧ•‹–‡ƒˆ–‡”„”‡ƒ•– ”‡ ‘•–”— –‹‘ǡƒ†–Š‡ƒŒ‘”‹–›‘ˆ’ƒ–‹‡–•’”‡ˆ‡”•–Š‡’‘•–•—”‰‹ ƒŽƒ„†‘‡ x  ˆŽƒ’’ƒ–‹‡–•ƒ”‡‡“—ƒŽŽ›ƒ••ƒ–‹•ˆ‹‡†™‹–Š–Š‡ƒ„†‘‡ƒ•’ƒ–‹‡–•ǡ™‹–Š ƒ–”‡†‘ˆŠ‹‰Š‡”•ƒ–‹•ˆƒ –‹‘‹–Š‡ ‰”‘—’ x Š‡ƒŒ‘”‹–›‘ˆ ˆŽƒ’’ƒ–‹‡–•‡š’‡”‹‡ ‡Dzƒ•‡š’‡ –‡†dz‘”DzŽ‡••–Šƒ ‡š’‡ –‡†dzƒ‘—–ƒ†˜‹•‹„‹Ž‹–›‘ˆ• ƒ””‹‰ x ‡™ ˆŽƒ’’ƒ–‹‡–•‰‘–Š”‘—‰Š•‡ ‘†ƒ”›’”‘ ‡†—”‡•ƒ––Š‡†‘‘”Ǧ•‹–‡ȋ‹ ‘—”‡’ƒ”–‡–Ȍ

75 75 x ‹‰‹ˆ‹ ƒ–Ž›‘”‡ ˆŽƒ’’ƒ–‹‡–•ƒ”‡•ƒ–‹•ˆ‹‡†™‹–Š–Š‡‹”„‘†›™Š‡†”‡••‡† ‘’ƒ”‡†–‘’ƒ–‹‡–• x ‹‰‹ˆ‹ ƒ–Ž›‘”‡’ƒ–‹‡–•‡š’‡”‹‡ ‡ƒƒŽ–‡”‡†„‘†›‹ƒ‰‡ ‘’ƒ”‡†–‘  ˆŽƒ’’ƒ–‹‡–• x  ‘—Ž†‹ ”‡ƒ•‡•‡š—ƒŽ†‡•‹”‡ǡ™Š‹Ž‡ ˆŽƒ’•—”‰‡”› ‘—Ž††‡ ”‡ƒ•‡•‡š—ƒŽ †‡•‹”‡ x  ˆŽƒ’’ƒ–‹‡–•ƒ”‡‘”‡™‘””‹‡†ƒ„‘—––Š‡‹”Š‡ƒŽ–Š–Šƒ’ƒ–‹‡–• ’‘•–‘’‡”ƒ–‹˜‡Ž› x  ˆŽƒ’’ƒ–‹‡–•ƒ”‡‘˜‡”ƒŽŽ•ƒ–‹•ˆ‹‡†™‹–Š–Š‡‹”„”‡ƒ•–”‡ ‘•–”— –‹‘

76 76 9 Clinical implications and future research

The main clinical implications of this thesis are the documented low donor-site morbidity and high patient satisfaction. These observations confirm two of many qualities of this free flap harvested from the lower abdomen. In my opinion, DIEAP flaps should continue to be the gold standard of autologous breast reconstruction. In the following text we bring to mind other clinical implications, and discuss future research concerning donor-site morbidity after abdominal flap harvesting. These thoughts are based on our observations as well as an extensive review of the literature while writing this thesis.

Clinical implications: 1) Continue current undermining practice: ‘—”‡’ƒ”–‡–ǡ–Š‡ƒ„†‘‹ƒŽ ˆŽƒ’‹•—†‡”‹‡†ƒŽŽ–Š‡™ƒ›—’–‘–Š‡š‹’Š‘‹†’”‘ ‡••ƒ†ƒŽ‘‰–Š‡ ‘•–ƒŽ ƒ”‰‹•ǤŠ‡ƒ„•‡ ‡‘ˆ•‹‡ ”‘•‹•ƒ†™‘—††‡Š‹• ‡ ‡‹’ƒ’‡” ǡƒ†–Š‡ ”ƒ’‹†Ž›‹ ”‡ƒ•‹‰’‡”ˆ—•‹‘‘„•‡”˜‡†™‹–Š‹–Š‡ˆ‹”•–’‘•–‘’‡”ƒ–‹˜‡†ƒ›ǡ‹†‹ ƒ–‡ –Šƒ––Š‡”‡‹•‘‡‡†ˆ‘”ƒ‘”‡Ž‹‹–‡†—†‡”‹‹‰‘ˆ–Š‡ƒ„†‘‹ƒŽˆŽƒ’ ȋ’‘–‡–‹ƒŽŽ›•’ƒ”‹‰Žƒ–‡”ƒŽ”‘™’‡”ˆ‘”ƒ–‘”•ȌǤŠ‹•‹••—’’‘”–‡†„›–Š‡ ‹•‹‰‹ˆ‹ ƒ–”‡•—Ž–•™Š‡ ‘’ƒ”‹‰ƒ„†‘‹ƒŽˆŽƒ’’‡”ˆ—•‹‘„‡–™‡‡Ž‹‹–‡†Ǧ —†‡”‹‹‰Ž‹’‘ƒ„†‘‹‘’Žƒ•–›ƒ†–”ƒ†‹–‹‘ƒŽƒ„†‘‹‘’Žƒ•–›Ǥȋͳͳ͹Ȍ 2) Aim at using medial row perforators for motor nerve preservation: ƒ’‡”  †‡‘•–”ƒ–‡†•‹‰‹ˆ‹ ƒ– Šƒ‰‡•–‘–Š‡‘’‡”ƒ–‡†”‡ –—•—• Ž‡’‘••‹„Ž› ”‡’”‡•‡–‹‰—• Ž‡ƒ–”‘’Š›ǤŠƒ–ƒ”‡–Š‡ ƒ—•‡ȋ•Ȍ‘ˆ–Š‹•‘„•‡”˜ƒ–‹‘ǫ‘—Ž† –Š‡†‡‘•–”ƒ–‡†—• Ž‡‘”„‹†‹–›„‡†—‡–‘–Š‡—•‡‘ˆŽƒ–‡”ƒŽ’‡”ˆ‘”ƒ–‘”• ƒ†Ȁ‘”—• Ž‡†‹˜‹•‹‘ǫ  Š‡ ‘Š‘”–†‹†ǡ‹ˆƒ –ǡ‹ Ž—†‡•‡˜‡”ƒŽˆŽƒ’•„ƒ•‡†‘Žƒ–‡”ƒŽ”‘™ ’‡”ˆ‘”ƒ–‘”•Ǥ —”–Š‡”‘”‡ǡ–Š‡”‡ –—•—• Ž‡™ƒ•’ƒ”–‹ƒŽŽ›†‹˜‹†‡†‹–™‘ ƒ•‡• ȋ‹ˆŽƒ’•‡‡†‹‰–™‘’‡”ˆ‘”ƒ–‘”•ȌǤŽ–Š‘—‰Š•–ƒ–‹•–‹ ƒŽƒƒŽ›•‡• ‘’ƒ”‹‰ˆŽƒ’• ‘ˆ‘‡˜‡”•—•–™‘’‡”ˆ‘”ƒ–‘”ȋ•Ȍƒ†‡†‹ƒŽ”‘™˜‡”•—•Žƒ–‡”ƒŽ”‘™†‹†‘–›‹‡Ž† •‹‰‹ˆ‹ ƒ–†ƒ–ƒǡ–Š‹• ‘—Ž†„‡’‘–‡–‹ƒŽ‡š’Žƒƒ–‹‘•ǤŠ‡•ƒŽŽ•ƒ’Ž‡•‹œ‡‡‡’• —•ˆ”‘†”ƒ™‹‰ƒ›†‡ˆ‹‹–‡ ‘ Ž—•‹‘•Ǥ  ‹ ‡‘–‘”‡”˜‡•Šƒ˜‡„‡‡•Š‘™–‘”— Ž‘•‡–‘–Š‡Žƒ–‡”ƒŽ”‘™‘ˆ ’‡”ˆ‘”ƒ–‘”•ǡ‡†‹ƒŽ”‘™’‡”ˆ‘”ƒ–‘”••Š‘—Ž†’”‡•—ƒ„Ž›„‡’”‹‘”‹–‹œ‡†Ǥȋͳʹͺǡʹ͸ͲȌ ˆŽƒ–‡”ƒŽ”‘™’‡”ˆ‘”ƒ–‘”ȋ•Ȍƒ”‡—•‡†ǡ’”‡ ƒ—–‹‘ƒ”›‡–Š‘†••Š‘—Ž†„‡–ƒ‡–‘ ’”‡•‡”˜‡–Š‡‘–‘”‡”˜‡–Š”‘—‰Šƒ–”ƒ—ƒ–‹ ǡ–‡†‹‘—•†‹••‡ –‹‘ǤŽ–‡”ƒ–‹˜‡Ž›ǡ ‘‡ ƒ‡’Ž‘›–Š‡ˆŽƒ’ƒ•†‹• —••‡†„‡Ž‘™Ǥȋͳ͸ʹȌ  ‡„‡Ž‹‡˜‡–Šƒ––Š‡”‡‹•”‘‘ˆ‘”‹’”‘˜‡‡– ‘ ‡”‹‰–Š‹•ƒ––‡”Ȃ „‘–Š„›‹ Ž—†‹‰ˆ‡™‡”Žƒ–‡”ƒŽ’‡”ˆ‘”ƒ–‘”•ƒ†‹’”‘˜‡–Š‡†‹••‡ –‹‘‘ˆŽƒ–‡”ƒŽ ’‡”ˆ‘”ƒ–‘”•™Š‡—•‡†Ǥ ˆ‡”˜‡•ƒ”‡•‡˜‡”‡†ǡ‘‡•Š‘—Ž† ‘•‹†‡”–‘”‡’ƒ‹”–Š‡ ‡”˜‡Ǥ 3) Preserving the internal mammary artery: •†‡‘•–”ƒ–‡†„›‡”‰¤”†‡–ƒŽǤǡ –Š‡—•‡‘ˆ •ȋ‡†Ǧ–‘‡†Ȍƒ•”‡ ‹’‹‡–˜‡••‡Ž•Šƒ•ƒ•‹‰‹ˆ‹ ƒ–‡‰ƒ–‹˜‡‡ˆˆ‡ – ‘ƒ„†‘‹ƒŽ•‹’‡”ˆ—•‹‘‹–Š‡‡’‹‰ƒ•–”‹ ”‡‰‹‘ǤȋͳͲ͹ȌŠ‹•’‡”ˆ—•‹‘†”‘’

77 77 ƒ’‘–‡–‹ƒŽŽ›„‡’”‡˜‡–‡†„›—•‹‰‹–‡”ƒŽƒƒ”›ƒ”–‡”›’‡”ˆ‘”ƒ–‘”• ȋ Ȍ‘”„›’‡”ˆ‘”‹‰‡†Ǧ–‘Ǧ•‹†‡ƒ”–‡”‹ƒŽƒƒ•–‘‘•‹•–‘–Š‡ Ǥȋʹ͸ͳȌ— Š ‡ƒ•—”‡• ‘—Ž†”‡†— ‡–Š‡”‹•‘ˆƒ„†‘‹ƒŽ™‘—†Š‡ƒŽ‹‰’”‘„Ž‡•ǡˆƒ–Ȁ•‹ ‡ ”‘•‹•ǡƒ†—• Ž‡ƒ–”‘’Š›‹–Š‡—’’‡”ƒ„†‘‹ƒŽ”‡‰‹‘ǤŠ‹••Š‘—Ž†„‡ ‹˜‡•–‹‰ƒ–‡†ˆ—”–Š‡”ȋ•‡‡„‡Ž‘™ȌǤ‘”‡‘˜‡”ǡ ’”‡•‡”˜ƒ–‹‘™‹ŽŽƒ‹–ƒ‹–Š‡ ‘’–‹‘‘ˆ—•‹‰–Š‡ ˆ‘”ˆ—–—”‡ ‘”‘ƒ”›ƒ”–‡”›„›’ƒ••Ǥȋʹ͸ͳȌ 4) Importance of semi-Fowler’s position during the first postoperative period? ‘—”•–ƒ†ƒ”†‹œ‡†’‘•–‘’‡”ƒ–‹˜‡”‘—–‹‡•ǡ’ƒ–‹‡–•ǯ„‡†•Šƒ˜‡ƒ͵Ͳι ˆŽ‡š‹‘‹ –Š‡Š‹’”‡‰‹‘ȋ•‡‹Ǧ ‘™Ž‡”ǯ•’‘•‹–‹‘Ȍǡƒ†’‹ŽŽ‘™•ƒ”‡‘ˆ–‡’Žƒ ‡†—†‡”–Š‡ ‡‡•ǤŠ‹•’‘•‹–‹‘‹•ƒ†˜‹•‡†–Š‡ˆ‹”•––™‘–‘–Š”‡‡’‘•–‘’‡”ƒ–‹˜‡†ƒ›•–‘”‡†— ‡ ƒ„†‘‹ƒŽ™ƒŽŽ–‡•‹‘ȋƒ† ‘•‡“—‡–Ž›”‹•‘ˆ•‹’‡”ˆ—•‹‘†”‘’ƒ†Ȁ‘” •—–—”‡”—’–—”‡Ȍƒ†’ƒ‹ǤŽ‹‰Š–Š‹’ȀŽ‘™‡”„ƒ ˆŽ‡š‹‘‹•ƒŽ•‘”‡ ‘‡†‡† †—”‹‰‘„‹Ž‹œƒ–‹‘Ǥ  –‡”•‘ˆ•‹’‡”ˆ—•‹‘ǡ–Š‹•‹‰Š–‘–„‡‡ ‡••ƒ”›†—‡–‘–Š‡ ‘’‡•ƒ–‘”›‡ Šƒ‹••‘„•‡”˜‡†™Š‡•–—†›‹‰‹ ”‘ ‹” —Žƒ–‹‘‹–Š‡ —†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’ǣƒ’‡” •Š‘™‡†–Šƒ–ƒŽŽœ‘‡•‹–Š‡—†‡”‹‡† ƒ„†‘‹ƒŽˆŽƒ’Šƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž›Š‹‰Š‡”‡ƒ’‡”ˆ—•‹‘ƒŽ”‡ƒ†›‘–Š‡ˆ‹”•– ’‘•–‘’‡”ƒ–‹˜‡†ƒ› ‘’ƒ”‡†–‘–Š‡‹”’”‡‘’‡”ƒ–‹˜‡‡ƒ•ǡ•—‰‰‡•–‹‰–Šƒ––Š‡ ’ƒ–‹‡–•ǯ’‘•‹–‹‘ƒ†‘„‹Ž‹œƒ–‹‘‹‰Š–„‡‘”ƒŽ‹œ‡†‡ƒ”Ž‹‡”ǫ  Žƒ•–‹ •—”‰‡‘•‹‘”‘–‘”‡ ‡–Ž›”‡’‘”–‡†–Š‡—•‡‘ˆƒ•‘Ǧ ƒŽŽ‡† Dzƒ ‡Ž‡”ƒ–‡†”‡ ‘˜‡”›’”‘–‘ ‘ŽdzǤȋʹ͸ʹȌ— Š’”‘–‘ ‘Ž•Šƒ˜‡•‡˜‡”ƒŽ’”‡Ǧ †‡–‡”‹‡†‰‘ƒŽ•ƒ† ‡–‡”‘‡ƒ”Ž›”‡•–‘”ƒ–‹‘‘ˆƒ‘”ƒŽ’Š›•‹‘Ž‘‰‹ ƒŽ•–ƒ–‡ ‹–Š‡’‡”‹‘’‡”ƒ–‹˜‡’‡”‹‘†ǡ–Š—•‹‹‹œ‹‰–Š‡‹’ƒ –‘ˆ•—”‰‹ ƒŽ•–”‡••ǤŠ‡ ‘”‘–‘’ƒ–‹‡–•™‡”‡ǡˆ‘”‹•–ƒ ‡ǡ‰‹˜‡”‡‰—Žƒ”„‡†•ƒ†‘„‹Ž‹œ‡†–‘–Š‡ ™ƒ•Š”‘‘ƒˆ–‡”ʹͶŠ‘—”•Ǥ‹Žƒ–‡”ƒŽ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘•™‡”‡ †‹• Šƒ”‰‡†‘–Š‡‘”‹‰‘ˆ’‘•–‘’‡”ƒ–‹˜‡†ƒ›͵Ǥ  ‘’ƒ”‹•‘ǡ‘—”—‹Žƒ–‡”ƒŽ  ˆŽƒ’’ƒ–‹‡–•ƒ”‡‘”ƒŽŽ›ƒ†‹––‡†ˆ‘”ˆ‘—”Ǧ•‹š†ƒ›•ǤŠ‡ƒ—–Š‘”• †‡‘•–”ƒ–‡†–Šƒ––Š‡‹”ƒ ‡Ž‡”ƒ–‡†”‡ ‘˜‡”›’”‘–‘ ‘Ž”‡†— ‡†–Š‡Ž‡‰–Š‘ˆ•–ƒ› ƒ†’ƒ–‹‡– ƒ”‡ ‘•–•™‹–Š‘—– ‘’”‘‹•‹‰’ƒ–‹‡–•ƒˆ‡–›ȋ™Š‡ ‘’ƒ”‡†–‘ƒ ‘Ǧ’”‘–‘ ‘Ž‰”‘—’ȌǤŠ‹•‹••‘‡–Š‹‰™‡•Š‘—Ž†Ž‘‘‹–‘Ǥ 5) Return to the use of color Doppler ultrasonography (CDU) for perforator mapping: Šƒ•„‡‡•‡‡ƒ––Š‡„‡•–”ƒ†‹‘Ž‘‰‹ ‘†ƒŽ‹–›‹’”‡‘’‡”ƒ–‹˜‡ ’‡”ˆ‘”ƒ–‘”ƒ’’‹‰ǡƒ†Šƒ•Ž‘•–‹–•’‘’—Žƒ”‹–›ˆ‘”ƒŽ‘‰–‹‡Ǥ‡˜‡”ƒŽ ‹ ”‘•—”‰‹ ƒŽ ‡–‡”•Šƒ˜‡ǡŠ‘™‡˜‡”ǡ”‡ ‡–Ž›”‡–—”‡†–‘–Š‡—•‡‘ˆǤȋʹ͸͵ǡ ʹ͸ͶȌ•–Š‡‹’Ž‹ ƒ–‡•”‹••ȋ ‘–”ƒ•–ǡšǦ”ƒ›‡š’‘•—”‡–‘–Š‡ƒ„†‘‹ƒŽ ”‡‰‹‘Ȍƒ†”‡“—‹”‡‡–•ȋƒ Š‹‡•ǡ”ƒ†‹‘‰”ƒ’Š‡”•ǡ”ƒ†‹‘Ž‘‰‹•–•ǡ‡– ǤȌǡ ‘ˆˆ‡”•ƒ•ƒˆ‡”ƒ†‘”‡ ‘•–Ǧ‡ˆˆ‡ –‹˜‡‘†ƒŽ‹–›Ǥ  ƒʹͲͳͻ ’—„Ž‹ ƒ–‹‘ǡ‹Œ—•‘˜‹ ‡–ƒŽǤ†‡‘•–”ƒ–‡†–Šƒ–‹•ƒ •ƒˆ‡ǡƒ —”ƒ–‡ǡƒ†”‡Ž‹ƒ„Ž‡–‘‘Ž–Šƒ–ƒ –—ƒŽŽ› ƒ‡‘—–„‡––‡”–ŠƒǤȋʹ͸͵ȌŠ‹• ‹••—’’‘”–‡†„›‘–Š‡””‡•‡ƒ” Š‰”‘—’•ƒŽ•‘ ‘’ƒ”‹‰–Š‡–™‘‘†ƒŽ‹–‹‡•Ǥȋʹ͸Ͷǡ ʹ͸ͷȌ–Š‡ ‘–”ƒ”›ǡ–Š‡”‡ƒ”‡ƒ”‰—‡–•ˆ‘”ƒ ‘–‹—‡†—•‡‘ˆǡ•— Šƒ•ǣͳȌ šƒ‹‹‰‘”‡•‡ –‹‘•‘ˆ–Š‡ƒ„†‘‹ƒŽ™ƒŽŽȋ„‡––‡”‘˜‡”˜‹‡™ȌǡʹȌ‡–‡ –‹‰ ‘”‡’‡”ˆ‘”ƒ–‘”•–Šƒǡ͵Ȍ‡Ž‹‡ƒ–‹‰‹–”ƒ—• —Žƒ”’‡”ˆ‘”ƒ–‘”’ƒ–Š™ƒ›•ǡ ͶȌ‡˜‡ƒŽ‹‰‹ƒ–”‘‰‡‹ ˜ƒ• —Žƒ”‹Œ—”›‹‘Ǧ˜‹”‰‹ƒ„†‘‡•ǡƒ†ͷȌ‡†— ‹‰ ‘’‡”ƒ–‹˜‡–‹‡Ǥȋʹ͸͸Ȍ  •—‰‰‡•––Šƒ–‹ ”‘•—”‰‹ ƒŽ ‡–‡”••Š‘—Ž†–”›–‘—•‡ƒ•— Šƒ•

78 78 ’‘••‹„Ž‡ȂŽ‹‹–‹‰”‹••ˆ‘”–Š‡’ƒ–‹‡–•ȋ‹ Ž—†‹‰”ƒ†‹ƒ–‹‘–‘–Š‡†‘‘”Ǧ•‹–‡Ȍ ƒ† ‘•–•Ǥ 6) More data to share under the preoperative counseling of DIEAP flap patients: Š‹•–Š‡•‹•‘—–Ž‹‡•†ƒ–ƒ–Šƒ–ƒ”‡˜ƒŽ—ƒ„Ž‡ˆ‘”–Š‡’ƒ–‹‡–•„‡ˆ‘”‡ †‡ ‹†‹‰‘™Š‡–Š‡”–‘‰‘ˆ‘”ƒ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘‘”‘–Ǥ  ‘•‹–‹˜‡†ƒ–ƒƒ”‡ǣͳȌ ‡™’ƒ–‹‡–•‡š’‡”‹‡ ‡ƒ„†‘‹ƒŽˆŽƒ’‡ ”‘•‹•ǡʹȌ ›‡–”›‘ˆ–Š‡–™‘Š‡‹Ǧƒ„†‘‡•‹•™‡ŽŽ’”‡•‡”˜‡†ǡ͵ȌŠ‡•—’”ƒ—„‹Ž‹ ƒŽ †‡ ”‡ƒ•‡•ȋ’‘••‹„Ž›”‡•—Ž–‹‰‹ƒ–‹‰Š–‡”ǡ„‡––‡”Ž‘‘‹‰—’’‡”ƒ„†‘‡ȌǡͶȌ ‡™’ƒ–‹‡–•‡š’‡”‹‡ ‡Š‡”‹ƒ•ǡͷȌŠ‡ƒŒ‘”‹–›‘ˆ ˆŽƒ’’ƒ–‹‡–•ƒ”‡ •ƒ–‹•ˆ‹‡†™‹–Š–Š‡‹”’‘•–•—”‰‹ ƒŽƒ„†‘‡ǡ͸Ȍ ˆŽƒ’’ƒ–‹‡–•ƒ”‡‡“—ƒŽŽ›ƒ• •ƒ–‹•ˆ‹‡†™‹–Š–Š‡ƒ„†‘‡ƒ•’ƒ–‹‡–•ǡƒ†͹Ȍ ‡‡”ƒŽ’ƒ–‹‡–•ƒ–‹•ˆƒ –‹‘‹• ˜‡”›Š‹‰ŠǤ ‡‰ƒ–‹˜‡†ƒ–ƒƒ”‡ǣͳȌŠ‡•Šƒ’‡‘ˆ‘’‡”ƒ–‡†”‡ –—•—• Ž‡ Šƒ‰‡•ƒˆ–‡” •—”‰‡”›ȋ›‡–ǡ–Š‡ˆ— –‹‘ƒŽ‹’ƒ –‘ˆ–Š‹• Šƒ‰‡‹•‘–‹˜‡•–‹‰ƒ–‡†„›—•ȌǡʹȌ Š‡‹ˆ”ƒ—„‹Ž‹ ƒŽ‹ ”‡ƒ•‡•ȋ’‘••‹„Ž›‰‹˜‹‰”‹•‡–‘ƒ„†‘‹ƒŽ™ƒŽŽŽƒš‹–› ƒ†„—Ž‰‹‰Ȍǡ͵Ȍ ˆŽƒ’• ƒ ƒ—•‡’‡”•‹•–‡–•‡”‘ƒ•ǡͶȌ ˆŽƒ’•—”‰‡”› ‘—Ž††‡ ”‡ƒ•‡•‡š—ƒŽ†‡•‹”‡ǡƒ†ͷȌ ˆŽƒ’•—”‰‡”› ‘—Ž† ƒ—•‡‹ ”‡ƒ•‡† Š‡ƒŽ–Š ‘ ‡”•Ǥ 7) Written information provision: ’ƒ’‡” ǡͻͲΨ‘ˆ–Š‡ ‰”‘—’™‡”‡ •ƒ–‹•ˆ‹‡†™‹–Š–Š‡’”‡‘’‡”ƒ–‹˜‡ ‘—•‡Ž‹‰ǤŠ‹•‹•ƒƒ ‡’–ƒ„Ž‡’”‘’‘”–‹‘ǡ Š‘™‡˜‡”ǡ™‡„‡Ž‹‡˜‡–Šƒ––Š‡”‡‹•”‘‘ˆ‘”ƒ‹’”‘˜‡‡–Ǥ“—ƒŽ‹–ƒ–‹˜‡•–—†› ’‡”ˆ‘”‡†„›‘––‡”‡–ƒŽǤ ‘ Ž—†‡†–Šƒ–ǣDzȋͳȌ‹ˆ‘”ƒ–‹‘’”‘˜‹•‹‘‹• ‹ ‘•‹•–‡–ƒ†–Š‡”‡‹•ƒ‹•ƒ– Š„‡–™‡‡’ƒ–‹‡–•ƒ†’”‘ˆ‡••‹‘ƒŽ•̵ ’‡” ‡’–‹‘•‘ˆ–Š‡ƒ†‡“—ƒ ›‘ˆ‹ˆ‘”ƒ–‹‘’”‘˜‹†‡†ǡȋʹȌ’ƒ–‹‡–•̵‹ˆ‘”ƒ–‹‘ ‡‡†•ƒ”‡ —””‡–Ž›‘–„‡‹‰‡–Ǥdzȋʹ͸͹Ȍ ‘‡†‘—†‘—„–‡†Ž›ˆƒ ‡ƒ„‡™‹Ž†‡”‹‰ƒ””ƒ›‘ˆ‘’–‹‘•™Š‡‘’–‹‰ ˆ‘”ƒ„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŠ‡›Š‘’‡ƒ†„‡Ž‹‡˜‡–Šƒ––Š‡‹”’Žƒ•–‹ •—”‰‡‘™‹ŽŽ ‰—‹†‡–Š‡•–‡ƒ†‹Ž›–Š”‘—‰Š–Š‡†‡ ‹•‹‘’”‘ ‡••Ǥ—”‹‰’”‡‘’‡”ƒ–‹˜‡ ‘—•‡Ž‹‰ǡŠ‘™‡˜‡”ǡ’Žƒ•–‹ •—”‰‡‘•‹‰Š–‘–Šƒ˜‡•—ˆˆ‹ ‹‡––‹‡–‘‹ˆ‘” ’ƒ–‹‡–•ȋ™‹–Š‘Ǧ‡†‹ ƒŽ„ƒ ‰”‘—†Ȍǡƒ†–‘ƒ•™‡”–Š‡“—‡•–‹‘•–Šƒ–•Š‡ ‹‰Š–’‘••‡••Ǥ—‡–‘Ž‹––Ž‡–‹‡ǡƒ††‹ˆˆ‡”‡–‘™Ž‡†‰‡ƒ†˜‘ ƒ„—Žƒ”›ǡ˜‡”„ƒŽ ‹ˆ‘”ƒ–‹‘‹•ˆ”‡“—‡–Ž›‹•—†‡”•–‘‘†ƒ†Ȁ‘”ˆ‘”‰‘––‡Ǥȋʹ͸͹Ȍ  ˆ‘”ƒ–‹‘ ‘ ‡”‹‰„”‡ƒ•–”‡ ‘•–”— –‹‘‘’–‹‘••Š‘—Ž†ǡ–Š‡”‡ˆ‘”‡ǡ „‡’”‘˜‹†‡†ƒ•™”‹––‡‹ˆ‘”ƒ–‹‘ȋ‡Ǥ‰ǤŽ‡ƒˆŽ‡–•™‹–Š Ž‡ƒ”ǡ ‘’”‡Š‡•‹˜‡ ‘–‡–ƒ†Žƒ‰—ƒ‰‡ǡƒ†’Ž‡–›‘ˆ’Š‘–‘‰”ƒ’Š•Ȁ‹ŽŽ—•–”ƒ–‹‘•Ȍǡ–Šƒ–’ƒ–‹‡–• ƒ ”‡ƒ†‹ƒ—†‹•–—”„‡†ƒ†•ƒˆ‡‡˜‹”‘‡–ǤŠ‡”‡•Š‘—Ž†„‡ƒ•‡’ƒ”ƒ–‡Ž‡ƒˆŽ‡– ˆ‘”–Š‡ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ƒ•–Š‡”‡ƒ”‡•‘ƒ›ƒ•’‡ –•–‘ ‘˜‡” ȋ‹†‹ ƒ–‹‘•Ȁ ‘–”ƒ‹†‹ ƒ–‹‘•ǡ–‹‹‰ǡ’”‡’ƒ”ƒ–‹‘•ǡ•—”‰‹ ƒŽ–‡ Š‹“—‡ǡ”‹•• ƒ†„‡‡ˆ‹–•ǡ”‡ ‘˜‡”›ǡ“—ƒŽ‹–›‘ˆŽ‹ˆ‡‹’ƒ –ǡ‡– ǤȌǤŠ‹•™‹ŽŽ•—’’‘”–’”‘ˆ‡••‹‘ƒŽ• ’”‘˜‹†‹‰‹ˆ‘”ƒ–‹‘ǡƒ†Š‡Ž’’ƒ–‹‡–• Š‘‘•‹‰–Š‡„‡•–„”‡ƒ•–”‡ ‘•–”— –‹‘ ‘’–‹‘ˆ‘”–Š‡•‡Ž˜‡•ǤŽ–‹ƒ–‡Ž›ǡ’ƒ–‹‡–•™‹ŽŽ’”‘„ƒ„Ž›„‡‘”‡•ƒ–‹•ˆ‹‡†Ǥ 8) DIEAP flap or SIEA flap?  ˆŽƒ’•ƒ”‡ƒƒ––”ƒ –‹˜‡‘’–‹‘ˆ‘”ƒ—–‘Ž‘‰‘—• „”‡ƒ•–”‡ ‘•–”— –‹‘ƒ•–Š‡ƒ„†‘‹ƒŽˆƒ• ‹ƒ‹•Ž‡ˆ– ‘’Ž‡–‡Ž›‹˜‹‘Žƒ–‡Ǥ  ˆŽƒ’•Šƒ˜‡ǡ–Š‡”‡ˆ‘”‡ǡ„‡‡˜‹‡™‡†ƒ•ƒˆ—”–Š‡”‹’”‘˜‡‡–‘ˆƒ„†‘‹ƒŽˆŽƒ’• ƒ†•—’‡”‹‘”–‘–Š‡ ˆŽƒ’ǤŠ‹•‹†‡ƒŠƒ•ǡŠ‘™‡˜‡”ǡ„‡‡ ŠƒŽŽ‡‰‡†„›ƒ Žƒ”‰‡—Ž–‹ ‡–‡”•–—†›’—„Ž‹•Š‡†‹‹ʹͲͳͺǤȋʹ͸ͺȌŠ‡•–—†›‹ Ž—†‡†͹ʹͲ

79 79 ’ƒ–‹‡–•ȋͺͻ’‡†‹ Ž‡†ǡͳͳͷˆ”‡‡ǡͶͶͷ ǡƒ†͹ͳ Ȍƒ† ‘’ƒ”‡† ‘’Ž‹ ƒ–‹‘•ƒ†•ƒ–‘‡ƒ†–™‘›‡ƒ”•’‘•–‘’‡”ƒ–‹˜‡Ž›ǤŠ‡ •–—†›•—”’”‹•‹‰Ž›”‡˜‡ƒŽ‡†Š‹‰Š‡””ƒ–‡•‘ˆ†‘‘”Ǧ•‹–‡ ‘’Ž‹ ƒ–‹‘•ȋ‡•’‡ ‹ƒŽŽ› •‡”‘ƒǡŠ‡ƒ–‘ƒǡ™‘—†‹ˆ‡ –‹‘ǡƒ†™‘—††‡Š‹• ‡ ‡Ȍƒˆ–‡” ˆŽƒ’• ™Š‡ ‘’ƒ”‡†–‘ ˆŽƒ’•ǤŠ‡‘˜‡”ƒŽŽ†‘‘”Ǧ•‹–‡ ‘’Ž‹ ƒ–‹‘”ƒ–‡ƒ‘‰ –Š‡ ˆŽƒ’•ƒ––™‘›‡ƒ”•™ƒ•ǡ‹ˆƒ –ǡ”ƒ–Š‡”Š‹‰Šȋͷ͵ǤʹΨȌǤŠ‡•‡”‡•—Ž–•”ƒ‹•‡ –Š‡ˆ‘ŽŽ‘™‹‰“—‡•–‹‘ǣŠ‘—Ž†–Š‡ ˆŽƒ’•–‹ŽŽ„‡•‡‡ƒ••—’‡”‹‘”ƒ†–Š‡”‡„› ”‡’Žƒ ‡–Š‡ ˆŽƒ’ƒ•–Š‡‰‘Ž†•–ƒ†ƒ”†‹ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘ǫ  ›‘’‹‹‘ǡ–Š‡”‡ƒ”‡•‡˜‡”ƒŽ ‘–”ƒ†‹ –‹‘•ˆ‘”–Š‹•’ƒ”ƒ†‹‰•Š‹ˆ–ǣ ‹”•–Ž›ǡ–Š‡”‡ƒ”‡ƒ›•—”‰‹ ƒŽǦ–‡ Š‹ ƒŽ†‹•ƒ†˜ƒ–ƒ‰‡•‘ˆ Š‘‘•‹‰ƒ ˆŽƒ’ǣ ͳȌŠ‡ ‹•‘ˆ–‡ƒ„•‡–‘”–‘‘•ƒŽŽǡʹȌŠ‡ ’‡†‹ Ž‡‹••Š‘”–‡”ǡ͵ȌŠ‡  ƒ‰‹‘•‘‡‹•‹ ‘•‹•–‡–ƒ†Ž‡••”‡Ž‹ƒ„Ž‡ȋƒ†–Š‡”‡ˆ‘”‡˜‹‡™‡†ƒ•ƒŠ‡‹Ǧ ˆŽƒ’Ȍǡƒ†ͶȌ‰”‘™‹‰„‘†›‘ˆŽ‹–‡”ƒ–—”‡ǡ‹ƒ††‹–‹‘–‘–Š‡ƒˆ‘”‡‡–‹‘‡† —Ž–‹ ‡–‡”•–—†›ǡ†‘ —‡–Š‹‰Š‡””ƒ–‡•‘ˆˆƒ–‡ ”‘•‹•ǡ•‡”‘ƒ•ǡ”‡‘’‡”ƒ–‹‘•ǡ ƒ†ˆŽƒ’ˆƒ‹Ž—”‡•ȋ‘•–Ž›†—‡–‘ƒ”–‡”‹ƒŽ ‘’Ž‹ ƒ–‹‘•ȌǤȋͳͷ͵ǡʹ͸ͻǦʹ͹ͶȌ ˆƒ –ǡ —–Ž‡”ƒ†—”‡’‘”–‡†–Šƒ– ˆŽƒ’•Šƒ˜‡–Š”‡‡–‹‡•–Š‡”ƒ–‡‘ˆ‹‡†‹ƒ–‡ ’‘•–‘’‡”ƒ–‹˜‡ ‘’Ž‹ ƒ–‹‘• ‘’ƒ”‡†–‘ ˆŽƒ’•Ǥȋʹ͹ͶȌ‡ ‘†Ž›ǡ–Š‡ ƒ‡•–Š‡–‹ ”‡•—Ž–•‘ˆ„”‡ƒ•–”‡ ‘•–”— –‹‘—•‹‰ ƒ† ˆŽƒ’•Šƒ˜‡„‡‡ ˆ‘—†–‘„‡‹†‹•–‹‰—‹•Šƒ„Ž‡Ǥȋʹ͸ͻȌŠ‹”†Ž›ǡ–Š‡ ˆŽƒ’Šƒ•‰ƒ‹‡†„”‘ƒ† ƒ ‡’–ƒ ‡ƒ†Šƒ•‘”‡”‡Ž‹ƒ„Ž‡ǡ ‘•‹•–‡–‘—– ‘‡•Ǥȋʹ͸ͺǡʹ͹ʹȌ  •—ƒ”›ǡ–Š‡ —””‡–„‡‡ˆ‹–•‘ˆ–Š‡ ˆŽƒ’†‘‘–‘—–™‡‹‰Š–Š‡”‹•• ‹‘•–’ƒ–‹‡–•ȋ‡•’‡ ‹ƒŽŽ›‹—‹Žƒ–‡”ƒŽ”‡ ‘•–”— –‹‘•ȌǤŠ‡ ˆŽƒ’ǡ Š‘™‡˜‡”ǡ„ƒŽƒ ‡•™‡ŽŽ„‡–™‡‡–Š‡”‹••ȋ‡Ǥ‰Ǥ†‘‘”Ǧ•‹–‡‘”„‹†‹–›Ȍƒ†„‡‡ˆ‹–• ȋ‡Ǥ‰ǤˆŽƒ’•—”˜‹˜ƒŽȌǡƒ†•Š‘—Ž†”‡ƒ‹–Š‡‰‘Ž†•–ƒ†ƒ”†ǤŠ‡ ˆŽƒ’•Š‘—Ž† ‘Ž›„‡—†‡”–ƒ‡‹ˆ˜‡”›•–”‹ – ”‹–‡”‹ƒƒ”‡‡–ǡƒ•’”‘’‘•‡†„›‡Ž„‡”‡– ƒŽǤȋʹ͹͵Ȍ‡–ǡ‹„‹Žƒ–‡”ƒŽ”‡ ‘•–”— –‹‘•ǡ™Š‡”‡–Š‡”‡‹•ƒ ‘•‹†‡”ƒ„Ž‡‡š–‡–‘ˆ †‘‘”Ǧ•‹–‡‘”„‹†‹–›—•‹‰ ˆŽƒ’•ǡ–Š‡ ˆŽƒ’‹‰Š–„‡‘”‡ ƒ†˜ƒ–ƒ‰‡‘—•ȋ‰‹˜‡–Šƒ––Š‡˜‡••‡Ž•ƒ”‡ƒ†‡“—ƒ–‡ȌǤȋʹ͸ͻȌ 9) DIEAP flap or free paraumbilical perforator adiposal flaps? ‹‹Žƒ”–‘–Š‡  ˆŽƒ’ǡ™‡„‡Ž‹‡˜‡–Šƒ––Š‡ˆ”‡‡’ƒ”ƒ—„‹Ž‹ ƒŽ’‡”ˆ‘”ƒ–‘”ƒ†‹’‘•ƒŽˆŽƒ’• †‡‘•–”ƒ–‡†„›‘•Š‹ƒ‡–ƒŽǤ™‹ŽŽˆƒ ‡•‹‹Žƒ” ŠƒŽŽ‡‰‡•Ǥȋʹ͹ͷȌŽ–Š‘—‰Š–Š‹• –‡ Š‹“—‡‹˜‘Ž˜‡•‘Ž›ƒƒ–‡”‹‘””‡ –—••Š‡ƒ–Š‹ ‹•‹‘ƒ†˜‡”›Ž‹‹–‡† ‹–”ƒ—• —Žƒ”†‹••‡ –‹‘ȋ ƒ—•‹‰Ž‡••‹ƒ–”‘‰‡‹ —• Ž‡ƒ†‡”˜‡†ƒƒ‰‡ǡƒ† ”‡†— ‡†‘’‡”ƒ–‹˜‡–‹‡Ȍǡ–Š‡•‡’‡”ˆ‘”ƒ–‘”•Šƒ˜‡ƒ†‹ƒ‡–‡”‘ˆͲǤͷǦͲǤ͹Ǥȋʹ͹ͷȌ Š‹•‹•ǡ‹ˆƒ –ǡˆƒ”•ƒŽŽ‡”–Šƒ–Š‡ —•‡†Ǥ‡•’‹–‡–Š‡•ƒŽŽ†‹ƒ‡–‡”ǡ–Š‡ ƒ’ƒ‡•‡’Žƒ•–‹ •—”‰‡‘•ƒƒ‰‡†–‘”‡ ‘•–”— –„”‡ƒ•–•—•‹‰ •—’‡”‹ ”‘• ‘’‡•ƒ†ƒƒ•–‘‘•‡†–Š‡•‡’‡”ˆ‘”ƒ–‘”•ƒ†•ƒŽŽ‡”˜‡••‡Ž•‹–Š‡ ƒš‹ŽŽƒ”›”‡‰‹‘ȋ–Š‘”ƒ ‘†‘”•ƒŽ•›•–‡ǡ–Š‘”ƒ ‘‡’‹‰ƒ•–”‹ ˜‡‹ǡƒ†Žƒ–‡”ƒŽ–Š‘”ƒ ‹  ˜‡••‡Ž•ȌǤŠ‡ƒ—–Š‘”•Šƒ˜‡ǡ„›–Šƒ–ǡ’”‘˜‡–Šƒ–‹–‹•ƒƒ‰‡ƒ„Ž‡Ǥ‡–ǡ™‡„‡Ž‹‡˜‡ –Šƒ––Š‹•–‡ Š‹“—‡™‹ŽŽ ƒ—•‡•Š‘”–‡”’‡†‹ Ž‡•ǡ•ƒŽŽ‡”ˆŽƒ’•ǡ‘”‡ ƒ”–‡”‹ƒŽȀ˜‡‘—•‹•—ˆˆ‹ ‹‡ ›ǡƒ†ˆŽƒ’ˆƒ‹Ž—”‡•Ǥ ƒ††‹–‹‘ǡ–Š‡•ƒŽŽ’‡”ˆ‘”ƒ–‘” †‹ƒ‡–‡”™‹ŽŽ ƒ—•‡‹•ƒ– Š™‹–Š–Š‡ •›•–‡ƒ†’”‘„Ž‡ƒ–‹  ‹ ”‘˜ƒ• —Žƒ”ƒƒ•–‘‘•‹•Ǥ  ‘‘˜‡” ‘‡–Š‡•‡†‹•ƒ†˜ƒ–ƒ‰‡•ǡ •„”— Ǧ„ƒ•‡†’Žƒ•–‹ •—”‰‡‘•Šƒ˜‡ Žƒ–‡”‘†‹ˆ‹‡†–Š‡’ƒ”ƒ—„‹Ž‹ ƒŽ’‡”ˆ‘”ƒ–‘”ƒ†‹’‘•ƒŽˆŽƒ’Ǥȋʹ͹͸ȌŠ‡›ˆ‘ŽŽ‘™‡† ’‡”ˆ‘”ƒ–‘”•‹–”ƒ—• —Žƒ”Ž›ƒ†‹ Ž—†‡†ƒ’’”‘š‹ƒ–‡Ž›͵ ‘ˆ–Š‡‡†‹ƒŽ‘”

80 80 Žƒ–‡”ƒŽ„”ƒ Š‘ˆ–Š‡ ȋ–‘ƒ Š‹‡˜‡ƒ„‹‰‰‡”ƒ†Ž‘‰‡”˜ƒ• —Žƒ”’‡†‹ Ž‡‘ˆ ƒ’’”‘š‹ƒ–‡Ž›͹ ȌǤŠ‡ •™‡”‡—•‡†ˆ‘”ƒƒ•–‘‘•‹•Ǥ ‡”‡ǡͳͲ‘ˆͳͷ ’ƒ–‹‡–•‡‡†‡†˜‡‘—••—’‡” Šƒ”‰‹‰†—‡–‘•‹‰•‘ˆ˜‡‘—• ‘‰‡•–‹‘ǡƒ† ‘‡ˆŽƒ’ˆƒ‹Ž‡†„‡ ƒ—•‡‘ˆŽƒ–‡˜‡‘—•–Š”‘„‘•‹•Ǥ ‡ƒ‰ƒ‹ǡ™‡„‡Ž‹‡˜‡–Šƒ––Š‡ ”‹••‘˜‡”•Šƒ†‘™–Š‡„‡‡ˆ‹–•ǡƒ†˜‡”›Ž‹––Ž‡†‘‘”Ǧ•‹–‡‘”„‹†‹–›‹•’‘–‡–‹ƒŽŽ› •’ƒ”‡†Ǥ 10) The high DIEAP flap”: ‘—”‡’ƒ”–‡–ǡ–Š‡”‡‹•ƒŽ™ƒ›•ƒ†‡•‹”‡–Š‡Ž‘™‡”–Š‡  ˆŽƒ’‹Š‘’‡‘ˆ ‘ ‡ƒŽ‹‰–Š‡• ƒ”–‹••—‡Ǥ‡•’‹–‡•— Š‡ƒ•—”‡•ǡ–Š‡  ˆŽƒ’• ƒ”‹•‘”ƒŽŽ›‡ƒ•‹Ž›˜‹•‹„Ž‡ƒ„‘˜‡–Š‡—†‡”™‡ƒ”Ǥ‡†‘ǡ‹‘–Š‡” ™‘”†•ǡ‘–•— ‡‡†‹Ž‡ƒ˜‹‰‹‹ƒŽŽ›˜‹•‹„Ž‡• ƒ””‹‰Ǥƒ›„‡‹–‹•–‹‡–‘ˆ—ŽŽ› ƒ ‡’––Š‡˜‹•‹„Ž‡• ƒ”‹–Š‡Ž‘™‡”ƒ„†‘‡ƒ†‡š’Ž‹ ‹–Ž›‹ˆ‘”’ƒ–‹‡–•ƒ„‘—– –Š‹•’”‡‘’‡”ƒ–‹˜‡Ž›ǫƒ›„‡‹–‹•–‹‡ˆ‘”ƒ‡˜‡Š‹‰Š‡” ˆŽƒ’ǫ  ƒ•‡†‘–Š‡‰‘‘†•‹’‡”ˆ—•‹‘ˆ‘—†’”‡‘’‡”ƒ–‹˜‡Ž›‹œ‘‡•͵ƒ†Ͷ‘ˆ ‘—”•–—†›ƒ†–Š‡ƒƒ–‘‹ ƒŽˆ‹†‹‰•‘ˆƒƒ†‡–ƒŽǤ†‘ —‡–‹‰Žƒ”‰‡ ’‡”ˆ‘”ƒ–‘”••—’”ƒ—„‹Ž‹ ƒŽŽ›ȋ͵ͳΨ‘ˆ–Š‡†‘‹ƒ–’‡”ˆ‘”ƒ–‘”•™‡”‡ˆ‘—†ƒ–‘” ƒ„‘˜‡–Š‡—„‹Ž‹ —•Ȍǡ•‡Ž‡ –‡†’ƒ–‹‡–•‹‰Š–ƒ –—ƒŽŽ›„‡‡ˆ‹–ˆ”‘ƒ‘”‡ ”ƒ‹ƒŽŽ›•Š‹ˆ–‡† ˆŽƒ’ǤȋͳͲ͵Ȍ ‡”‡ǡƒ‡†Dz–Š‡Š‹‰Š ˆŽƒ’dzǤ— ŠˆŽƒ’•ǡ ‹ Ž—†‹‰‘”‡–‹••—‡•—’”ƒ—„‹Ž‹ ƒŽŽ›ǡ ‘—Ž†›‹‡Ž†Žƒ”‰‡”ƒ†‘”‡ ‡–”ƒŽ‹œ‡† ’‡”ˆ‘”ƒ–‘”•ǡ„‡––‡”’‡”ˆ—•‡†ˆŽƒ’•ǡƒ†ˆ‡™‡” ‹” —Žƒ–‘”› ‘’Ž‹ ƒ–‹‘•Ǥ  Š‡”‡ƒ”‡ǡ‘ˆ ‘—”•‡ǡ†‹•ƒ†˜ƒ–ƒ‰‡•‘ˆƒŠ‹‰Š‡” ˆŽƒ’ǣ ƒ††‹–‹‘–‘ƒ ‘•’‹ —‘—•• ƒ”ǡ–Š‡Š‹‰Š ˆŽƒ’™‹ŽŽ‡‰‡†‡”—„‹Ž‹ ƒŽ•—”‰‡”›ƒ† ’”‘„ƒ„Ž›‹ Ž—†‡Ž‡••ˆƒ––‹••—‡ȋ”‡•—Ž–‹‰‹•ƒŽŽ‡”ˆŽƒ’˜‘Ž—‡•ȌǤƒ›„‡–Š‡ ‡‡†‘ˆŽ‹’‘•— –‹‘’‘•–‘’‡”ƒ–‹˜‡Ž›™‹ŽŽ„‡‰”‡ƒ–‡”ƒ•ƒ‹†Ǧƒ„†‘‹ƒŽˆŽƒ’™‹ŽŽ ƒ‡–Š‡”‡†—†ƒ–ˆƒ––‹••—‡‹–Š‡Ž‘™‡”ƒ„†‘‡‘”‡˜‹•‹„Ž‡ǫ  Šƒ–„‡‹‰•ƒ‹†ǡ™‡„‡Ž‹‡˜‡–Šƒ––Š‡Š‹‰Š ˆŽƒ’™‹ŽŽ’”‘˜‹†‡ƒ˜‡”› ”‘„—•–ˆŽƒ’™‹–ŠŽ‹––Ž‡ˆŽƒ’ ‘’Ž‹ ƒ–‹‘•Ǥ Žƒ’•—”˜‹˜ƒŽ‹•’”‹‘”‹–‹œ‡†‘˜‡”†‘‘”Ǧ •‹–‡‘”„‹†‹–›ƒ†ƒ‡•–Š‡–‹ •Ǥ Š‡ˆ‘ŽŽ‘™‹‰ˆ‹‰—”‡•‹ŽŽ—•–”ƒ–‡–Š‡ƒ„—†ƒ ‡‘ˆ†‘‹ƒ–’‡”ˆ‘”ƒ–‘”• •—’”ƒ—„‹Ž‹ ƒŽŽ›ǡƒ†–Š‡ ‘ ‡’–‘ˆ–Š‡Š‹‰Š ˆŽƒ’‘—–Ž‹‡†„›ƒƒ†‡– ƒŽǤȋͳͲ͵Ȍ

81 81

Fig. 17 Physical location of the dominant perforators. X-axis marks the level of the umbilicus. Y-axis marks the midline. Note that 31 % of the dominant perforators are at or above the level of the umbilicus. Used with kind permission from Prof. Saad (Drexel University College of Medicine, Philadelphia, USA)

Fig. 18 The standard DIEAP flap design with the locations of the dominant perforators. Note that approximately one third of the perforators are at the edge or outside of the flap design (scale: each hash mark is 2 cm). Used with kind permission from Prof. Saad (Drexel University College of Medicine, Philadelphia, USA) 

82 82  

 Fig. 19 The cranially shifted DIEAP flap. Note that the perforators that were outside the design in figure 18 are now well within the boundaries of the flap (scale: each hash mark is 2 cm). Used with kind permission from Prof. Saad (Drexel University College of Medicine, Philadelphia, USA)

Future research: 1) Compare the undermined abdominal flap perfusion between DIEAP flaps using different recipient vessels: •ƒ ‘–‹—ƒ–‹‘‘ˆ–Š‡•–—†›„›‡”‰¤”†‡– ƒŽǤȋͳͲ͹Ȍƒ†’ƒ’‡” ǡ‹–™‘—Ž†Šƒ˜‡„‡‡‹–‡”‡•–‹‰–‘•–—†›–Š‡—†‡”‹‡† ƒ„†‘‹ƒŽˆŽƒ’’‡”ˆ—•‹‘ȋ ”ƒ‹ƒŽ–‘ ƒ—†ƒŽȌ‹ ˆŽƒ’•ƒƒ•–‘‘•‡†™‹–Š †‹ˆˆ‡”‡––‡ Š‹“—‡•ƒ†Ȁ‘””‡ ‹’‹‡–˜‡••‡Ž•Ǥ‡ ‘—Ž†ǡˆ‘”‹•–ƒ ‡ǡ ‘’ƒ”‡ ‡†Ǧ–‘Ǧ‡†ǡ ‡†Ǧ–‘Ǧ•‹†‡ǡƒ† ǤŠ‹••–—†› ‘—Ž†Šƒ˜‡’”‘˜‹†‡†—• ™‹–Š‘”‡•‘—†‡˜‹†‡ ‡‹–‡”•‘ˆ™Š‹ Š–‡ Š‹“—‡ƒ†”‡ ‹’‹‡–˜‡••‡Ž–‘ —•‡Ǥ 2) Employ new radiologic instruments in studying rectus muscle morbidity: ‡™‡”‡‘–ƒ„Ž‡–‘ ‘ˆ‹”–Š‡‡–‹‘Ž‘‰›‘ˆƒ†”‡ –—•—• Ž‡ Šƒ‰‡•‹ ’ƒ’‡” †—‡–‘–Š‡—•‡‘‘Ǧ ‘–”ƒ•–‡Šƒ ‡†• ƒ•Ǥƒ‰‡–‹ ”‡•‘ƒ ‡ ‹ƒ‰‹‰ǡƒ‰‡–‹ ”‡•‘ƒ ‡‡Žƒ•–‘‰”ƒ’Š›ǡƒ†—Ž–”ƒ•‘—†‡Žƒ•–‘‰”ƒ’Š›ƒ”‡ „‡––‡”‘†ƒŽ‹–‹‡•–‘•–—†›•— Š–‹••—‡ Šƒ‰‡•ǡƒ† ‘—Ž†Šƒ˜‡„‡‡—•‡†‹ƒ •‹‹Žƒ”•‡–Ǧ—’Ǥ 3) CT volume study investigating full rectus muscle length: •‡ƒ”Ž‹‡”†‹• —••‡†ǡ ‘’ƒ”‹‰—• Ž‡˜‘Ž—‡•‹•ƒ„‡––‡”‡–Š‘†–Šƒ ‘’ƒ”‹‰—• Ž‡œ‘‡• ȋ ”‘••Ǧ•‡ –‹‘•ȌǤ‘†ƒ›ǡ ƒ‡–ƒŽǤ‹•–Š‡‘Ž›”‡•‡ƒ” Š‰”‘—’–Šƒ–Šƒ•’—„Ž‹•Š‡† •— Šƒ‹˜‡•–‹‰ƒ–‹‘Ǥȋͳ͵ʹȌŠ‡›†‹†ǡŠ‘™‡˜‡”ǡ‘Ž› ‘’ƒ”‡–Š‡”‡ –—•—• Ž‡ ˜‘Ž—‡•ˆ”‘–Š‡—„‹Ž‹ —•ƒ†–‘–Š‡DzŽ‘™‡”ƒ”‰‹dzǤŠ‡–Š‡”–Š‡DzŽ‘™‡” ƒ”‰‹dz”‡’”‡•‡–•–Š‡’—„‹ •›’Š›•‹•‘”–Š‡ ƒ—†ƒŽ„‘”†‡”‘ˆ–Š‡Šƒ”˜‡•–‡†  ˆŽƒ’ȋ‘”•‘‡–Š‹‰‡Ž•‡Ȍǡ‹•— Ž‡ƒ”–‘—•Ǥ Šƒ˜‡–”‹‡†–‘ ‘–ƒ ––Š‡

83 83 ‘””‡•’‘†‹‰ƒ—–Š‘”–™‹ ‡Ǥ••‹‰‹ˆ‹ ƒ–”‡ –—•—• Ž‡ Šƒ‰‡•Šƒ˜‡„‡‡ •Š‘™–‘ƒ’’‡ƒ”ƒŽ•‘•—’”ƒ—„‹Ž‹ ƒŽŽ›ȋͺ͵Ȍǡ–Š‡ˆ—ŽŽŽ‡‰–Š‘ˆ–Š‡”‡ –—•—• Ž‡• •Š‘—Ž†„‡‹ Ž—†‡†‹–Š‹•‹˜‡•–‹‰ƒ–‹‘Ǥ 4) Compare DIEAP flaps with and without rectus plication: ‡ –—•’Ž‹ ƒ–‹‘‹• ”ƒ–Š‡”ˆ”‡“—‡–Ž›—†‡”–ƒ‡‹’”‘ ‡†—”‡•ǡ„—–”ƒ”‡Ž›’‡”ˆ‘”‡†‹  ˆŽƒ’•—”‰‡”›ȋ‡•’‡ ‹ƒŽŽ›‹‘—”‡’ƒ”–‡–ȌǤ•’ƒ’‡” †‡‘•–”ƒ–‡†•‹‰‹ˆ‹ ƒ– Šƒ‰‡•–‘–Š‡’‘•–‘’‡”ƒ–‹˜‡Ž›ǡ™Š‡”‡‹ˆ”ƒ—„‹Ž‹ ƒŽ‹ ”‡ƒ•‡†ǡƒ•–—†› ‘’ƒ”‹‰ ˆŽƒ’•™‹–Šƒ†™‹–Š‘—–”‡ –—•’Ž‹ ƒ–‹‘™‘—Ž†Šƒ˜‡„‡‡ ‹–‡”‡•–‹‰Ǥƒ–‡•‘ˆƒ„†‘‹ƒŽ ‘–‘—” Šƒ‰‡•ƒ†ƒ„†‘‹ƒŽƒ‡•–Š‡–‹ • ƒ••‡••‡†„›’Žƒ•–‹ •—”‰‡‘•ǡƒ†’ƒ–‹‡–Ǧ”‡’‘”–‡†‘—– ‘‡•ƒ†•ƒ–‹•ˆƒ –‹‘ǡ ‘—Ž†Šƒ˜‡„‡‡ ‘’ƒ”‡†ǤŠ‡•–—†›™‘—Ž†„‡‡ˆ‹–ˆ”‘ƒ’”‘•’‡ –‹˜‡†‡•‹‰–‘ Ž‹‹–„‹ƒ•Ǥ –‹‰Š–‡˜‡„‡’‘••‹„Ž‡–‘’‡”ˆ‘”ƒ”ƒ†‘‹œ‡† ‘–”‘ŽŽ‡†–”‹ƒŽ ȋȌǡŠ‘™‡˜‡”ǡ–Š‹•‹•ƒ”‰—ƒ„Ž‡†—‡–‘–Š‡ƒˆ‘”‡‡–‹‘‡†”‹••ƒ••‘ ‹ƒ–‡†™‹–Š ”‡ –—•’Ž‹ ƒ–‹‘Ǥ  —Š‘œ‡–ƒŽǤŠƒ˜‡ǡ‹ˆƒ –ǡ’‡”ˆ‘”‡†•— Šƒ•–—†›ǡŠ‘™‡˜‡”ǡ‹–™ƒ• ”‡–”‘•’‡ –‹˜‡ƒ†‹ Ž—†‡†•‡˜‡”ƒŽ†‹ˆˆ‡”‡––‡ Š‹“—‡•Ǥȋͺ͹ȌŠ‡ƒ—–Š‘”• ”‡’‘”–‡†–Šƒ–ƒŽŽ’ƒ–‹‡–•ƒ Š‹‡˜‡†ƒ‹’”‘˜‡†ƒ„†‘‹ƒŽ ‘–‘—”ǡƒ†–Šƒ–ͻ͵Ǥʹ Ψ™‡”‡•ƒ–‹•ˆ‹‡†™‹–Š–Š‡‹””‡•—Ž–•Ǥ‡–ǡ™Š‡‹–”‘†— ‹‰•‡˜‡”ƒŽ–‡ Š‹“—‡• ȋ‹ Ž—†‹‰Ž‹’‘•— –‹‘Ȍǡ‹–‹•†‹ˆˆ‹ —Ž––‘†‡–‡”‹‡–Š‡’‘•‹–‹˜‡Ȁ‡‰ƒ–‹˜‡‡ˆˆ‡ –•‘ˆ ”‡ –—•’Ž‹ ƒ–‹‘•‡’ƒ”ƒ–‡Ž›Ǥ 5) Compare DIEAP flaps with and without (barbed) progressive tension suture: ‡”•‹•–‡–•‡”‘ƒ•™‡”‡”‡ ‘”†‡†‹’ƒ’‡” Ǥ‘—Ž†–Š‡•‡Šƒ˜‡„‡‡ ’”‡˜‡–‡†„› Šƒ‰‹‰–Š‡–‡ Š‹“—‡‘ˆ†‘‘”Ǧ•‹–‡ Ž‘•—”‡ǫ •ȋ„ƒ”„‡†Ȍ ’”‘‰”‡••‹˜‡–‡•‹‘•—–—”‡„‡––‡”–Šƒ†”ƒ‹•‹–‡”•‘ˆ•‡”‘ƒ”ƒ–‡ǡ‘”•Š‘—Ž† –Š‡–™‘–‡ Š‹“—‡•„‡—•‡†–‘‰‡–Š‡”ǫ  ‘†ƒ›ǡ–Š‡”‡ƒ”‡•‘‡’—„Ž‹ ƒ–‹‘• ‘ ‡”‹‰ȋ„ƒ”„‡†Ȍ’”‘‰”‡••‹˜‡ –‡•‹‘•—–—”‡•‹ ˆŽƒ’•—”‰‡”›ǣƒ›‘ Ž‹‹ •–—†› ‘’ƒ”‡†„ƒ”„‡† ’”‘‰”‡••‹˜‡–‡•‹‘•—–—”‡ƒ††”ƒ‹•ƒ†ˆ‘—†‹•‹‰‹ˆ‹ ƒ–•‡”‘ƒ”ƒ–‡•Ǥȋʹ͹͹Ȍ •‹‰‹ˆ‹ ƒ–†ƒ–ƒ™‡”‡ƒŽ•‘”‡’‘”–‡†‹ƒ•–—†› ‘’Ž‡–‡†ƒ–ƒ›‘Ž‹‹ ƒ† ‘—–Š™‡•–‡”‡†‹ ƒŽ‡–‡”–Šƒ– ‘’ƒ”‡†–Š”‡‡‰”‘—’•‘ˆ†‘‘”Ǧ•‹–‡ Ž‘•—”‡•ǣ „ƒ”„‡†’”‘‰”‡••‹˜‡–‡•‹‘•—–—”‡•™‹–Šǡƒ†™‹–Š‘—–ǡ†”ƒ‹•ǡƒ†‘Ž› †”ƒ‹•Ǥȋʹ͹ͺȌ–Š‡‘–Š‡”Šƒ†ǡƒ—Ž–‹Ǧ ‡–‡”•–—†›–Šƒ– ‘’ƒ”‡† ˆŽƒ’• ™‹–Šƒ†™‹–Š‘—–’”‘‰”‡••‹˜‡–‡•‹‘•—–—”‡•ȋ™Š‡”‡„‘–Š‰”‘—’•Šƒ††”ƒ‹•Ȍ †‡‘•–”ƒ–‡†–Šƒ–ƒ„†‘‹ƒŽ“—‹Ž–‹‰•‹‰‹ˆ‹ ƒ–Ž›†‡ ”‡ƒ•‡†‡ƒ–‘–ƒŽ ƒ„†‘‹ƒŽ†”ƒ‹ƒ‰‡ȋʹ͵ͺŽ˜•ͷʹͺŽǡPαͲǤͲͲͲͷȌǤȋʹ͹ͻȌŠ‡”‡ƒ”‡ǡ‹‘–Š‡”• ™‘”†•ǡ•‘‡— ‡”–ƒ‹–›‹–‡”•‘ˆ–Š‡‡ˆˆ‡ –‘ˆȋ„ƒ”„‡†Ȍ’”‘‰”‡••‹˜‡–‡•‹‘ •—–—”‡ǡƒ†™Š‡–Š‡”‹–ƒƒ‰‡•–‘ˆ—ŽŽ›”‡’Žƒ ‡ƒ„†‘‹ƒŽ†”ƒ‹•Ǥ”‘•’‡ –‹˜‡ •–—†‹‡•™‹–Š–™‘Ȁ–Š”‡‡Žƒ”‰‡” ‘Š‘”–• ‘—Ž†›‹‡Ž†‘”‡†ƒ–ƒ‹†‹ ƒ–‹‰–Š‡„‡•– ™ƒ›‘ˆ Ž‘•‹‰–Š‡†‘‘”Ǧ•‹–‡Ǥ 6) Compare DIEAP flaps with and without the “CALP” technique: –‡”‡•–‹‰Ž›ǡ ‹• ‘–‹‡–ƒŽǤ‹’Ž‡‡–‡†–Š‡Dzdzȋ ƒ—ŽƒǦƒ••‹•–‡†ǡŽ‹‹–‡†—†‡”‹‹‰ǡ ƒ†’”‘‰”‡••‹˜‡Š‹‰ŠǦ–‡•‹‘•—–—”‡Ȍ–‡ Š‹“—‡‹ ˆŽƒ’•—”‰‡”›ǡ™Š‹ Šǡ –Š”‘—‰Šƒ”‡–”‘•’‡ –‹˜‡ƒƒŽ›•‹•ǡŽ‡ƒ†–‘•‹‰‹ˆ‹ ƒ–Ž›†‡ ”‡ƒ•‡††ƒ‹Ž›ƒ„†‘‹ƒŽ †”ƒ‹ƒ‰‡ǡ‡ƒ”Ž‹‡”†”ƒ‹”‡‘˜ƒŽǡƒ†ƒ†”ƒƒ–‹ ƒŽŽ›Ž‘™‡”•‡”‘ƒ”ƒ–‡Ǥȋͳͷ͸Ȍ ƒ•‡†‘–Š‡‹””‡•—Ž–•ǡ’”‘‰”‡••‹˜‡–‡•‹‘•—–—”‹‰‹‰Š–‘–„‡•—ˆˆ‹ ‹‡–„› ‹–•‡Žˆǡƒ†•Š‘—Ž†’‘–‡–‹ƒŽŽ›„‡ ‘„‹‡†™‹–Š ƒ—ŽƒǦƒ••‹•–‡†ƒ†Ž‹‹–‡†

84 84 —†‡”‹‹‰–‡ Š‹“—‡•Ǥ••— Šǡ ‘’ƒ”‹‰ ˆŽƒ’•™‹–Šƒ†™‹–Š‘—––Š‡ –‡ Š‹“—‡‹•ƒ‘–Š‡”‹–‡”‡•–‹‰•–—†›Ȃ’”‡ˆ‡”ƒ„Ž›’‡”ˆ‘”‡†ƒ•ƒ ƒ†‡“—ƒ–‡Ž›’‘™‡”‡†Ǥ 7) Compare DIEAP flaps with and without fibrin glue: › ‘’ƒ”‹‰ ˆŽƒ’ †‡ˆ‡ – Ž‘•—”‡•™‹–Šƒ†™‹–Š‘—–ˆ‹„”‹‰Ž—‡ǡ ƒ‰‡–ƒŽǤ†‘ —‡–‡†ƒ•‹‰‹ˆ‹ ƒ– ”‡†— –‹‘‘ˆ–‘–ƒŽ†”ƒ‹ƒ‰‡˜‘Ž—‡•ƒ†—„‡”‘ˆ†ƒ›•„‡ˆ‘”‡†”ƒ‹”‡‘˜ƒŽ„› ƒ’’Ž›‹‰ˆ‹„”‹‰Ž—‡Ǥ™‘‹ŽŽ‹Ž‹–‡”•‘ˆˆ‹„”‹‰Ž—‡™‡”‡™‹†‡Ž›•’”ƒ›‡†—†‡”–Š‡ —†‡”‹‡†ƒ„†‘‹ƒŽˆŽƒ’„‡ˆ‘”‡ˆ‹ƒŽ Ž‘•—”‡Ǥ”‘‰”‡••‹˜‡–‡•‹‘•—–—”‡• ™‡”‡—•‡†‹„‘–Š‰”‘—’•Ǥ‘•‡”‘ƒ™ƒ•”‡ ‘”†‡†ȋͷͶ’ƒ–‹‡–•‹–‘–ƒŽǢͶ͵ ’ƒ–‹‡–•‹‹–‡”˜‡–‹‘‰”‘—’ƒ†ͳͳ’ƒ–‹‡–•‹ ‘–”‘Ž‰”‘—’ȌǤŠ‡—•‡‘ˆˆ‹„”‹ ‰Ž—‡‹‰Š–„‡ƒ•ƒ”–ƒ†‡ƒ•‹Ž›’‡”ˆ‘”‡†•–”ƒ–‡‰›‹•‡”‘ƒ’”‡˜‡–‹‘Ǥ‘”‡ †ƒ–ƒƒ”‡‡‡†‡†Ȃ‹†‡ƒŽŽ›ƒŽ•‘ˆ”‘’ƒ–‹‡– ‘Š‘”–•™‹–Š‘—–’”‘‰”‡••‹˜‡–‡•‹‘ •—–—”‡•Ǥ 8) Compare DIEAP flaps with and without closed incision negative pressure therapy: ƒ‰‡–ƒŽǤȋαͳͲǡ„‹’‡†‹ Ž‡† ˆŽƒ’•Ȍƒ†—ŽŽ‡”ǦŽ‘‘ˆ‡–ƒŽǤȋαͷͳǡ  ƒ†ˆŽƒ’•Ȍ†‡‘•–”ƒ–‡†‹’”‘˜‡†• ƒ”“—ƒŽ‹–›ƒ†”‡†— ‡† ‹ ‹†‡ ‡‘ˆ™‘—††‡Š‹• ‡ ‡”‡•’‡ –‹˜‡Ž›„›—•‹‰ Ž‘•‡†‹ ‹•‹‘‡‰ƒ–‹˜‡ ’”‡••—”‡–Š‡”ƒ’›ǤȋʹͺͲǡʹͺͳȌŠ‡•‡‹’”‘˜‡‡–•‹‰Š–„‡ƒ”‡•—Ž–‘ˆ™‡ŽŽǦ ƒ’’”‘š‹ƒ–‡†™‘—†‡†‰‡•ǡ”‡†— ‡†‡†‡ƒǡ‹’”‘˜‡†’‡”ˆ—•‹‘ǡ‡š—†ƒ–‡ ”‡‘˜ƒŽǡƒ†Ž‡••‡š–‡”ƒŽ ‘–ƒ‹ƒ–‹‘ǤȋʹͺͲǡʹͺͳȌ –™‘—Ž†Šƒ˜‡„‡‡‘ˆ ‹–‡”‡•––‘’‡”ˆ‘”ƒ•–—†› ‘’ƒ”‹‰†‘‘”Ǧ•‹–‡‘”„‹†‹–›ȋ• ƒ”“—ƒŽ‹–›ǡ™‘—† †‡Š‹• ‡ ‡ǡ‹ˆ‡ –‹‘ǡ•‡”‘ƒǡ‡– ǤȌ„‡–™‡‡ȋ—‹Žƒ–‡”ƒŽȌ ˆŽƒ’•™‹–Š Ž‘•‡† ‹ ‹•‹‘‡‰ƒ–‹˜‡’”‡••—”‡–Š‡”ƒ’›ƒ†•–ƒ†ƒ”†•—”‰‹ ƒŽ†”‡••‹‰Ǥ 9) Compare DIEAP flaps with and without aesthetic refinement procedures: •‹ƒ†‡“—ƒ–‡ƒ––‡–‹‘‰‹˜‡–‘ƒ‡•–Š‡–‹ ”‡ˆ‹‡‡–‘ˆ–Š‡†‘‘”Ǧ•‹–‡ǫŠ‘—Ž† ™‡†‡†‹ ƒ–‡†Ž›†‹• —••ƒ‡•–Š‡–‹ ”‡ˆ‹‡‡–’”‘ ‡†—”‡•’”‡Ǧƒ†’‘•–‘’‡”ƒ–‹˜‡Ž› ™‹–Š–Š‡’ƒ–‹‡–•ǫ”‡• ƒ””‡˜‹•‹‘ǡ†‘‰Ǧ‡ƒ” ‘””‡ –‹‘ǡƒ†Ž‹’‘•— –‹‘ƒ––Š‡ †‘‘”Ǧ•‹–‡ƒƒ–—”ƒŽ’ƒ”–‘ˆ–Š‡„”‡ƒ•–”‡ ‘•–”— –‹‘’”‘ ‡••ǫ  –ƒ†Ž‡”‡–ƒŽǤ†‹†ǡ‹ˆƒ –ǡ’”‘’‘•‡–Šƒ–ƒ‡•–Š‡–‹ ”‡ˆ‹‡‡–’”‘ ‡†—”‡• •Š‘—Ž†„‡‹–‡‰”ƒ–‡†‹–Š‡•–ƒ†ƒ”†‹œ‡† ˆŽƒ’’”‘ ‡†—”‡Ǥȋ͵ͷȌŠ‡› ’‡”ˆ‘”‡†ƒ„†‘‹ƒŽ†‘‘”Ǧ•‹–‡”‡˜‹•‹‘†—”‹‰–Š‡•‡ ‘†•–ƒ‰‡‘ˆ ”‡ ‘•–”— –‹‘ǡ‹ Ž—†‹‰‡š ‹•‹‘ƒ†Ž‘™‡”‹‰‘ˆ–Š‡• ƒ”ǡƒ†Ž‹’‘•— –‹‘‘ˆ–Š‡ ƒ„†‘‡ƒ†‘•’—„‹•Ǥ ––‘‘–Š‡ƒ˜‡”ƒ‰‡Ž›Ž‡••–ŠƒŠƒŽˆƒŠ‘—”ǡƒ†–Š‡ ”‡’‘”–‡†”‡•—Ž–•ƒ”‡‰‘‘†Ǥ  –ƒ†ƒ”†‹œ‡†ƒ‡•–Š‡–‹ ”‡ˆ‹‡‡–’”‘ ‡†—”‡•ƒ––Š‡†‘‘”Ǧ•‹–‡‹•ƒ ‹–‡”‡•–‹‰‹†‡ƒǡƒ†’‘–‡–‹ƒŽŽ›ƒ‹–‡”˜‡–‹‘–Šƒ– ƒƒ—‰‡–’ƒ–‹‡– •ƒ–‹•ˆƒ –‹‘‘ˆ–Š‡†‘‘”Ǧ•‹–‡Ǥ ’Ž‡‡–ƒ–‹‘‘ˆƒ‡•–Š‡–‹ ”‡ˆ‹‡‡–’”‘ ‡†—”‡• †‘ǡŠ‘™‡˜‡”ǡˆ—ŽŽ›†‡’‡†‘–Š‡’ƒ–‹‡–•ǯ‘–‹˜ƒ–‹‘ƒ† ‘•‡–ˆ‘”—†‡”‰‘‹‰ ƒ††‹–‹‘ƒŽ•—”‰‡”›ǡƒ†‘–Š‡”‡•‘—” ‡•‘ˆ–Š‡†‡’ƒ”–‡–ȋ–‹‡ǡˆƒ ‹Ž‹–‹‡•ǡ ˆ—†‹‰ǡ’Žƒ•–‹ •—”‰‡‘•ǡ‡– ǤȌǤ  ‘”‡”‡•‡ƒ” Š‹•‡‡†‡†–‘ Žƒ”‹ˆ›–Š‡”‘Ž‡‘ˆƒ‡•–Š‡–‹ ”‡ˆ‹‡‡– ’”‘ ‡†—”‡•ƒ––Š‡†‘‘”Ǧ•‹–‡ǤŠ‹•™‹ŽŽ’”‘„ƒ„Ž›„‡ƒ”‡–”‘•’‡ –‹˜‡•—”‰‡”›ǡƒ•–Š‡ ‡‡†ƒ†™‹ŽŽˆ‘”•— Š’”‘ ‡†—”‡•ƒ”‡‘–’‡” ‡’–‹„Ž‡„‡ˆ‘”‡–Š‡ˆ‹”•–•–ƒ‰‡‘ˆ ”‡ ‘•–”— –‹‘Šƒ•„‡‡ ‘’Ž‡–‡†ǤŽ–‡”ƒ–‹˜‡Ž›ǡ‘‡ ƒ”‡ ”—‹–’‘•–Ǧˆ‹”•–•–ƒ‰‡ ”‡ ‘•–”— –‹‘’ƒ–‹‡–•ƒ†’‡”ˆ‘”ƒ’”‘•’‡ –‹˜‡•–—†›ˆ”‘–Š‡”‡Ǥ

85 85 10) A prospective study comparing preoperative and postoperative abdominal PROMs in DIEAP flap surgery: ‹††ƒ‡–ƒŽǤ”‡’‘”–‡†–Šƒ–͵ͶΨȋ̱ͳȀ͵Ȍ‘ˆ–Š‡‹”  ˆŽƒ’’ƒ–‹‡–•’”‡ˆ‡””‡†–Š‡‹”’”‡•—”‰‹ ƒŽƒ„†‘‡ǤȋͷʹȌŠ‹•‹•ƒ ‘ ‡” ƒ†•‘‡–Š‹‰™Š‹ Š•Š‘—Ž†„‡ˆ—”–Š‡”Ž‘‘‡†‹–‘Ǥ’”‘•’‡ –‹˜‡•–—†›ǡŽ‹‹–‹‰ –Š‡‡š–‡–‘ˆ„‹ƒ•ǡ™‹ŽŽ’”‘˜‹†‡‘”‡•‘—†‡˜‹†‡ ‡Ǥ 11) Investigate the delayed SIEA flap: ”‡‰‘”‹«‡–ƒŽǤŽ‹‰ƒ–‡†–Š‡‹’•‹Žƒ–‡”ƒŽ ‹ ʹ͸’ƒ–‹‡–•—†‡”‰‘‹‰•—”‰‡”›ˆ‘”Ž‘™‡”Ǧ‡š–”‡‹–›˜ƒ”‹ ‘•‡˜‡‹•Ǥȋʹ͹ͳȌ› —–‹Ž‹œ‹‰–Š‡†‡Žƒ›’Š‡‘‡‘ǡ–Š‡›ƒ Š‹‡˜‡†„‘–Šƒ•‹‰‹ˆ‹ ƒ–Ž›‹ ”‡ƒ•‡†  ˜‡••‡Ž†‹ƒ‡–‡”ȋΪʹ͸ΨȌƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž›‹ ”‡ƒ•‡† „Ž‘‘†ˆŽ‘™ȋΪͳʹ͹ΨȌǤ ƒ•‡†‘–Š‡‹”‘„•‡”˜ƒ–‹‘•ǡ–Š‡ƒ—–Š‘”•’”‘’‘•‡†ƒ†‡Žƒ›’”‘ ‡†—”‡—†‡”Ž‘ ƒŽ ƒ‡•–Š‡•‹ƒƒ†‹Ž†•‡†ƒ–‹‘‹ƒ‘ˆˆ‹ ‡Ǧ„ƒ•‡†•‡––‹‰‘‡Ǧ–™‘™‡‡ȋ•Ȍ’”‹‘”–‘ –Š‡’Žƒ‡†„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ†‡Žƒ›‡† ˆŽƒ’ ‘—Ž†’‘–‡–‹ƒŽŽ›ƒ Š‹‡˜‡ ƒƒ†‡“—ƒ–‡˜ƒ• —Žƒ”’‡†‹ Ž‡ƒ†ˆŽƒ’’‡”ˆ—•‹‘ȋ™‹–Šˆ‡™‡” ‘’Ž‹ ƒ–‹‘•ƒ† ˆŽƒ’ˆƒ‹Ž—”‡•Ȍǡƒ†ƒ‹‹ƒŽŽ›†ƒƒ‰‡††‘‘”Ǧ•‹–‡Ǥ•— ‡••ˆ—Ž†‡Žƒ›‡† ˆŽƒ’ Šƒ•ǡ‹ˆƒ –ǡ„‡‡”‡’‘”–‡†„›’Žƒ•–‹ •—”‰‡‘•ƒ–‡–Š •”ƒ‡Ž‡ƒ ‘‡••‡†‹ ƒŽ ‡–‡”‹‘•–‘ǤȋʹͺʹȌ  Ž–Š‘—‰Šƒ†‡Žƒ›‡† ˆŽƒ’‡ ‡••‹–ƒ–‡•ƒƒ††‹–‹‘ƒŽ’”‘ ‡†—”‡ǡ •ƒ ”‹ˆ‹ ‡•–Š‡‹’•‹Žƒ–‡”ƒŽ ǡƒ†’‘–‡–‹ƒŽŽ›‹–”‘†— ‡•”‹••ǡ–Š‹•‹•ƒ ‹–‡”‡•–‹‰ˆŽƒ’ ‘ ‡’–Ǥ –‹‰Š–„‡ƒ™ƒ›‘ˆ”‡†— ‹‰–Š‡•‹‰‹ˆ‹ ƒ–’”‘„Ž‡• ˆƒ ‡†”‡‰ƒ”†‹‰ƒ”–‡”‹ƒŽ‹•—ˆˆ‹ ‹‡ ›‹ ˆŽƒ’•Ǥ ›‘’‹‹‘ǡ–Š‡†‡Žƒ›‡†  ˆŽƒ’ ‘—Ž†’‘–‡–‹ƒŽŽ›”‡’Žƒ ‡–Š‡ ˆŽƒ’ƒ•‰‘Ž†•–ƒ†ƒ”†Ȃ‡•’‡ ‹ƒŽŽ›‹ —‹Žƒ–‡”ƒŽ„”‡ƒ•–”‡ ‘•–”— –‹‘•ǤŠ‡†‡Žƒ›‡† ˆŽƒ’‡‡†•ǡŠ‘™‡˜‡”ǡ‘”‡ †‡†‹ ƒ–‡†”‡•‡ƒ” Š„‡ˆ‘”‡‹’Ž‡‡–ƒ–‹‘Ǥ –‡”•‘ˆ”‡•‡ƒ” Šƒ’’”‘ƒ Š‡•ǡ–Š‡†‡Žƒ›‡† ˆŽƒ’• ‘—Ž†„‡ˆ—”–Š‡” •–—†‹‡†’”‡ˆ‡”ƒ„Ž›—•‹‰ƒ’’”‘’”‹ƒ–‡ƒ‹ƒŽ‘†‡Ž•Ǥ ˆ–Š‡ƒ‹ƒŽ‘†‡Ž• †‡‘•–”ƒ–‡ƒ‡ˆˆ‡ –‹˜‡ǡ”‡Ž‹ƒ„Ž‡ǡƒ†•ƒˆ‡’”‘ ‡†—”‡ǡ‘‡‹‰Š– ‘–‹—‡–Š‡ ”‡•‡ƒ” Š’”‘ ‡••ƒ†”‡ ”—‹–’ƒ–‹‡–•Ǥ‡’‘••‹„Ž‡•–—†›‹•–‘’”‘•’‡ –‹˜‡Ž› ”‡ ”—‹–ƒŽƒ”‰‡ ‘Š‘”–‘ˆ’ƒ–‹‡–•‘’–‹‰ˆ‘”ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘ǡƒ† —•‡–Š‡†‡ ‹•‹‘Ǧƒ‹‰ƒŽ‰‘”‹–Š‘ˆ™Š‡–‘’”‘ ‡‡†™‹–Š†‡Žƒ›‡† ˆŽƒ’•ƒ• ’”‘’‘•‡†„› ”‡‰‘”‹«‡–ƒŽǤȋ ‹‰ǤʹͲȌǤȋʹ͹ͳȌƒ–‹‡–•ƒ–‹•ˆƒ –‹‘ǡ†‘‘”Ǧ•‹–‡ ‘”„‹†‹–›ǡƒ†ˆŽƒ’‘—– ‘‡• ƒ„‡ ‘’ƒ”‡†„‡–™‡‡†‡Žƒ›‡† ƒ†  ˆŽƒ’•ǤŽ–‡”ƒ–‹˜‡Ž›ǡ‘‡ ‘—Ž† ‘’ƒ”‡•‹‹Žƒ”‘—– ‘‡•„‡–™‡‡†‡Žƒ›‡† ǡ ‘Ǧ†‡Žƒ›‡† ǡƒ† ˆŽƒ’•‹ƒ”‡–”‘•’‡ –‹˜‡ˆƒ•Š‹‘ǤŠ‹•™‹ŽŽ‹ Ž—†‡ ‘”‡„‹ƒ•Ǥ

86 86 

Fig. 20 The proposed decision-making algorithm of when to proceed with delaying the SIEA flap. Used with kind permission from Dr Gregori«(Department of Plastic and Reconstructive Surgery, University Medical Centre Maribor, Maribor, Slovenia)

12) Investigate the APEX flap (in unilateral breast reconstruction): ‘–‘ˆ–Š‡ ’”‡••ǡ–Š‡˜‡”›‡š ‹–‹‰ȋƒ„†‘‹ƒŽ’‡”ˆ‘”ƒ–‘”‡š Šƒ‰‡ȌˆŽƒ’Šƒ•„‡‡ ’”‘’‘•‡†„›ƒ„”‡ƒ•–”‡ ‘•–”— –‹‘ ‡–‡”‹‡™”Ž‡ƒ•Ǥȋͳ͸ʹȌŠ‡„ƒ•‹•‘ˆ –Š‡‹””‡•‡ƒ” Š‹•–Š‡ƒƒ–‘‹ ƒŽ˜ƒ”‹ƒ–‹‘•‹’‡”ˆ‘”ƒ–‘”ƒ””ƒ‰‡‡––Šƒ–ƒ› Š‹†‡”–Š‡’Žƒ•–‹ •—”‰‡‘ǯ•ƒ„‹Ž‹–›–‘‡ˆˆ‡ –‹˜‡Ž›ƒ˜‘‹†—• Ž‡ƒ†‡”˜‡ –”ƒ•‡ –‹‘ȋ™‹–Š‘—–‹’ƒ‹”‹‰ˆŽƒ’’‡”ˆ—•‹‘ȌǤŠ‡›Šƒ˜‡ǡ„ƒ•‡†‘–Š‹• †‹Ž‡ƒǡ’”‡•‡–‡†ƒ‡™–‡ Š‹“—‡‘ˆŠƒ”˜‡•–‹‰–Š‡˜ƒ• —Žƒ”’‡†‹ Ž‡ǤŠ‡ ’—„Ž‹ ƒ–‹‘‹ Ž—†‡•‡š ‡ŽŽ‡–ˆ‹‰—”‡•ƒ†˜‹†‡‘•Ǥ  Š‡ˆŽƒ’’‹ •—’™Š‡”‡–Š‡ ˆŽƒ’ˆƒŽŽ••Š‘”–‹–‡”•‘ˆˆŽƒ’• –Šƒ–‡‡†‘”‡–Šƒ‘‡’‡”ˆ‘”ƒ–‘”„—––Š‡’‡”ˆ‘”ƒ–‘”•ƒ˜ƒ‹Žƒ„Ž‡ƒ”‡‹•ƒŽ‹‰‡† ȋ‘Ǧ”‡ –‹Ž‹‡ƒ”Ȍƒ†•‡’ƒ”ƒ–‡†„›‹–‡”’‘•‡†„—†Ž‡•‘ˆ”‡ –—•—• Ž‡Ǥ •Ǧ Ȁ ˆŽƒ’•—”‰‡”›ǡ•— Š—• Ž‡„—†Ž‡•‹‰Š–„‡†‹˜‹†‡†–‘‹ Ž—†‡„‘–Š ’‡”ˆ‘”ƒ–‘”•Ǥ ˆŽƒ’•—”‰‡”›ǡŠ‘™‡˜‡”ǡ–Š‡‹•ƒŽ‹‰‡†’‡”ˆ‘”ƒ–‘”•ƒ”‡ ‹†‹˜‹†—ƒŽŽ›†‹•ƒ••‡„Ž‡†„‡‡ƒ–Š–Š‡—• Ž‡ȋ’”‡˜‡–‹‰—• Ž‡ƒ†‡”˜‡ †‹˜‹•‹‘Ȍǡƒ†Žƒ–‡””‡Ǧ ‘‡ –‡†‘ƒ•–‡”‹Ž‡•‹†‡–ƒ„Ž‡–‘ˆ‘”–Š‡˜ƒ• —Žƒ” ’‡†‹ Ž‡ȋ ‹‰ǤʹͳȌǤŠ‡‹•ƒŽ‹‰‡†’‡”ˆ‘”ƒ–‘”•ƒ”‡‹ Ž—†‡†–Š”‘—‰Š–Š‹• Dz‡š Šƒ‰‡dz‘ˆ–Š‡‹”ƒ–‹˜‡”‘—–‹‡’ƒ––‡”•ƒ†–Š‡ˆ‘ŽŽ‘™‹‰˜ƒ• —Žƒ””‡”‘—–‹‰Ǥ Š‡ƒ—–Š‘”•™”‹–‡ǣDz‡†‹ Ž‡†‹•ƒ••‡„Ž›†‡Ž‹˜‡”•–Š‡ˆ”‡‡†‘–‘‡‰‹‡‡”–Š‡ ˜ƒ• —Žƒ”‹–›”‡“—‹”‡†‹””‡•’‡ –‹˜‡‘ˆ–Š‡ƒƒ–‘›‡ ‘—–‡”‡†Ǥdzȋͳ͸ʹȌŠ‡ ˆŽƒ’‡”‰‡•ǡ‹•— Šƒƒ‡”ǡ“—ƒŽ‹–›’‡”ˆ—•‹‘™‹–Š‘—––Š‡–”ƒ†‡Ǧ‘ˆˆ‘ˆ •–”— –—”ƒŽ•ƒ ”‹ˆ‹ ‡™Š‡‡ ‘—–‡”‹‰‹•ƒŽ‹‰‡†’‡”ˆ‘”ƒ–‘”•Ǥ‡––‡”—• Ž‡ƒ†

87 87 ‡”˜‡’”‡•‡”˜ƒ–‹‘ƒ”‡ƒ Š‹‡˜‡†Ǥ 

 Fig. 21 The APEX flap. Based on the multiple, non-linear perforator supply, a pedicle disassembly is performed to prevent myotomy (sparing muscle fibers and nerves). The disassembled pedicle is later re-connected before recipient-site anastomosis. Used with kind permission from Dr. F. DellaCroce (Center for Restorative Breast Surgery, New Orleans, Louisiana, USA) Š‡ƒ—–Š‘”•‘ˆ–Š‡•–—†›Šƒ˜‡’”‘’‘•‡†ƒƒŽ‰‘”‹–Š‹–‡”•‘ˆ™Š‡–‘ —•‡ƒˆŽƒ’˜‡”•—•‘–Š‡”ƒ„†‘‹ƒŽˆ”‡‡ˆŽƒ’•ȋ ‹‰ǤʹʹȌǤ –Š‡‹”•‡”‹‡•‘ˆ͵͸Ͷ ˆŽƒ’•ȋƒŽŽ„‹Žƒ–‡”ƒŽ„”‡ƒ•–”‡ ‘•–”— –‹‘•Ȍǡ–Š‡›”‡’‘”–‡†ƒ ‘˜‡”•‹‘”ƒ–‡‘ˆ ͶͳǤͷΨˆ”‘’Žƒ‡† ˆŽƒ’•—”‰‡”›–‘ˆŽƒ’•—”‰‡”›—•‹‰–Š‹• ƒŽ‰‘”‹–ŠǤ‡ƒƒ††‹–‹‘ƒŽ‘’‡”ƒ–‹˜‡–‹‡™Š‡—•‹‰–Š‡ˆŽƒ’™ƒ•͵Ͷ ‹—–‡•’‡”ˆŽƒ’Ǥ Žƒ’ƒ††‘‘”Ǧ•‹–‡ ‘’Ž‹ ƒ–‹‘•™‡”‡‹’”‡••‹˜‡Ž›Ž‘™ǡƒ† ƒ„†‘‹ƒŽŠ‡”‹ƒȀ„—Ž‰‹‰™ƒ•‡ƒ”Ž› ‘’Ž‡–‡Ž›‡Ž‹‹ƒ–‡†Ǥ••— Šǡ–Š‡ ‹–”‘†— –‹‘‘ˆ†‹†‘–ƒ††ƒ›”‹•ȋƒ’ƒ”–ˆ”‘‹ ”‡ƒ•‡†‘’‡”ƒ–‹˜‡–‹‡ȌǤ ‘–Š‡”’‘–‡–‹ƒŽƒ†˜ƒ–ƒ‰‡‘ˆ–Š‡ˆŽƒ’‹•–Š‡’‘••‹„‹Ž‹–›‘ˆŽ‘™‡”‹‰ –Š‡ ˆŽƒ’Ǥ•†‹• —••‡†—†‡”Dz–Š‡Š‹‰Š ˆŽƒ’dzƒ„‘˜‡ǡ—–‹Ž‹œƒ–‹‘ƒ† ‡–”ƒŽ‹œƒ–‹‘‘ˆ†‘‹ƒ–ǡ’‡”‹—„‹Ž‹ ƒŽ’‡”ˆ‘”ƒ–‘”•ƒ”‡‰‘‘†•–”ƒ–‡‰‹‡•‹ ƒ Š‹‡˜‹‰™‡ŽŽǦ’‡”ˆ—•‡†ˆŽƒ’•ǤŠ‹•†”‹˜‡•ǡŠ‘™‡˜‡”ǡ–Š‡•—”‰‡‘–‘Š‹‰Š‡”–Š‡ ‹ ‹•‹‘ƒŽ’ƒ––‡”–‘ ƒ’–—”‡–Š‡ǤŠ‡”‡•—Ž–‹•ƒŠ‹‰ŠǦ”‹†‹‰• ƒ”Ž‹‡™Š‹ Š ‘—Ž†„‡ƒ‡•–Š‡–‹ ƒŽŽ›†‹•’Ž‡ƒ•‹‰Ǥ›—•‹‰–Š‡ˆŽƒ’ ‘ ‡’–ǡ‘‡†‘‡•‘–

88 88 ‡ ‡••ƒ”‹Ž›‡‡†–‘‰‘ˆ‘”–Š‡†‘‹ƒ–’‡”ˆ‘”ƒ–‘”Ǥ •–‡ƒ†ǡ–Š”‘—‰Š’‡†‹ Ž‡ †‹•ƒ••‡„Ž›ǡ‘‡ ƒ‹ ‘”’‘”ƒ–‡ƒ ‘—’Ž‡‘ˆ‡†‹—Ǧ•‹œ‡†ǡ›‡–”‡Ž‹ƒ„Ž‡ǡ ’‡”ˆ‘”ƒ–‘”•Ž‘ ƒ–‡†‘”‡ ƒ—†ƒŽŽ›Ǥ  Š‡”‡ƒ”‡ǡ‡˜‹†‡–Ž›ǡ•‡˜‡”ƒŽ’‘••‹„Ž‡ƒ†˜ƒ–ƒ‰‡•‘ˆ‹ Ž—†‹‰–Š‡ ˆŽƒ’‹‘—”ˆ”‡‡’‡”ˆ‘”ƒ–‘”ˆŽƒ’ƒ”•‡ƒŽǤŠ‡ˆŽƒ’‹•ǡ‘–Š‡‘–Š‡”Šƒ†ǡ •—„•–ƒ–‹ƒŽŽ›‘”‡–‡ Š‹ ƒŽ†‡ƒ†‹‰Ǥ –”‡“—‹”‡••‹ŽŽ•–‘ƒ ‘‘†ƒ–‡ ’‡†‹ Ž‡†‹•ƒ••‡„Ž›ƒ†‹ Ž—†‡•—’‡” Šƒ”‰‹‰ȋ Ȁ Ȍ™Š‡†‡‡‡†‘ˆ „‡‡ˆ‹–Ǥ –ƒŽ•‘ƒ††•ƒ‡•–Š‡•‹ƒ–‹‡–‘ƒƒŽ”‡ƒ†›Ž‘‰ǦŽƒ•–‹‰‘’‡”ƒ–‹˜‡ ’”‘ ‡†—”‡ǤŠ‡”‡ˆ‘”‡ǡ‘”‡”‡•‡ƒ” Š‹•‡‡†‡†–‘—†‡”•–ƒ†–Š‡’‘–‡–‹ƒŽ „‡‡ˆ‹–•‘ˆ—• Ž‡ƒ†‡”˜‡’”‡•‡”˜ƒ–‹‘–Š”‘—‰Š•— Š ŠƒŽŽ‡‰‹‰’‡†‹ Ž‡ †‹•ƒ••‡„Ž›Ǥ‹ŽŽ‘–Š‡”‹ ”‘•—”‰‹ ƒŽ ‡–‡”•„‡ƒ„Ž‡–‘‰‡–‡“—‹˜ƒŽ‡–Ž›‰‘‘† ”‡•—Ž–•ǫ  ›‘’‹‹‘ǡ–Š‡ˆŽƒ’‘ˆˆ‡”••—”‰‹ ƒŽˆ”‡‡†‘–Šƒ–Šƒ˜‡„‡‡ ‹••‡†‡ƒ”Ž‹‡”Ǥ –‹•ƒ‰‘‘†‡šƒ’Ž‡‘ˆƒ‹‘˜ƒ–‡‹†‡ƒ–Šƒ– ƒ”‡•—Ž–‹Ž‡•• †‘‘”Ǧ•‹–‡‘”„‹†‹–›Ǥ•–Š‡ˆŽƒ’•–—†›‹ Ž—†‡•‘Ž›„‹Žƒ–‡”ƒŽ„”‡ƒ•– ”‡ ‘•–”— –‹‘•ǡ–Š‡”‡‹•ƒ‡‡†–‘•–—†›‹–•”‘Ž‡‹—‹Žƒ–‡”ƒŽ„”‡ƒ•– ”‡ ‘•–”— –‹‘Ǥ 

Fig. 22 The APEX algorithm. Used with kind permission from Dr. F. DellaCroce (Center for Restorative Breast Surgery, New Orleans, Louisiana, USA)

89 89 13) Investigate the endoscopic DIEAP flap (“eDIEAP"): ‰”‘—’‘ˆƒ”‹•Ǧ„ƒ•‡† ’Žƒ•–‹ •—”‰‡‘•Šƒ•–Š”‘—‰Šƒ‡š’‡”‹‡–ƒŽǡ ƒ†ƒ˜‡”‹ •–—†›•Š‘™‡†–Šƒ– ‡†‘• ‘’‹  †‹••‡ –‹‘‹•ˆ‡ƒ•‹„Ž‡ƒ†”‡’”‘†— ‹„Ž‡Ȃ’‘–‡–‹ƒŽŽ› ‹‹‹œ‹‰†‘‘”Ǧ•‹–‡‘”„‹†‹–›„›”‡†— ‹‰–Š‡Ž‘‰ǡ˜‡”–‹ ƒŽˆƒ• ‹ƒ ‹ ‹•‹‘Ǥȋʹͺ͵ȌŠ‡›”ƒ‹•‡†ͳͲ ˆŽƒ’•‹ˆ‹˜‡ ƒ†ƒ˜‡”•ǡ™Š‡”‡–Š‡’”‡Ǧˆƒ• ‹ƒŽ  ˆŽƒ’Šƒ”˜‡•–‹‰ƒ†‹–”ƒ—• —Žƒ”’‡”ˆ‘”ƒ–‘”†‹••‡ –‹‘™ƒ•’‡”ˆ‘”‡† —•‹‰•–ƒ†ƒ”†–‡ Š‹“—‡ǡŠ‘™‡˜‡”ǡƒ‹–”ƒǦˆƒ• ‹ƒŽǡ‡†‘• ‘’‹ ƒ’’”‘ƒ Š™ƒ• ’‡”ˆ‘”‡†–‘ˆ”‡‡–Š‡’‡†‹ Ž‡ƒ–‹–•‘”‹‰‹ Ž‘•‡–‘–Š‡‡š–‡”ƒŽ‹Ž‹ƒ ƒ”–‡”›ǤŠ‡ ’”‘ ‡†—”‡”‡“—‹”‡†–Š”‡‡•ƒŽŽ–”‘ ƒ”‹ ‹•‹‘•ȋͷȌƒ†‘‡–”ƒ†‹–‹‘ƒŽˆƒ ‹ƒ ‹ ‹•‹‘‘ˆʹ ȋ”ƒ‰‡ǢͳǤͷǦʹǤͷ ȌǤ‡ƒ’‡†‹ Ž‡Ž‡‰–Š™ƒ•ͳʹ ȋ”ƒ‰‡ǢͻǦͳͷ Ȍǡƒ†–Š‡’‡†‹ Ž‡†‹••‡ –‹‘–‘‘ƒ˜‡”ƒ‰‡Ž›͹Ͳ‹ȋ”ƒ‰‡ǢͶͷǦͳͳͲ‹ȌǤ 14) Investigate the use of minimally invasive pedicle harvest with Jacob’s ladder incisions: •ƒƒŽ–‡”ƒ–‹˜‡–‘–Š‡‡†‘• ‘’‹ ƒ’’”‘ƒ Š†‡• ”‹„‡†ƒ„‘˜‡ǡ ’Žƒ•–‹ •—”‰‡‘•ˆ”‘–—––‰ƒ”–Šƒ˜‡†‡• ”‹„‡†ƒ‹‹ƒŽŽ›‹˜ƒ•‹˜‡’‡†‹ Ž‡ Šƒ”˜‡•–™‹–Š ƒ ‘„ǯ•Žƒ††‡”‹ ‹•‹‘•„ƒ•‡†‘•‡˜‡‘’‡”ƒ–‡†’ƒ–‹‡–•ȋ•‹š —‹Žƒ–‡”ƒŽǡ‘‡„‹Žƒ–‡”ƒŽȌǤȋʹͺͶȌ –Š‡‹”Ž‡––‡”ǡ–Š‡ƒ—–Š‘”•†‡• ”‹„‡ƒ†‹ŽŽ—•–”ƒ–‡ –Š‡—•‡‘ˆ•–ƒ†ƒ”†”‡–”ƒ –‘”•ȋ‡ƒ„Ž‹‰ƒ–—‡Ž‡†ǡ•—„ˆƒ• ‹ƒŽǡ‹‹ƒŽŽ› ‹˜ƒ•‹˜‡†‹••‡ –‹‘Ȍǡ•ƒ‰‹––ƒŽ•’Ž‹––‹‰‘ˆ—• Ž‡ˆ‹„”‡•ǡ•’ƒ”‹‰‘ˆ•‡‰‡–ƒŽ ‘–‘”‡”˜‡•ǡƒ†–Š‡‡‡†‘ˆ–™‘Ȁ–Š”‡‡–”ƒ•˜‡”•‡‹ ‹•‹‘•ȋˆƒ ‹Ž‹–ƒ–‹‰–Š‡ ’”‘š‹ƒŽǦ†‹•–ƒŽ†‹••‡ –‹‘ȌǤŠ‹•‡–Š‘†’”‡•‡”˜‡•‘”‡‘ˆ–Š‡ƒ–‡”‹‘”•Š‡ƒ–Š‘ˆ –Š‡”‡ –—•—• Ž‡ ‘’ƒ”‡†–‘–Š‡•–ƒ†ƒ”† ˆŽƒ’’”‘ ‡†—”‡Ǥ 15) Investigate the robot-assisted DIEAP flap:  ‡„”—ƒ”›ʹͲͳͺǡƒˆ‡™‘–Š• ƒˆ–‡”–Š‡‡ ’—„Ž‹ ƒ–‹‘‡–‹‘‡†ƒ„‘˜‡ǡƒ‘–Š‡”‰”‘—’‘ˆ ”‡ Š’Žƒ•–‹  •—”‰‡‘•’—„Ž‹•Š‡†ƒ ƒ†ƒ˜‡”•–—†›–Šƒ–ƒ••‡••‡†–Š‡ˆ‡ƒ•‹„‹Ž‹–›‘ˆ”‘„‘–Ǧƒ••‹•–‡† †‹••‡ –‹‘‘ˆ–Š‡˜ƒ• —Žƒ”’‡†‹ Ž‡ǤȋʹͺͷȌ ‡”‡ǡ–Š‡’”‡Ǧˆƒ• ‹ƒŽƒ†‹–”ƒǦ—• —Žƒ” †‹••‡ –‹‘•™‡”‡ ‘˜‡–‹‘ƒŽŽ›’‡”ˆ‘”‡†ȋŽ‹‡–Š‡‡ Ȍǡƒ†ƒ”‘„‘–‹  ƒ’’”‘ƒ Š™ƒ•—•‡†–‘ ‘’Ž‡–‡–Š‡˜ƒ• —Žƒ”’‡†‹ Ž‡†‹••‡ –‹‘‹ƒ‹–”ƒǦˆƒ• ‹ƒŽ ƒ‡”ǤŠ‡ƒ—–Š‘”•Ž‹•––Š‡ƒ›ƒ†˜ƒ–ƒ‰‡•‘ˆ”‘„‘–Ǧƒ••‹•–‡††‹••‡ –‹‘™Š‹ Š ‘—Ž†ˆƒ ‹Ž‹–ƒ–‡–Š‡ƒ””‘™‹–”ƒǦˆƒ• ‹ƒŽ†‹••‡ –‹‘Ǥ‹‹Žƒ”–‘–Š‡‡ ǡ–Š‡ ”‘„‘–Ǧƒ••‹•–‡† ˆŽƒ’ ‘—Ž†‰”‡ƒ–Ž›”‡†— ‡–Š‡ˆƒ• ‹‘–‘›‡‡†‡†ƒ† –Š‡”‡„›’”‡•‡”˜‡‘”‡‘ˆ–Š‡ƒ–‡”‹‘””‡ –—••Š‡ƒ–ŠǤ‘”‡‘˜‡”ǡ‘ˆƒ• ‹ƒŽ‹ ‹•‹‘ „‡Ž‘™–Š‡ƒ” —ƒ–‡Ž‹‡™ƒ•‡‡†‡†Ǥ  Š‡•ƒ‡›‡ƒ”ǡ‹‡’–‡„‡”ǡ–Š‡ˆ‹”•– ƒ•‡”‡’‘”–‘ˆƒ ˆŽƒ’ Šƒ”˜‡•–‡†„›–Š‡—•‡‘ˆ†ƒ‹ ‹”‘„‘–™ƒ•’—„Ž‹•Š‡†Ǥȋʹͺ͸Ȍ‹–”ƒǦƒ„†‘‹ƒŽ ȋ‘–‹–”ƒǦˆƒ• ‹ƒŽȌ†‹••‡ –‹‘™ƒ•—•‡†–‘Šƒ”˜‡•––Š‡’‡†‹ Ž‡ǤŠ‡’”‘ ‡†—”‡–‘‘ ƒŽ‘•–‹‡Š‘—”•ǡ‹ Ž—†‹‰ƒƒ††‹–‹‘ƒŽʹͲ‹—–‡•–‘†‘ –Š‡”‘„‘–ǤŠ‡ ”‘„‘–Ǧƒ••‹•–‡††‹••‡ –‹‘‘ˆ–Š‡‹–”ƒǦƒ„†‘‹ƒŽ’‡†‹ Ž‡–‘‘ƒ’’”‘š‹ƒ–‡Ž›ͶͲ ‹—–‡•ǤŠ‡‘—–Šƒ”‘Ž‹ƒǦ„ƒ•‡†•—”‰‡‘•†‡‘•–”ƒ–‡†„›–Š‹•–Šƒ––Š‡”‘„‘–Ǧ ƒ••‹•–‡† ˆŽƒ’‹•’‘••‹„Ž‡ǤŠ‡“—‡•–‹‘‹•ǣ ‘™— Š†‘‘”Ǧ•‹–‡‘”„‹†‹–› ‹••’ƒ”‡†ǫ•ƒƒ––‡”‘ˆˆƒ –ǡ„›—•‹‰–Š‡‹–”ƒǦƒ„†‘‹ƒŽƒ’’”‘ƒ Šȋ†ƒƒ‰‹‰ „‘–Š–Š‡’‘•–‡”‹‘””‡ –—••Š‡ƒ–Šƒ†–Š‡’‡”‹–‘‡—Ȍǡ‘‡ ‘—Ž†’‘–‡–‹ƒŽŽ›‡† —’‹ ”‡ƒ•‹‰–Š‡†‘‘”Ǧ•‹–‡‘”„‹†‹–›Ǥȋʹͺ͹ȌŠ‡’ƒ–‹‡–Šƒ†ǡŠ‘™‡˜‡”ǡ‘•‹‰ ‘ˆ ‘’Ž‹ ƒ–‹‘ƒ–‹‡Ǧ‘–Š•ˆ‘ŽŽ‘™Ǧ—’Ǥ  Š‡‘•–”‡ ‡–’—„Ž‹ ƒ–‹‘ ‘ ‡”‹‰–Š‡”‘„‘–Ǧƒ••‹•–‡† ˆŽƒ’ ƒ‡‹ ‡„”—ƒ”›ʹͲʹͲƒ†™ƒ•™”‹––‡„›”‘ˆǤ‡Ž„‡”ƒ––Š‡‹˜‡”•‹–›‘ˆ‡šƒ• †‡”•‘ƒ ‡”‡–‡”ǤȋʹͺͺȌ ‡„‡Ž‹‡˜‡•–Šƒ––Š‡”‘„‘–Ǧƒ••‹•–‡†ƒ’’”‘ƒ Šǡ

90 90 ‘„‹‹‰‘’‡†‹••‡ –‹‘‘ˆ–Š‡’‡”ˆ‘”ƒ–‘”ƒ†‹–”ƒǦƒ„†‘‹ƒŽ†‹••‡ –‹‘‘ˆ –Š‡’‡†‹ Ž‡ǡ ‘—Ž†„‡–Š‡‡š–Ž‘‰‹ ƒŽ•–‡’‹–Š‡‡˜‘Ž—–‹‘‘ˆƒ—–‘Ž‘‰‘—•„”‡ƒ•– ”‡ ‘•–”— –‹‘Ǥ› ‘„‹‹‰–Š‡–‡ Š‹“—‡•ǡ–Š‡’‘–‡–‹ƒŽ”‡•—Ž–‹•ƒ ˆŽƒ’ ™‹–Š–Š‡•Š‘”–‡•–ˆƒ• ‹ƒŽ‹ ‹•‹‘ƒ†Ž‘‰‡•–’‡†‹ Ž‡Ž‡‰–ŠǤŠ‡‹”‡ƒ”Ž› ‡š’‡”‹‡ ‡™‹–Š–Š‹•–‡ Š‹“—‡‹•’”‘‹•‹‰Ȃ•—‰‰‡•–‹‰Ž‡••’‘•–‘’‡”ƒ–‹˜‡’ƒ‹ǡ •Š‘”–‡”•–ƒ›•ǡƒ†‡Šƒ ‡†‘˜‡”ƒŽŽ”‡ ‘˜‡”›Ǥƒ–‹‡–•‡Ž‡ –‹‘ƒ†–‡ Š‹ ƒŽ †‡• ”‹’–‹‘ƒ”‡†‹• —••‡†‹–Š‡ƒ”–‹ Ž‡Ǥ  ‡•’‹–‡–Š‡•‡’”‘‹•‹‰”‡’‘”–• ‘ ‡”‹‰–Š‡”‘„‘–Ǧƒ••‹•–‡† ˆŽƒ’ǡ ‘”‡‡š’‡”‹‡ ‡‹•‡‡†‡†Ǥ ‘™— Š–”ƒ‹‹‰‹•‡ ‡••ƒ”›–‘‹–”‘†— ‡”‘„‘–Ǧ ƒ••‹•–‡†•—”‰‡”›‹‘—”‡’ƒ”–‡–ǫŠƒ–ƒ”‡–Š‡”‹••‘ˆŠƒ”˜‡•–‹‰–Š‡ˆŽƒ’‹ –Š‹•ƒ‡”ǫ •–Š‡‹–”ƒǦˆƒ ‹ƒŽƒ’’”‘ƒ Š‘ˆ†‹••‡ –‹‰–Š‡˜ƒ• —Žƒ”’‡†‹ Ž‡ ˆ‡ƒ•‹„Ž‡‹ Ž‹‹ ƒŽ ƒ•‡•ǫ‘‡•–Š‡’‘–‡–‹ƒŽŽ›”‡†— ‡††‘‘”Ǧ•‹–‡‘”„‹†‹–› ‘—–™‡‹‰Š–Š‡‡š–‡†‡†‘’‡”ƒ–‹˜‡–‹‡ƒ†‹ ”‡ƒ•‡† ‘•–•ǫ  Final reflections: Š‘’‡–Šƒ––Š‹•†‘ –‘”ƒŽ–Š‡•‹•Šƒ•’”‘˜‹†‡†˜ƒŽ—ƒ„Ž‡‹ˆ‘”ƒ–‹‘‹ –Š‡’”‘ ‡••‘ˆ‹’”‘˜‹‰ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘•Ǥ –Š‡‡†ǡ ƒ•›•‡Žˆǣ • –Š‡ —””‡– ˆŽƒ’’”‘ ‡†—”‡•ƒ–‹•ˆƒ –‘”›ǫ‘™‡‡‡†–‘‹ ”‡ƒ•‡‘’‡”ƒ–‹˜‡–‹‡ ƒ† ‘•–•ǡ”ƒ‹•‡–Š‡„ƒ”„›—•‹‰–Š‡‘•–ƒ†˜ƒ ‡†•—”‰‹ ƒŽ–‡ Š‘Ž‘‰›ǡƒ†’‘••‹„Ž› ’—–’ƒ–‹‡–ƒ–”‹•™‹–Š‡™‡–Š‘†•ǫ  ›‘’‹‹‘ǡ™‡Šƒ˜‡ˆ‘—†ƒ–”—•–‡†ˆ”‹‡†‹–Š‡ —””‡– ˆŽƒ’ ’”‘ ‡†—”‡Ǥ —”–Š‡”‹’”‘˜‡‡–•ƒ”‡‘–‡ ‡••ƒ”‹Ž›ƒ”‡•—Ž–‘ˆ‡™ƒ†‘”‡ ƒ†˜ƒ ‡†•—”‰‹ ƒŽ–‡ Š‹“—‡•Ǥ ‰‡—‹‡Ž›„‡Ž‹‡˜‡–Šƒ––Š‡”‡ƒ”‡‡ƒ•‹‡”™ƒ›•‘ˆ ‹’”‘˜‹‰„”‡ƒ•–”‡ ‘•–”— –‹‘•Ǥ—”†ƒ›Ǧ–‘Ǧ†ƒ› Ž‹‹ ƒŽ’”ƒ –‹ ‡‹•‹ˆƒ –ˆ‹ŽŽ‡†™‹–Š Ž‘™ǦŠƒ‰‹‰ˆ”—‹–•ǡ™Š‹ Š ƒǡ‹ˆ”‡ ‘‰‹œ‡†ǡ‹’”‘˜‡•ƒˆ‡–›ƒ†‘—– ‘‡•Ǥ‘‡‘ˆ› ‹†‡ƒ•ƒ”‡ǣͳȌ ’”‘˜‡†’”‡‘’‡”ƒ–‹˜‡ ‘—•‡Ž‹‰ȋ•—’’‘”–‡†„›™‡ŽŽǦ‹ŽŽ—•–”ƒ–‡†ǡ™”‹––‡ ’ƒ–‹‡–‹ˆ‘”ƒ–‹‘ȌǡʹȌ‘”‡ƒ––‡–‹‘–‘–Š‡†‘‘”†‡ˆ‡ – Ž‘•—”‡ȋ–›’‹ ƒŽŽ›’‡”ˆ‘”‡† „›”‡•‹†‡–•Ȍǡƒ†͵Ȍ–ƒ†ƒ”†‹œ‡†ˆ‘ŽŽ‘™Ǧ—’”‘—–‹‡•ȋ‹ Ž—†‹‰’Š›•‹ ƒŽ‡šƒ‹ƒ–‹‘‘ˆ –Š‡†‘‘”Ǧ•‹–‡ȌǤ–Š‡”ǡ‘”‡Ž‘‰Ǧ–‡”‰‘ƒŽ•ǡƒ”‡ǣͳȌŠ‘”–‡”•—”‰‹ ƒŽ™ƒ‹––‹‡•ˆ‘” „”‡ƒ•–”‡ ‘•–”— –‹‘ǡʹȌŽ‹‹ ƒŽ†ƒ–ƒ”‡‰‹•–”›ǡ͵Ȍ–ƒ†ƒ”†‹œ‡†‹ ”‘•—”‰‹ ƒŽ –”ƒ‹‹‰Ȁˆ‡ŽŽ‘™•Š‹’•ȋ‹‘”™ƒ›Ȍǡƒ†ͶȌ ƒ†‹ƒ˜‹ƒ—Ž–‹ ‡–‡”•–—†‹‡•Ǥ    Šƒ›‘—ˆ‘”–ƒ‹‰›‘—”–‹‡”‡ƒ†‹‰›†‘ –‘”ƒŽ–Š‡•‹•Ǥ     

91 91 10 References

ͳǤ ‹–ŠǤ”‹‰‹ƒ†—•‡•‘ˆ’”‹—‘‘ ‡”‡ǦǦƒ„‘˜‡ƒŽŽǡ†‘‘Šƒ”Ǩ Ž‹Šƒ”ƒ ‘ŽǤ ʹͲͲͷǢͶͷȋͶȌǣ͵͹ͳǦ͹Ǥ ʹǤ ”‡ˆ–”‡‰‹•–‡”‡–Ǥ%”•”ƒ’’‘”–ʹͲͳͺ‡†”‡•—Ž–ƒ–‡”‘‰ˆ‘”„‡†”‹‰•–‹Ž–ƒˆ”ƒƒ•Œ‘ƒŽ–˜ƒŽ‹–‡–•”‡‰‹•–‡” ˆ‘”„”›•–”‡ˆ–Ǥ•Ž‘ǢʹͲͳͻǤ ͵Ǥ ‡”‘‡•‹ǡƒ• ‹‡ŽŽ‹ǡƒ”‹ƒ‹ǡ ”‡ ‘ǡƒ ‘œœ‹ǡ—‹‹ǡ‡–ƒŽǤ™‡–›Ǧ›‡ƒ”ˆ‘ŽŽ‘™Ǧ—’‘ˆƒ ”ƒ†‘‹œ‡†•–—†› ‘’ƒ”‹‰„”‡ƒ•–Ǧ ‘•‡”˜‹‰•—”‰‡”›™‹–Š”ƒ†‹ ƒŽƒ•–‡ –‘›ˆ‘”‡ƒ”Ž›„”‡ƒ•– ƒ ‡”Ǥ‰Ž ‡†ǤʹͲͲʹǢ͵Ͷ͹ȋͳ͸Ȍǣͳʹʹ͹Ǧ͵ʹǤ ͶǤ Š”‹•–‹ƒ•‡ǡƒ”•–‡•‡ǡŒŽ‡”–•‡ǡ”‘ƒǡˆˆ‡”•‡ǡ‘†‹Ž•‡ǡ‡–ƒŽǤ”‡ƒ•– ‘•‡”˜‹‰•—”‰‡”›˜‡”•—•ƒ•–‡ –‘›ǣ‘˜‡”ƒŽŽƒ†”‡Žƒ–‹˜‡•—”˜‹˜ƒŽǦƒ’‘’—Žƒ–‹‘„ƒ•‡†•–—†›„› –Š‡ƒ‹•Š”‡ƒ•–ƒ ‡”‘‘’‡”ƒ–‹˜‡ ”‘—’ȋ ȌǤ –ƒ ‘ŽǤʹͲͳͺǢͷ͹ȋͳȌǣͳͻǦʹͷǤ ͷǤ — ǡ ”‘‘– ǡ‘†‡ǡ—• Šǡ ‘Ž–•Žƒ†‡”ǡ‹ Ǥ‡˜‹‡™‘ˆ ƒ –‘”• ˆŽ—‡ ‹‰‘‡̵• Š‘‹ ‡‘ˆƒ•–‡ –‘›‡”•—•”‡ƒ•–‘•‡”˜‹‰Š‡”ƒ’›‹ƒ”Ž›–ƒ‰‡”‡ƒ•–ƒ ‡”ǣ›•–‡ƒ–‹  ‡˜‹‡™ǤŽ‹”‡ƒ•–ƒ ‡”ǤʹͲͳͺǢͳͺȋͶȌǣ‡ͷ͵ͻǦ‡ͷͶǤ ͸Ǥ  Šƒ—••ǡƒ Š‡• ǡ ƒ”†‡”Ǥ”‡ƒ•–‡ ‘•–”— –‹‘ƒˆ–‡”ƒ•–‡ –‘›Ǥ ”‘–—”‰Ǥ ʹͲͳͷǢʹǣ͹ͳǤ ͹Ǥ ƒǡ‹Ž˜ƒǤ††”‡••‹‰–Š‡’ƒ”ƒ†‘š‘ˆ‹ ”‡ƒ•‹‰ƒ•–‡ –‘›”ƒ–‡•‹ƒ‡”ƒ‘ˆ†‡Ǧ‡• ƒŽƒ–‹‘‘ˆ –Š‡”ƒ’›ǣ‘—‹ ƒ–‹‘•–”ƒ–‡‰‹‡•Ǥ”‡ƒ•–ǤʹͲͳͺǢ͵ͺǣͳ͵͸ǦͶ͵Ǥ ͺǤ ‡”Ž‡––‹ ǡ ‘•‘– ǡ‡Ž•‘ ǡ‹•ƒ ǡ— ›Ǥ”‡ƒ•–”‡ ‘•–”— –‹‘ƒˆ–‡”„”‡ƒ•– ƒ ‡”ǤŽƒ•– ‡ ‘•–”—”‰ǤʹͲͳͳǢͳʹ͹ȋ͸ȌǣͳʹͶ‡Ǧ͵ͷ‡Ǥ ͻǤ ‘‹‡•‘• ǡ ”ƒ ǡ‘”†‡‹”‘ Ǥ”‡ƒ•–”‡ ‘•–”— –‹‘ˆ‘ŽŽ‘™‹‰ ‘•‡”˜ƒ–‹˜‡ƒ•–‡ –‘‹‡•ǣ ’”‡†‹ –‘”•‘ˆ ‘’Ž‹ ƒ–‹‘•ƒ†‘—– ‘‡•Ǥ Žƒ†—”‰ǤʹͲͳͷǢͶȋ͸ȌǣͶͺͶǦͻ͸Ǥ ͳͲǤ ‡Ž•‘ ǡ‡‡ ǡ‹•ƒ ǤŠ‡ — –‹‘ƒŽ ’ƒ –‘ˆ”‡ƒ•–‡ ‘•–”— –‹‘ǣ˜‡”˜‹‡™ƒ†’†ƒ–‡Ǥ Žƒ•–‡ ‘•–”—”‰ Ž‘„’‡ǤʹͲͳͺǢ͸ȋ͵Ȍǣ‡ͳ͸ͶͲǤ ͳͳǤ › Šǡƒ‰ǡ‰‡Ž‘˜ǡ ƒ””‹‰Ž‡ǡ‘›Ž‡ ǡŽǦœƒ™‹ǡ‡–ƒŽǤ”‡ƒ•–”‡ ‘•–”— –‹‘’‘•– ƒ•–‡ –‘›Ǧ‡–̵• ‘‘‰Ž‡‹–Ǥ ‡••‹„‹Ž‹–›ǡ”‡ƒ†ƒ„‹Ž‹–›ƒ†“—ƒŽ‹–›‘ˆ‘Ž‹‡‹ˆ‘”ƒ–‹‘Ǥ”‡ƒ•–Ǥ ʹͲͳ͹Ǣ͵ʹǣͳʹ͸ǦͻǤ ͳʹǤ ‹‰Š–ǡ—”‘ǡ”‡ƒ‡›ǡ”‹– ŠŽ‡›ǤŠ‡ –‡”‡–ǣŠƒ–ƒ”‡‘—”’ƒ–‹‡–•‡š’‘•‡†–‘™Š‡ ‘•‹†‡”‹‰„”‡ƒ•–”‡ ‘•–”— –‹‘ˆ‘ŽŽ‘™‹‰ƒ•–‡ –‘›ǫ”‡ƒ•–ǤʹͲͳͶǢʹ͵ȋ͸Ȍǣ͹ͻͻǦͺͲ͸Ǥ ͳ͵Ǥ ƒ”‰ƒ•ǡ‘‘Ž‡ ǡŠ—ƒ‰ ǡ ƒ‘”ǡ‡‡ǤŽ‹‡’ƒ–‹‡–”‡•‘—” ‡•ˆ‘”„”‡ƒ•– ”‡ ‘•–”— –‹‘ǣƒƒƒŽ›•‹•‘ˆ”‡ƒ†ƒ„‹Ž‹–›ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͶǢͳ͵Ͷȋ͵ȌǣͶͲ͸Ǧͳ͵Ǥ ͳͶǤ Ž„‘”‘œǡƒ Šǡ‡Š”ƒ”ƒ ǡ‹•ƒ ǡ—•‹ ǡ ƒ”–Š›ǡ‡–ƒŽǤ’ƒ”ƒ†‹‰•Š‹ˆ–‹ǤǤ ”‡ƒ•–”‡ ‘•–”— –‹‘ǣ‹ ”‡ƒ•‹‰‹’Žƒ–”ƒ–‡•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳ͵Ǣͳ͵ͳȋͳȌǣͳͷǦʹ͵Ǥ ͳͷǤ ‡ƒŽǡŽ„‘”‘œǡ‹•ƒ ǡ ƒ”–Š›ǡ‡Š”ƒ”ƒ ǡ—•‹ ǡ‡–ƒŽǤ’ƒ”ƒ†‹‰•Š‹ˆ–‹ǤǤ „”‡ƒ•–”‡ ‘•–”— –‹‘ǣƒ”–ʹǤŠ‡‹ˆŽ—‡ ‡‘ˆ Šƒ‰‹‰ƒ•–‡ –‘›’ƒ––‡”•‘”‡ ‘•–”— –‹˜‡ ”ƒ–‡ƒ†‡–Š‘†ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳ͵Ǣͳ͵ͳȋ͵Ȍǣ͵ʹͲ‡Ǧ͸‡Ǥ ͳ͸Ǥ ƒ„”‹‡Žǡ‘‘†• ǡ̵ ƒŽŽ‘ǡ‡ƒ”†ǡ—”Žƒ†ǡ‡Ž–‘ ǡ͵”†Ǥ‘’Ž‹ ƒ–‹‘•Ž‡ƒ†‹‰–‘ •—”‰‡”›ƒˆ–‡”„”‡ƒ•–‹’Žƒ–ƒ–‹‘Ǥ‰Ž ‡†Ǥͳͻͻ͹Ǣ͵͵͸ȋͳͲȌǣ͸͹͹ǦͺʹǤ ͳ͹Ǥ ‘––‡”ǡ‘”‘› ǡ—–”‡•• ǡ‹ŽŽ‹ƒ•‘ǡŠ‹•‡”ǡŠ”—•Šǡ‡–ƒŽǤŠ‘”–Ǧ–‡”•ƒˆ‡–› ‘—– ‘‡•‘ˆƒ•–‡ –‘›ƒ†‹‡†‹ƒ–‡‹’Žƒ–Ǧ„ƒ•‡†„”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Šƒ†™‹–Š‘—– ‡•Šȋ‹Ȍǣƒ—Ž–‹ ‡–”‡ǡ’”‘•’‡ –‹˜‡ ‘Š‘”–•–—†›Ǥƒ ‡– ‘ŽǤʹͲͳͻǢʹͲȋʹȌǣʹͷͶǦ͸͸Ǥ ͳͺǤ ‹—ǡ ”‡‹Œ•ǡŽ‡‹ ǡ ‡‹„ƒ—ǡ˜‡‡ǡ‘”‡œ‘ǡ‡–ƒŽǤƒ–‹‡–•™‹–Šƒ„†‘‹ƒŽǦ„ƒ•‡†ˆ”‡‡ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ƒ†‡ ƒ†‡ƒˆ–‡”•—”‰‡”›ǣ ‘’”‡Š‡•‹˜‡Ž‘‰Ǧ–‡”ˆ‘ŽŽ‘™Ǧ—’•–—†›Ǥ  Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳͺǢ͹ͳȋͻȌǣͳ͵ͲͳǦͻǤ ͳͻǤ ސ•‡–Šǡ ‘Žƒ†ǡ‹†Š‘Ž†–ǡ%„›Š‘Ž ǡ–ƒ˜‡Ǥ—ƒŽ‹–›‘ˆŽ‹ˆ‡ǡ’ƒ–‹‡–•ƒ–‹•ˆƒ –‹‘ ƒ† ‘•‡–‹ ‘—– ‘‡ƒˆ–‡”„”‡ƒ•–”‡ ‘•–”— –‹‘—•‹‰ ˆŽƒ’‘”‡š’ƒ†ƒ„Ž‡„”‡ƒ•–‹’Žƒ–Ǥ  Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͲͺǢ͸ͳȋͳͲȌǣͳͳͺͺǦͻͶǤ ʹͲǤ ƒ–‘•ƒǡ‹ ǡ‹ ǡ ƒ‹ŽŽ ǡ‹Ž‹• ǡ—•‹ Ǥ‘‰Ǧ–‡”ƒ–‹‡–Ǧ‡’‘”–‡†—– ‘‡•‹ ‘•–ƒ•–‡ –‘›”‡ƒ•–‡ ‘•–”— –‹‘Ǥ —”‰ǤʹͲͳͺǤ ʹͳǤ ‹†Š‘Ž†–Ǥ‹ ”‘ ‹” —Žƒ–‹‘ƒ†”‡‹‡”˜ƒ–‹‘‹„”‡ƒ•–”‡ ‘•–”— –‹‘—•‹‰†‡‡’‹ˆ‡”‹‘” ‡’‹‰ƒ•–”‹ ƒ”–‡”›’‡”ˆ‘”ƒ–‘”ˆŽƒ’•Ǥ•Ž‘ǣ‹˜‡”•‹–›‘ˆ•Ž‘ǢʹͲͳ͵Ǥ ʹʹǤ Š‡˜”ƒ›Ǥ’†ƒ–‡‘”‡ƒ•–‡ ‘•–”— –‹‘•‹‰ ”‡‡ǡ ǡƒ†  Žƒ’•Ǥ‡‹Žƒ•– —”‰ǤʹͲͲͶǢͳͺȋʹȌǣͻ͹ǦͳͲͶǤ ʹ͵Ǥ ‘Ž•–”ڏ ǤŠ‡ˆ”‡‡ƒ„†‘‹‘’Žƒ•–›ˆŽƒ’ƒ†‹–•—•‡‹„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ‡š’‡”‹‡–ƒŽ •–—†›ƒ† Ž‹‹ ƒŽ ƒ•‡”‡’‘”–Ǥ ƒ† Žƒ•–‡ ‘•–”—”‰Ǥͳͻ͹ͻǢͳ͵ȋ͵ȌǣͶʹ͵Ǧʹ͹Ǥ

92 92 ʹͶǤ ƒ”–”ƒ’ˆǡ Š‡ˆŽƒǡŽƒ Ǥ”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Šƒ–”ƒ•˜‡”•‡ƒ„†‘‹ƒŽ‹•Žƒ†ˆŽƒ’Ǥ Žƒ•–‡ ‘•–”—”‰ǤͳͻͺʹǢ͸ͻȋʹȌǣʹͳ͸ǦʹͷǤ ʹͷǤ ”‹‡†ƒ ǡ”‰‡–ƒǡ†‡”•‘Ǥ‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ˆ”‡‡ˆŽƒ’ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘ ƒˆ–‡””ƒ†‹ ƒŽƒ•–‡ –‘›ǤŽƒ•–‡ ‘•–”—”‰ǤͳͻͺͷǢ͹͸ȋ͵ȌǣͶͷͷǦ͸ͲǤ ʹ͸Ǥ ”‘––‹‰ ǤŠ‡ˆ”‡‡ƒ„†‘‹‘’Žƒ•–›ˆŽƒ’ˆ‘”‹‡†‹ƒ–‡„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŽƒ•–—”‰Ǥ ͳͻͻͳǢʹ͹ȋͶȌǣ͵ͷͳǦͶǤ ʹ͹Ǥ ŽŽ‡ ǡ”‡‡ ‡Ǥ‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŽƒ•–—”‰Ǥ ͳͻͻͶǢ͵ʹȋͳȌǣ͵ʹǦͺǤ ʹͺǤ ƒ‹–Ǧ›”ǡ Šƒ˜‡”‹‡ǡ‘Š”‹ Š Ǥ‡”ˆ‘”ƒ–‘”ˆŽƒ’•ǣŠ‹•–‘”›ǡ ‘–”‘˜‡”•‹‡•ǡ’Š›•‹‘Ž‘‰›ǡ ƒƒ–‘›ǡƒ†—•‡‹”‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͻǢͳʹ͵ȋͶȌǣͳ͵ʹ‡ǦͶͷ‡Ǥ ʹͻǤ Ž‘†‡‡Žǡƒƒ†—›– ǡ‘•–”‡› ǡ ƒ†‹ǡƒ––‘ ǡŽŽ‡ ǡ‡–ƒŽǤŠ‡̶ ‡–̶ ‘•‡•—•‘’‡”ˆ‘”ƒ–‘”ˆŽƒ’–‡”‹‘Ž‘‰›ǣ’”‡Ž‹‹ƒ”›†‡ˆ‹‹–‹‘•ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲͲ͵ǢͳͳʹȋͷȌǣͳ͵͹ͺǦͺ͵Ǣ“—‹œͺ͵ǡͷͳ͸Ǣ†‹• —••‹‘ͺͶǦ͹Ǥ ͵ͲǤ ƒœœ‘Žƒ ǡƒœœ‘Žƒ Ǥ ‹•–‘”›‘ˆˆƒ–‰”ƒˆ–‹‰ǣˆ”‘”ƒˆƒ––‘•–‡ ‡ŽŽ•ǤŽ‹Žƒ•–—”‰Ǥ ʹͲͳͷǢͶʹȋʹȌǣͳͶ͹Ǧͷ͵Ǥ ͵ͳǤ ‡ŽŽ‹‹ǡ ”‹‡ ‘ǡƒ’‘•‹‘ǤŠ‡• ‹‡ ‡„‡Š‹†ƒ—–‘Ž‘‰‘—•ˆƒ–‰”ƒˆ–‹‰Ǥ‡†—”‰ȋ‘†ȌǤ ʹͲͳ͹ǢʹͶǣ͸ͷǦ͹͵Ǥ ͵ʹǤ —ŠŽǡ‡†•–‡†ǡƒ•‰ƒƒ”†Ǥ—–‘Ž‘‰‘—•ˆƒ–‰”ƒˆ–‹‰ƒˆ–‡”„”‡ƒ•– ‘•‡”˜‹‰•—”‰‡”›ǣ”‡ƒ•– ‹ƒ‰‹‰ Šƒ‰‡•ƒ†’ƒ–‹‡–Ǧ”‡’‘”–‡†‘—– ‘‡Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳͺǢ͹ͳȋͳͳȌǣͳͷ͹ͲǦ͸Ǥ ͵͵Ǥ —••‡ǡŠ‘Ž‘•› ǡ‡‹–‰ƒ••‡”ǡ”ƒ†•–‡––‡”ǡ”ƒ‹–‹‰‡” ǡ‡—”‡‹–‡” ǡ‡–ƒŽǤ—–‘Ž‘‰‘—•ˆƒ– ‰”ƒˆ–‹‰ˆ‘”‡Šƒ ‡‡–‘ˆ„”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Šƒ–”ƒ•˜‡”•‡›‘ —–ƒ‡‘—•‰”ƒ ‹Ž‹•ˆŽƒ’ǣ ‘Š‘”–•–—†›Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳͺǢ͹ͳȋͳͳȌǣͳͷͷ͹Ǧ͸ʹǤ ͵ͶǤ —ŠŽǡƒ”Ž••‘ǡƒ•‰ƒƒ”†Ǥ ƒ–‰”ƒˆ–‹‰ˆ‘”ƒŽŽ‡˜‹ƒ–‹‰’‡”•‹•–‡–’ƒ‹ƒˆ–‡”„”‡ƒ•– ƒ ‡” –”‡ƒ–‡–ǣ”ƒ†‘‹œ‡† ‘–”‘ŽŽ‡†–”‹ƒŽǤ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳ͸Ǣ͸ͻȋͻȌǣͳͳͻʹǦʹͲʹǤ ͵ͷǤ –ƒŽ†‡”ǡ ƒ”†‘ǡŽŽ‡ ǡƒ†‡‰Š‹Ǥ‡•–Š‡–‹ ‡ˆ‹‡‡–‘ˆ–Š‡„†‘‹ƒŽ‘‘”‹–‡ƒˆ–‡” —–‘Ž‘‰‘—•”‡ƒ•–‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͷǢͳ͵͸ȋ͵ȌǣͶͷͷǦ͸ͳǤ ͵͸Ǥ ‘’’‡ǡ‡„‡””‡‹–‡”ǡ—”Ž‡‘–ǡ‡Ž–‘‹‡‹ ǡ–ƒ„‹Ž‡ǡƒ—Šƒ‡Ǥ”‡ƒ•–”‡ ‘•–”— –‹‘ †‡‘˜‘„›™ƒ–‡”ǦŒ‡–ƒ••‹•–‡†ƒ—–‘Ž‘‰‘—•ˆƒ–‰”ƒˆ–‹‰ǦǦƒ”‡–”‘•’‡ –‹˜‡•–—†›Ǥ ‡”‡† ‹Ǥ ʹͲͳ͵Ǣͳͳǣ‘ ͳ͹Ǥ ͵͹Ǥ ‡”Ž›ǡ”Š‘Ž–ǡƒ”•‡ǡ‹’’‡”ǡ”‡†‰ƒƒ”†ǡ ”ƒ‘™ǡ‡–ƒŽǤˆˆ‹ ƒ ›‘ˆ„”‡ƒ•– ”‡ ‘•–”— –‹‘™‹–Šˆƒ–‰”ƒˆ–‹‰ǣ•›•–‡ƒ–‹ ”‡˜‹‡™ƒ†‡–ƒǦƒƒŽ›•‹•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡– —”‰ǤʹͲͳͺǢ͹ͳȋͳʹȌǣͳ͹ͶͲǦͷͲǤ ͵ͺǤ ‡Žƒ›ǡ‡”—–ƒǡ —‡”‹†Ǥ †‹ ƒ–‹‘•ƒ†‘–”‘˜‡”•‹‡•‹‘–ƒŽ”‡ƒ•–‡ ‘•–”— –‹‘™‹–Š ‹’‘‘†‡Ž‹‰ǤŽ‹Žƒ•–—”‰ǤʹͲͳͺǢͶͷȋͳȌǣͳͳͳǦ͹Ǥ ͵ͻǤ ‡ƒŽ›ǡŽŽ‡ ǡ”ǤŠ‡‡˜‘Ž—–‹‘‘ˆ’‡”ˆ‘”ƒ–‘”ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ǣ–™‡–››‡ƒ”•ƒˆ–‡”–Š‡ ˆ‹”•– ˆŽƒ’Ǥ ‡ ‘•–”‹ ”‘•—”‰ǤʹͲͳͶǢ͵ͲȋʹȌǣͳʹͳǦͷǤ ͶͲǤ Ž‘†‡‡Žǡƒ†—›– ǡ‘•–”‡› Ǥ—”‰‹ ƒŽǦ–‡ Š‹ ƒŽƒ•’‡ –•‘ˆ–Š‡ˆ”‡‡†‹‡’ˆŽƒ’ˆ‘”„”‡ƒ•– ”‡ ‘•–”— –‹‘Ǥ’‡”ƒ–‹˜‡‡ Š‹“—‡•‹Žƒ•–‹ ƒ†‡ ‘•–”— –‹˜‡—”‰‡”›ǤͳͻͻͻǢ͸ȋͳȌǣʹ͹Ǧ͵͹Ǥ ͶͳǤ ”‡–‘ ǡƒŠ‹ƒ‹ǡƒ‹–Ǧ›”Ǥƒ• —Žƒ”ƒƒ–‘›‘ˆ–Š‡†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”› ’‡”ˆ‘”ƒ–‘”ˆŽƒ’ǣƒ•›•–‡ƒ–‹ ”‡˜‹‡™ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͶǢͳ͵ͶȋͷȌǣͺͳͲ‡Ǧʹͳ‡Ǥ ͶʹǤ —Š‘œǡ •Š‹†ƒ ǡ–—”–œ ǡ—Šƒǡ‘–ƒ‰ǡƒ‹–‘ ǡ‡–ƒŽǤ ’‘”–ƒ ‡‘ˆŽƒ–‡”ƒŽ”‘™ ’‡”ˆ‘”ƒ–‘”˜‡••‡Ž•‹†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’Šƒ”˜‡•–‹‰ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲͲͶǢͳͳ͵ȋʹȌǣͷͳ͹ǦʹͶǤ Ͷ͵Ǥ ‡‹–ƒǡ ‡Ž‡”‡” ǡ—”—•ǡƒ–‡Œ‹ ǡ ‰‹ƒ‹ Ǥƒ–‘‹ ƒŽˆ‡ƒ–—”‡•‘ˆ’‡”ˆ‘”ƒ–‘”„Ž‘‘† ˜‡••‡Ž•‹–Š‡†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’Ǥ” Žƒ•–—”‰ǤʹͲͲͲǢͷ͵ȋ͵ȌǣʹͲͷǦͺǤ ͶͶǤ ‰˜ƒŽ†•‡ǡ‹†Š‘Ž†–ǡސ•‡–ŠǤ  Žƒ’ƒ–‹‡–•“—ƒŽŽ›ƒ•ƒ–‹•ˆ‹‡†™‹–Š–Š‡ „†‘‡ƒ•„†‘‹‘’Žƒ•–›ƒ–‹‡–•ǤŽƒ•–‡ ‘•–”—”‰ Ž‘„’‡ǤʹͲͳͺǢ͸ȋͺȌǣ‡ͳͺ͹͸Ǥ ͶͷǤ ƒŠƒ„‡†‹ƒǡ‘‘Ž‡›ǡ‹‰Šǡƒ•‘Ǥ‘–‘—”ƒ„‘”ƒŽ‹–‹‡•‘ˆ–Š‡ƒ„†‘‡ƒˆ–‡”„”‡ƒ•– ”‡ ‘•–”— –‹‘™‹–Šƒ„†‘‹ƒŽˆŽƒ’•ǣ–Š‡”‘Ž‡‘ˆ—• Ž‡’”‡•‡”˜ƒ–‹‘ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲͲʹǢͳͲͻȋͳȌǣͻͳǦͳͲͳǤ Ͷ͸Ǥ Š”‹•–‹‡ǡŠ—ŽœŠ‡‘ǡ‘‘”‡ǡˆ‹ˆ‹Ǥ‹˜—Ž‰‡–Š‡„—Ž‰‡ǣƒ‹–‡”ƒ–‹‘ƒŽ•—”˜‡›‘ˆ ƒ„†‘‹ƒŽ†‘‘”•‹–‡‘”„‹†‹–›‹ˆ”‡‡ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ Žƒ•–—”‰ ƒ†—”‰Ǥ ʹͲͳͻǣͳǦ͸Ǥ Ͷ͹Ǥ ‰‡„‡”‰ǡƒ•—••‡ǡޔ‡•‡ Ǥ‘’ƒ”‹‰–Š‡†‘‘”Ǧ•‹–‡‘”„‹†‹–›—•‹‰ ǡ ‘” ǦˆŽƒ’•ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹˜‡•—”‰‡”›ǣƒ‡–ƒǦƒƒŽ›•‹•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰Ǥ ʹͲͳʹǢ͸ͷȋͳͳȌǣͳͶ͹ͶǦͺͲǤ ͶͺǤ ‡‹†‡•–—‡ ‡”ǡ‡‰Ž‡”ǡ—†‡”ǡ†”‡‡ǡƒŠƒŒƒǡ‹–œ‡ŽǤ›‘•‘‘‰”ƒ’Š‹ •–—†›‘ˆ ƒ„†‘‹ƒŽ™ƒŽŽ†›ƒ‹ •–‘ƒ••‡••†‘‘”•‹–‡‘”„‹†‹–›ƒˆ–‡”‹ ”‘•—”‰‹ ƒŽ„”‡ƒ•–”‡ ‘•–”— –‹‘ ™‹–Šƒ ‘”ƒ•ǦʹˆŽƒ’Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳ͸Ǣ͸ͻȋͷȌǣͷͻͺǦ͸Ͳ͵Ǥ

93 93 ͶͻǤ Ž‘†‡‡Žǡƒ†‡”•–”ƒ‡–‡ ǡ‘•–”‡› ǡƒƒ†—›–ǡ‘ƒ”†ǡ›•‡•ǡ‡–ƒŽǤŠ‡†‘‘” •‹–‡‘”„‹†‹–›‘ˆˆ”‡‡ ˆŽƒ’•ƒ†ˆ”‡‡ˆŽƒ’•ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ” Žƒ•–—”‰Ǥ ͳͻͻ͹ǢͷͲȋͷȌǣ͵ʹʹǦ͵ͲǤ ͷͲǤ Šƒ‰ ǡŠƒ‰ ǡ‘–‘Ǧ‹”ƒ†ƒǡŠƒ‰ ǡ‘•”ƒ–‹ǡ‘„„ ǡ‡–ƒŽǤ‘’”‡Š‡•‹˜‡ƒƒŽ›•‹•‘ˆ †‘‘”Ǧ•‹–‡‘”„‹†‹–›‹ƒ„†‘‹ƒŽŽ›„ƒ•‡†ˆ”‡‡ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲͳ͵Ǣͳ͵ʹȋ͸Ȍǣͳ͵ͺ͵ǦͻͳǤ ͷͳǤ ƒǡ‡Ž„‡” ǡ‡”Ž‡––‹ Ǥ„†‘‹ƒŽ™ƒŽŽˆ‘ŽŽ‘™‹‰ˆ”‡‡‘” ˆŽƒ’”‡ ‘•–”— –‹‘ǣƒ ‡–ƒǦƒƒŽ›•‹•ƒ† ”‹–‹ ƒŽ”‡˜‹‡™ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͻǢͳʹͶȋ͵Ȍǣ͹ͷʹǦ͸ͶǤ ͷʹǤ ‹††ƒ ǡ‘• ǡƒ‰‡ ǡŠƒ†‡” ǡ ‡”•ƒ–ǡ‹‰‘”‹‡ǡ‡–ƒŽǤ ˆŽƒ’ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘ǣ ”‡–”‘•’‡ –‹˜‡‡˜ƒŽ—ƒ–‹‘‘ˆ’ƒ–‹‡–•ƒ–‹•ˆƒ –‹‘‘ƒ„†‘‹ƒŽ”‡•—Ž–•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰Ǥ ʹͲͳͶǢ͸͹ȋ͸Ȍǣ͹ͺͻǦͻ͸Ǥ ͷ͵Ǥ ƒ†‡ ǡƒ–ˆ‘”† ǡ‘”ƒŽ† ǡ”ƒŠƒŽŽ ǡ ‹‰—•Ǥ‡”ˆ‘”ƒ–‘”ƒ’’‹‰”‡†— ‡•–Š‡‘’‡”ƒ–‹˜‡ –‹‡‘ˆ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ǣ•›•–‡ƒ–‹ ”‡˜‹‡™ƒ†‡–ƒǦƒƒŽ›•‹•‘ˆ’”‡‘’‡”ƒ–‹˜‡ —Ž–”ƒ•‘—†ǡ ‘’—–‡†–‘‘‰”ƒ’Š›ƒ†ƒ‰‡–‹ ”‡•‘ƒ ‡ƒ‰‹‘‰”ƒ’Š›Ǥ Žƒ•–‡ ‘•–”‡•–Š‡– —”‰ǤʹͲͳͺǢ͹ͳȋͶȌǣͶ͸ͺǦ͹͹Ǥ ͷͶǤ ‹–œ‰‡”ƒŽ†̵‘‘”ǡ‘œ‡ǡŠ‘™†Š”›ǡƒ†ǡƒƒ”‹•Šƒǡ ”‹ˆˆ‹–Š•Ǥ ”‡‘’‡”ƒ–‹˜‡ ‘’—–‡†–‘‘‰”ƒ’Š›ƒ‰‹‘‰”ƒ’Š›ˆ‘”’Žƒ‹‰ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ ”‡†— ‡•‘’‡”ƒ–‹˜‡–‹‡ƒ†‘˜‡”ƒŽŽ ‘’Ž‹ ƒ–‹‘•Ǥ Žƒ†—”‰ǤʹͲͳ͸ǢͷȋʹȌǣͻ͵ǦͺǤ ͷͷǤ ‹– ǡŽ‡‹ǡ‡”‡”Ǥ‘˜‡”˜‹‡™‘ˆ‡–Š‘†•ˆ‘”˜ƒ• —Žƒ”ƒ’’‹‰‹–Š‡’Žƒ‹‰‘ˆˆ”‡‡ ˆŽƒ’•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳͲǢ͸͵ȋͻȌǣ‡͸͹ͶǦͺʹǤ ͷ͸Ǥ ‡†‘ƒ•› ǡ‹ Žǡƒ†–‡ǡ ƒ•Ž‹ǡ Š”‘‡‰‡†‘”ˆ‡” Ǥ‡‘—•—’‡”†”ƒ‹ƒ‰‡‹  Žƒ’ ”‡ƒ•–‡ ‘•–”— –‹‘ǣŠ‡ ’ƒ –‘ˆ—’‡”ˆ‹ ‹ƒŽ ˆ‡”‹‘”’‹‰ƒ•–”‹ ‡‹‹••‡ –‹‘‘„†‘‹ƒŽ ‡”‘ƒ ‘”ƒ–‹‘ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͺǢͳͶͳȋʹȌǣʹͲ͸‡Ǧͳʹ‡Ǥ ͷ͹Ǥ ƒŒƒ–ǡ‹– ǡ‘œ‡ǡ ƒ”–ƒ ǡ‹••ǡ‹Ž†ƒŽǡ‡–ƒŽǤ‡•–Š‡–‹ ”‡ˆ‹‡‡–•ƒ† ”‡‘’‡”ƒ–‹˜‡’”‘ ‡†—”‡•ˆ‘ŽŽ‘™‹‰͵͹Ͳ ‘•‡ —–‹˜‡ ƒ† ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘•ǣ ’‘”–ƒ– ‘•‹†‡”ƒ–‹‘•ˆ‘”’ƒ–‹‡– ‘•‡–Ǥ‡•–Š‡–‹ Žƒ•–—”‰ǤʹͲͳͲǢ͵Ͷȋ͵Ȍǣ͵Ͳ͸ǦͳʹǤ ͷͺǤ ƒ‡ ǡ—”‡ƒ—ǡ‹ƒǡƒŠ‘”•– ǡ ‘ˆ‡”ǤŠ‡’Ž‡ƒ•‹‰‡†”‡•—Ž–ƒˆ–‡” ˆŽƒ’ „”‡ƒ•–”‡ ‘•–”— –‹‘ǣƒ”‡˜‹‡™‘ˆƒ††‹–‹‘ƒŽ‘’‡”ƒ–‹‘•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰Ǥ ʹͲͲͻǢ͸ʹȋͳȌǣ͹ͳǦ͸Ǥ ͷͻǤ ƒ–ƒŽ‘ǡ•ƒ”‹ǡ ƒ–‡• ǡƒ–‡Žǡ‘†‹ •‘ǡŠ—”ƒƒǤ‘̵– ‘”‰‡––Š‡„†‘‹ƒŽƒŽŽǣ ƒ‰‹‰’‡ –”—‘ˆ„†‘‹ƒŽƒŽŽ Œ—”‹‡•ƒˆ–‡”‘’‡‡–”ƒ–‹‰”ƒ—ƒǤƒ†‹‘‰”ƒ’Š‹ •Ǥ ʹͲͳ͹Ǣ͵͹ȋͶȌǣͳʹͳͺǦ͵ͷǤ ͸ͲǤ ”‡› ǡ‹œ‡ŽŽ Ǥƒ–‘›‘ˆ–Š‡ƒ„†‘‹ƒŽ™ƒŽŽǣ’‘ƒ–‡Ǣȏ ‡••†ƒ–‡ʹͲͳͻǦͲ͹ǦʹͷȐǤ˜ƒ‹Žƒ„Ž‡ ˆ”‘ǣŠ––’•ǣȀȀ™™™Ǥ—’–‘†ƒ–‡Ǥ ‘Ȁ ‘–‡–•Ȁƒƒ–‘›Ǧ‘ˆǦ–Š‡Ǧƒ„†‘‹ƒŽǦ™ƒŽŽǤ ͸ͳǤ ‘„‹ǡ‡Œƒ‹ Ǥƒ–‘‹ ƒ† Ž‹‹ ƒŽ”‡Ǧ‡˜ƒŽ—ƒ–‹‘‘ˆƒ’‡”̵•ǡ ƒ”’ƒ̵•ǡƒ†‘ŽŽ‡•̵ ˆƒ• ‹ƒ‡Ǥ—”‰ ›‡ ‘Ž„•–‡–ǤͳͻͶͻǢͺͺȋͷȌǣͷͶͷǦͷͻǤ ͸ʹǤ —‡”Ž‡—šǡ‘”‹ŽŽ‘ǡ ‘Ž‹˜‡–ǡ‹––‘— Ǥƒ–‘›ƒ†’Š›•‹‘Ž‘‰›‘ˆ•—„ —–ƒ‡‘—•ƒ†‹’‘•‡–‹••—‡ „›‹˜‹˜‘ƒ‰‡–‹ ”‡•‘ƒ ‡‹ƒ‰‹‰ƒ†•’‡ –”‘• ‘’›ǣ”‡Žƒ–‹‘•Š‹’•™‹–Š•‡šƒ†’”‡•‡ ‡‘ˆ ‡ŽŽ—Ž‹–‡Ǥ‹‡•‡ Š‘ŽǤʹͲͲʹǢͺȋʹȌǣͳͳͺǦʹͶǤ ͸͵Ǥ ‡†‡”•‘ǡ‡–ǡ‹•ƒ Ǥ‡ Š‹ ƒŽ‹’ǣƒ” ƒ”’ƒ̵• ƒ• ‹ƒ–‘ ƒ ‹Ž‹–ƒ–‡”‘’‡”„†‘‹ƒŽ Ž‘•—”‡—”‹‰—–‘Ž‘‰‘—•”‡ƒ•–‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰ Ž‘„’‡Ǥ ʹͲͳ͹ǢͷȋͶȌǣ‡ͳ͵Ͳ͵Ǥ ͸ͶǤ ‘Šƒǡ ‹Ž•–”ƒ’ ‹‹ǡƒ‹ǡ‹––Ž‡ǡƒ–‘•Ǧƒ‘•ǡ ‘Ž†ƒ„‡” ǡ‡–ƒŽǤ—„ —–ƒ‡‘—• –‹••—‡ǣ–‘•—–—”‡‘”‘––‘•—–—”‡ƒ– ‡•ƒ”‡ƒ•‡ –‹‘Ǥ ˆ‡ –‹•„•–‡– ›‡ ‘ŽǤͳͻͻͶǢͳȋ͸ȌǣʹͷͻǦ͸ͶǤ ͸ͷǤ ‘œ‡ǡ•Š–‘ǡƒ›Ž‘” Ǥ‡˜‹‡™‹‰–Š‡˜ƒ• —Žƒ”•—’’Ž›‘ˆ–Š‡ƒ–‡”‹‘”ƒ„†‘‹ƒŽ™ƒŽŽǣ ”‡†‡ˆ‹‹‰ƒƒ–‘›ˆ‘”‹ ”‡ƒ•‹‰Ž›”‡ˆ‹‡†•—”‰‡”›ǤŽ‹ƒ–ǤʹͲͲͺǢʹͳȋʹȌǣͺͻǦͻͺǤ ͸͸Ǥ ‘œ‡ǡ—””ƒ›ǡ•Š–‘ǡŽ‘‘ ǡ–‡ŽŽƒǡŠ‹ŽŽ‹’• ǡ‡–ƒŽǤŠ‡ —–ƒ‡‘—• ‘—”•‡‘ˆ †‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”•ǣ‹’Ž‹ ƒ–‹‘•ˆ‘”ˆŽƒ’–Š‹‹‰Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰Ǥ ʹͲͲͻǢ͸ʹȋͺȌǣͻͺ͸ǦͻͲǤ ͸͹Ǥ ƒ–Š‡• ǡƒŠƒ‹ ǤŽƒ••‹ˆ‹ ƒ–‹‘‘ˆ–Š‡˜ƒ• —Žƒ”ƒƒ–‘›‘ˆ—• Ž‡•ǣ‡š’‡”‹‡–ƒŽƒ† Ž‹‹ ƒŽ ‘””‡Žƒ–‹‘ǤŽƒ•–‡ ‘•–”—”‰ǤͳͻͺͳǢ͸͹ȋʹȌǣͳ͹͹Ǧͺ͹Ǥ ͸ͺǤ ‹ƒǡ‡”–‹‘ ǡŠ‹’Ž‡›ǡŠ‘Œƒǡ—„„•ǡ‘—ƒ•Ǥ‡–”—•ƒ’‡”ǣŠ‹•–‘”›ƒ†‘˜‡”˜‹‡™ ‘ˆ–Š‡ Ž‹‹ ƒŽ‹’‘”–ƒ ‡‘ˆƒ’‡”̵•ˆƒ• ‹ƒ‹•—”‰‹ ƒŽƒƒ–‘›ǤŽ‹ƒ–ǤʹͲͳͶǢʹ͹ȋͶȌǣͷ͵͹ǦͶͶǤ ͸ͻǤ ‡––‡šǡ ƒŽ‘—šǡ„‡ŽŽƒ‘’‡œǡƒ•ƒ‘˜ƒǡ‡”–”ƒ†ǡŠ‹Žƒ†”‹ƒ‘•Ǥȏ‘Šƒ”˜‡•–ƒ  ˆŽƒ’‹•–‡ƒ†‘ˆƒ ˆŽƒ’‹„”‡ƒ•–”‡ ‘•–”— –‹‘ǣ–‡ Š‹ ƒŽ‘–‡ȐǤŠ‹”Žƒ•–•–Š‡–ǤʹͲͳͺǤ ͹ͲǤ ‡”› ǡ—–Ž‡”ǡ‘‘† ǡ ƒŽŽƒŽ‹Ǥ”‡†‹ –‹‰ƒ†’Žƒ‹‰ˆ‘” ˆŽƒ’—–‹Ž‹•ƒ–‹‘‹„”‡ƒ•– ”‡ ‘•–”— –‹‘ǣƒŽ‰‘”‹–Š ‘„‹‹‰’”‡Ǧ‘’‡”ƒ–‹˜‡ ‘’—–‡†–‘‘‰”ƒ’Š›ƒƒŽ›•‹•ƒ†‹–”ƒǦ ‘’‡”ƒ–‹˜‡ƒ‰‹‘•‘‡ƒ••‡••‡–Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳ͹Ǣ͹Ͳȋ͸Ȍǣ͹ͻͷǦͺͲͲǤ

94 94 ͹ͳǤ –‡ ‘ǡœœ‡ƒ ǡƒ Š‹ǡ‘”œ‹‘ƒ–‘ǡ‡Š”ǡƒ„ƒŽ†‘ǡ‡–ƒŽǤ‡ –—•ƒ„†‘‹‹•—• Ž‡ ‹‡”˜ƒ–‹‘ǣƒƒƒ–‘‹ ƒŽ•–—†›™‹–Š•—”‰‹ ƒŽ‹’Ž‹ ƒ–‹‘•‹ ˆŽƒ’Šƒ”˜‡•–‹‰Ǥ—”‰ƒ†‹‘Ž ƒ–ǤʹͲͳͺǢͶͲȋͺȌǣͺ͸ͷǦ͹ʹǤ ͹ʹǤ ƒ–ƒ”ƒ••‘ǡƒ–ƒ”ƒ••‘ǡƒ–ƒ”ƒ••‘ Ǥ„†‘‹‘’Žƒ•–›ǣ Žƒ••‹ ’”‹ ‹’Ž‡•ƒ†–‡ Š‹“—‡ǤŽ‹ Žƒ•–—”‰ǤʹͲͳͶǢͶͳȋͶȌǣ͸ͷͷǦ͹ʹǤ ͹͵Ǥ –ƒƒŽ‡•‡ǡŽƒ†‡”ǡ–”ƒ†‡ŽŽǡ‡”‰ŠǤ•›•–‡ƒ–‹ ”‡˜‹‡™‘ˆ‘—– ‘‡•‘ˆƒ„†‘‹‘’Žƒ•–›Ǥ  Žƒ•–—”‰ ƒ†—”‰ǤʹͲͳʹǢͶ͸ȋ͵ǦͶȌǣͳ͵ͻǦͶͶǤ ͹ͶǤ —–‘–ǡ‡””‘”ǡŽ‡”‹ǡŠƒ‘—ƒ–ǡ‹‘—ǡ‘ ƒ”ƒǤ ’”‘˜‹‰ƒˆ‡–›ƒˆ–‡” „†‘‹‘’Žƒ•–›ǣ‡–”‘•’‡ –‹˜‡‡˜‹‡™‘ˆͳͳʹͺƒ•‡•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͺǢͳͶʹȋʹȌǣ͵ͷͷǦ͸ʹǤ ͹ͷǤ ‹ƒǡŠƒ‘ ǡƒ‘Ǥƒˆ‡–›‘ˆ‹’‘ƒ„†‘‹‘’Žƒ•–›‡”•—•„†‘‹‘’Žƒ•–›ǣ›•–‡ƒ–‹ ‡˜‹‡™ ƒ†‡–ƒǦƒƒŽ›•‹•Ǥ‡•–Š‡–‹ Žƒ•–—”‰ǤʹͲͳͻǢͶ͵ȋͳȌǣͳ͸͹Ǧ͹ͶǤ ͹͸Ǥ ƒ’ƒ†‘’—Ž‘•ǡ–ƒˆˆŽ‡”ǡ‹” ‡˜ƒǡ ‡”‹ Š ǡƒ’ƒ†‘’‘—Ž‘•ǡ‘˜ƒ •ǡ‡–ƒŽǤ‘‡• ƒ„†‘‹‘’Žƒ•–›Šƒ˜‡ƒ’‘•‹–‹˜‡‹ˆŽ—‡ ‡‘“—ƒŽ‹–›‘ˆŽ‹ˆ‡ǡ•‡ŽˆǦ‡•–‡‡ǡƒ†‡‘–‹‘ƒŽ•–ƒ„‹Ž‹–›ǫ Žƒ•–‡ ‘•–”—”‰ǤʹͲͳʹǢͳʹͻȋ͸Ȍǣͻͷ͹‡Ǧ͸ʹ‡Ǥ ͹͹Ǥ ƒ’ƒ†‘’—Ž‘•ǡ‡‹‡”ǡ ‡”‹ Š ǡ ‡”• Š„ƒ Šǡ‘˜ƒ •ǡƒ Š‡• ǡ‡–ƒŽǤ‡•–Š‡–‹  ƒ„†‘‹‘’Žƒ•–›Šƒ•ƒ’‘•‹–‹˜‡‹’ƒ –‘“—ƒŽ‹–›‘ˆŽ‹ˆ‡’”‘•’‡ –‹˜‡Ž›Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰Ǥ ʹͲͳͻǢ͹ʹȋͷȌǣͺͳ͵ǦʹͲǤ ͹ͺǤ ƒ›Ž‘”ǡ‡”–‡ǡƒ†‡” ‘‡ ǡ ƒŠƒƒ”‹ǡ ‰”ƒǡ‘ ”‹‡ˆˆ ǡ‡–ƒŽǤ„†‘‹‘’Žƒ•–› ’”‘˜‡•‘™ƒ ƒ‹ƒ†”‹ƒ”›  ‘–‹‡ ‡ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͺǢͳͶͳȋ͵Ȍǣ͸͵͹ǦͶͷǤ ͹ͻǤ ƒ””—–Š‡”• ǡ‘ ƒǡ —Ž•‡ ǡ ƒŠƒ Ǥ ’”‘˜‡‡–‹•–”‡••—”‹ƒ”›‹ ‘–‹‡ ‡ƒˆ–‡” ƒ„†‘‹‘’Žƒ•–›Ǥ‡•–Š‡–—”‰ ǤʹͲͳͶǢ͵Ͷȋ͹ȌǣͳͲͻͳǦͺǤ ͺͲǤ —•Š‹ǡ”ƒ‡œŽ‹ ǡ ƒœ‹Ž‹ǡ Šƒœ‹ǡ‘••‡”–ǤŠ‡ ’ƒ –‘ˆ‘†›‘–‘—”‹‰”‘ ‡†—”‡• ‘”‘Ž‘‰‹ —– ‘‡•‹ƒ••‹˜‡‡‹‰Š–‘••ƒ–‹‡–•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳ͹Ǣͳ͵ͻȋͷȌǣͳͲͺ͸‡Ǧ ͻʹ‡Ǥ ͺͳǤ ‘Žƒ‹ǡ—ˆˆ‹‡Ž† ǡ‡ƒǡ‘”‰ƒ ǤŠ‡‡ˆˆ‡ –‘ˆƒ„†‘‹‘’Žƒ•–›‘—”‹ƒ”›‹ ‘–‹‡ ‡ ‹™‘‡ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͲǢͳʹ͸ȋͶȌǣʹͲ͸‡Ǧͻ‡Ǥ ͺʹǤ ‘”•’Žƒ•–‹‹”—”‰‹•ˆ‘”‡‹‰Ǥ‡–‹‰•Ž‹Œ‡”ˆ‘”’Žƒ•–‹‹”—”‰‹‹‘ˆˆ‡–Ž‹‰”‡‰‹ȋʹͲͳ͸ȌǤȏ ‡••†ƒ–‡ ʹͲʹͲǦͲͳǦͳͷȐǤ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣŠ––’•ǣȀȀ™™™ǤŽ‡‰‡ˆ‘”‡‹‰‡Ǥ‘Ȁˆ‘”‡‹‰•Ž‡††Ȁˆƒ‰‡†Ȁ‘”•Ǧ ’Žƒ•–‹‹”—”‰‹•Ǧˆ‘”‡‹‰Ȁˆƒ‰Ȁ”‡–‹‰•Ž‹Œ‡”Ȁ‡–‹‰•Ž‹Œ‡”Ǧˆ‘”Ǧ’Žƒ•–‹‹”—”‰‹Ǧ‹Ǧ‘ˆˆ‡–Ž‹‰Ǧ ”‡‰‹Ȁ͓ͶͻͻͲͲǤ ͺ͵Ǥ ސ•‡–Šǡ —–Š‡”ǡ”ƒ„”ƒ†ǡ ‘‰†‡•–ƒ ǡ ‘Žƒ†ǤŽ–”ƒ•‘‘‰”ƒ’Š‹ ‡˜ƒŽ—ƒ–‹‘‘ˆ–Š‡ ”‡ –—•ƒ„†‘‹‹•—• Ž‡ƒˆ–‡”„”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Š–Š‡ ˆŽƒ’ǤŽƒ•–—”‰Ǥ ʹͲͲͷǢͷͶȋͷȌǣͶͺ͵Ǧ͸Ǥ ͺͶǤ ‡‘‰ǡ‡‡ǡ‹ Ǥ‡–ƒǦƒƒŽ›•‹•‘ˆˆŽƒ’’‡”ˆ—•‹‘ƒ††‘‘”•‹–‡ ‘’Ž‹ ƒ–‹‘•ˆ‘”„”‡ƒ•– ”‡ ‘•–”— –‹‘—•‹‰’‡†‹ Ž‡†˜‡”•—•ˆ”‡‡ƒ† ˆŽƒ’•Ǥ”‡ƒ•–ǤʹͲͳͺǢ͵ͺǣͶͷǦͷͳǤ ͺͷǤ ‘ ǡ‹ǡ‹ǡ‡‡ ǤŠ‡‘™  Žƒ’ǣŠƒ ‡‡––‘–Š‡„†‘‹ƒŽ‘‘”‹–‡Ǥ Žƒ•–‡ ‘•–”—”‰ǤʹͲͳ͸Ǣͳ͵͹ȋͳȌǣ͹‡Ǧͳ͵‡Ǥ ͺ͸Ǥ ‘ ǡ‹ ǤŠ‡‘™  Žƒ’ˆ‘””‡ƒ•–‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰ Ž‘„’‡Ǥ ʹͲͳͺǢ͸ȋ͵Ȍǣ‡ͳ͵͸ͷǤ ͺ͹Ǥ —Š‘œǡ–—”–œ ǡ‘–ƒ‰ǡ””—†ƒ ǡŽ†”‹‰Š‹ǡ ‡’‡”Ž‹ǡ‡–ƒŽǤŽ‹‹ ƒŽ‘—– ‘‡‘ˆ ƒ„†‘‹ƒŽ™ƒŽŽƒˆ–‡” ˆŽƒ’Šƒ”˜‡•–‹‰ƒ†‹‡†‹ƒ–‡ƒ’’Ž‹ ƒ–‹‘‘ˆƒ„†‘‹‘’Žƒ•–› –‡ Š‹“—‡•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͷǢͳͳ͸ȋ͹ȌǣͳͺͺͳǦͻ͵Ǥ ͺͺǤ —‡ƒ—ǡ–‡‡„‡”‰‡ǡ‹Ž••‘ ǡ–”‘„‡”‰Ǥƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘‘‹–‘”‹‰ƒ† ‹ƒ‰‹‰ǣ‘˜‡Žƒ’’”‘ƒ Š‡•Ǥ‡†‹‘Ž‰‘’—–ǤʹͲͲ͹ǢͶͷȋͷȌǣͶʹͳǦ͵ͷǤ ͺͻǤ ƒƒ”‘–ƒǡ‹–‘ ǡƒ‰Ž‹ƒ”‘ǡƒ”‘Ǥ—””‡–—•‡•‘ˆ†‹ƒ‰‘•–‹ Š‹‰ŠǦˆ”‡“—‡ ›‹ †‡”ƒ–‘Ž‘‰›Ǥ—” ƒ†‹‘ŽǤͳͻͻͺǢʹ͹—’’ŽʹǣʹͳͷǦʹ͵Ǥ ͻͲǤ ‘Ž‘‰‹ƒ ǡ Šƒˆˆ‡” ǡ‡””‘‹Ǥ‡”ƒ–‘Ž‘‰›ǡͶ–Š‡†‹–‹‘ǣŽ•‡˜‹‡”ǢʹͲͳ͹Ǥ ͻͳǤ ‡›‡Žǡ‹ Š™ƒ”†– ǡƒŽœ‡” ǡ–‡‰‡ƒǡƒ••ƒˆǡŽ‡‹„‘‰ƒ”†ǡ‡–ƒŽǤŠƒ”ƒ –‡”‹œƒ–‹‘‘ˆ–Š‡ ‘Ǧ‹˜ƒ•‹˜‡ƒ••‡••‡–‘ˆ–Š‡ —–ƒ‡‘—•‹ ”‘ ‹” —Žƒ–‹‘„›Žƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘• ƒ‡”Ǥ ‹ ”‘ ‹” —Žƒ–‹‘ǤʹͲͳͲǢͳ͹ȋͷȌǣ͵ͷͺǦ͸͸Ǥ ͻʹǤ ˜‡†ƒǡŠ‡””› ǡ–”‹‰‹‹ǡ›ƒ Ǥƒ•‡”‘’’Ž‡”‹ƒ‰‹‰‘ˆ•‹‹ ”‘ ‹” —Žƒ–‹‘Ǥ –ƒ ‡”‡‡”‡‘ŽǤͳͻͻͺǢ͹ͺȋʹȌǣͳͳͶǦͺǤ ͻ͵Ǥ ƒ”†‡ŽŽǡ ƒ‘„••‘ǡ‹Ž••‘ Ǥƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘‹ƒ‰‹‰„›†›ƒ‹ Ž‹‰Š–• ƒ––‡”‹‰Ǥ ”ƒ•‹‘‡†‰Ǥͳͻͻ͵ǢͶͲȋͶȌǣ͵ͲͻǦͳ͸Ǥ ͻͶǤ ‘”›”ǡƒ”–‡••‘ǡ˜‡••‘ ǡ‹Ž••‘ ǡ‘ŽŽ‡”Ǥ‡™†‡˜‹ ‡ ‘„‹‹‰Žƒ•‡” ‘’’Ž‡”’‡”ˆ—•‹‘‹ƒ‰‹‰ƒ††‹‰‹–ƒŽ’Š‘–‘‰”ƒ’Š›ǤŽ‹Š›•‹‘ŽǤͳͻͻ͸Ǣͳ͸ȋͷȌǣͷ͵ͷǦͶͳǤ ͻͷǤ ••‡š ǡ›”‡ǤŽƒ•‡”‘’’Ž‡”• ƒ‡”ˆ‘”‹ƒ‰‹‰„Ž‘‘†ˆŽ‘™‹•‹Ǥ ‹‘‡†‰Ǥ ͳͻͻͳǢͳ͵ȋ͵ȌǣͳͺͻǦͻͶǤ

95 95 ͻ͸Ǥ ‡”‹‡†Ǥ‡”‹ ƒ ͵›•–‡Ǥȏ ‡••†ƒ–‡ʹͲͳͻǦͳͲǦʹͺȐǤ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣ Š––’•ǣȀȀ™™™Ǥ‡†ƒ–ƒǤ œȀ̴†‘ •Ȁ’‡”‹‡†Ȁ‡̴’‡”‹‡†̴’‡”‹• ƒ̴’‹͵Ǥ’†ˆǤ ͻ͹Ǥ ”‡†”‹••‘ ǡƒ”••‘ǡ–”‘„‡”‰Ǥ‡ƒ•—”‡‡–†‡’–Šƒ†˜‘Ž—‡‹Žƒ•‡”‘’’Ž‡”ˆŽ‘™‡–”›Ǥ ‹ ”‘˜ƒ• ‡•ǤʹͲͲͻǢ͹ͺȋͳȌǣͶǦͳ͵Ǥ ͻͺǤ ‡”‹‡†Ǥ‹ ”‘ ‹” —Žƒ–‹‘ ƒ‰‹‰‡ Š‹“—‡•Ǥȏ ‡••†ƒ–‡ʹͲͳͻǦͲͻǦ͵ͲȐǤ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣ Š––’ǣȀȀ™™™Ǥ’‡”‹‡†Ǥ ‘Ǥ Ȁ„”‘ Š—”‡•Ȁ‹ ”‘ ‹” —Žƒ–‘”›̴‹ƒ‰‹‰̴–‡ Š‹“—‡•̴‡”‹‡†Ǥ’†ˆǤ ͻͻǤ —‰‡”ǡ ”ǤŠ‡ƒƒ–‘‹ ”ƒ–‹‘ƒŽ‡ˆ‘”ƒ„†‘‹ƒŽŽ‹’‡ –‘›Ǥ—”‰Ǥͳͻ͹ͻǢͶͷȋͻȌǣ͸ͳʹǦ͹Ǥ ͳͲͲǤ ‡‡ ǡ‹ ǡƒǡƒŽ‹ƒ”•‹‰ǡ ƒ—ǡƒǡ‡–ƒŽǤŠƒ‰‡•‹–Š‡Ž‘ ƒŽ‘”’Š‘Ž‘‰›‘ˆ–Š‡ ”‡ –—•ƒ„†‘‹‹•—• Ž‡ˆ‘ŽŽ‘™‹‰–Š‡ ˆŽƒ’ǣƒ—Ž–”ƒ•‘‘‰”ƒ’Š‹ •–—†›Ǥ” Žƒ•–—”‰Ǥ ʹͲͲͶǢͷ͹ȋͷȌǣ͵ͻͺǦͶͲͷǤ ͳͲͳǤ ”‘‡•‡ ǡ‡‹†‡”•ǡŽ‡‹”‡•‹ ǡ—›•‘• ǡƒ‰‡ Ǥ‘’ƒ”‹‰†‹ˆˆ‡”‡–‘†ƒŽ‹–‹‡•ˆ‘”–Š‡ †‹ƒ‰‘•‹•‘ˆ‹ ‹•‹‘ƒŽŠ‡”‹ƒǣƒ•›•–‡ƒ–‹ ”‡˜‹‡™Ǥ ‡”‹ƒǤʹͲͳͺǢʹʹȋʹȌǣʹʹͻǦͶʹǤ ͳͲʹǤ ‹— Š‹ǡ—”ƒƒ‹ ǡƒ•Š‹™ƒ ǡ ‘ƒǡƒ–‘ ǡ‰‹‘Ǥ‘”’Š‘‡–”‹ ƒŽ•–—†›‘ˆ–Š‡ ƒ”–‡”‹ƒŽ’‡”ˆ‘”ƒ–‘”•‘ˆ–Š‡†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’Ǥ—”‰ƒ†‹‘Žƒ–Ǥ ʹͲͲͳǢʹ͵ȋ͸Ȍǣ͵͹ͷǦͺͳǤ ͳͲ͵Ǥ ƒƒ†ǡ‡„‘™‡ǡ ‘‰ƒǡ‹•‡ǡ ‹Žƒ‹”‡ ǡƒ†‡‰Š‹ǡ‡–ƒŽǤ‘ ƒŽ‹œƒ–‹‘‘ˆ–Š‡†‘‹ƒ– †‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›’‡”ˆ‘”ƒ–‘”„› ‘’—–‡†–‘‘‰”ƒ’Š›ƒ‰‹‘‰”ƒǣ†‘‡•–Š‡•–ƒ†ƒ”† †‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›’‡”ˆ‘”ƒ–‘”ˆŽƒ’†‡•‹‰‹ Ž—†‡–Š‡†‘‹ƒ–’‡”ˆ‘”ƒ–‘”ǫŽƒ•– —”‰ǤʹͲͳͶǢ͹ʹȋ͸Ȍǣ͸͹ͲǦ͵Ǥ ͳͲͶǤ ƒ”• ǡ”ƒ Š›ǡ—‹‰•Ǥ›ƒ‹ ˜ƒ”‹ƒ–‹‘•‹„Ž‘‘†ˆŽ‘™ƒ•‡ƒ•—”‡†„›Žƒ•‡” ‘’’Ž‡”˜‡Ž‘ ‹‡–”›ǣƒ•–—†›‹”ƒ–•‹ˆŽƒ’•ǤŽƒ•–‡ ‘•–”—”‰ǤͳͻͺͶǢ͹͵ȋͷȌǣͺͲͶǦͳͲǤ ͳͲͷǤ ›†‹ǡƒ˜‹Ž‹Ǥšƒ‹‹‰‹ ”‘ ‹” —Žƒ–‹‘‹’”‘˜‡•–Š‡ƒ‰‹‘•‘‡–Š‡‘”›‹‡š’Žƒ‹‹‰–Š‡ †‡Žƒ›’Š‡‘‡‘‹ƒ”ƒ„„‹–‘†‡ŽǤ ‡ ‘•–”‹ ”‘•—”‰ǤʹͲͲ͵Ǣͳͻȋ͵Ȍǣͳͺ͹ǦͻͶǤ ͳͲ͸Ǥ ސ•‡–Šǡ ‘Žƒ†Ǥ˜ƒŽ—ƒ–‹‘‘ˆ‹ ”‘ ‹” —Žƒ–‹‘ƒ†™‘—†Ǧ Ž‘•‹‰–‡•‹‘ƒˆ–‡” —†‡”‹‹‰–Š‡•‹Ǥ•–—†›‹ƒ’‘” ‹‡‘†‡Ž—•‹‰Žƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘‹ƒ‰‹‰Ǥ—”‘’‡ƒ ‘—”ƒŽ‘ˆŽƒ•–‹ —”‰‡”›ǤʹͲͲͶǢʹ͹ȋ͸ȌǣʹͻͷǦ͹Ǥ ͳͲ͹Ǥ ‡”‰¤”†ǡ‡” ‡” ǡ†‡‡‡”†Ǥ –‡”ƒŽƒƒ”›‡••‡Ž•̵ ’ƒ –‘„†‘‹ƒŽ‹‡”ˆ—•‹‘ ‹ ”‡‡„†‘‹ƒŽ Žƒ’”‡ƒ•–‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰ Ž‘„’‡ǤʹͲͳ͹ǢͷȋͳʹȌǣ‡ͳ͸ͲͳǤ ͳͲͺǤ ”ƒ ‘™•‹ ǡ‹•‘ǡƒŽ˜ƒ–Ǧ‡Ž‹•ǡ ƒŽŽ‹™‹ŽŽ Ǥ‡–Š‘†‘Ž‘‰‹ ƒŽ‹••—‡•‹–Š‡ƒ••‡••‡–‘ˆ •‹‹ ”‘˜ƒ• —Žƒ”‡†‘–Š‡Ž‹ƒŽˆ— –‹‘‹Š—ƒ•Ǥ”‡†•Šƒ”ƒ ‘Ž ‹ǤʹͲͲ͸Ǣʹ͹ȋͻȌǣͷͲ͵ǦͺǤ ͳͲͻǤ ƒ›Ž‘” ǡ‘”Ž‡–– ǡ•Š–‘ǤŠ‡ — –‹‘ƒŽ‰‹‘•‘‡ǣŽ‹‹ ƒŽ ’Ž‹ ƒ–‹‘•‘ˆ–Š‡ ƒ–‘‹ ƒŽ‘ ‡’–ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳ͹ǢͳͶͲȋͶȌǣ͹ʹͳǦ͵͵Ǥ ͳͳͲǤ ƒ‹–Ǧ›”ǡ‘‰ǡ Šƒ˜‡”‹‡ǡ‘ŒƒŽŽƒŽǡ‘Š”‹ Š ǤŠ‡’‡”ˆ‘”ƒ•‘‡–Š‡‘”›ǣ˜ƒ• —Žƒ” ƒƒ–‘›ƒ† Ž‹‹ ƒŽ‹’Ž‹ ƒ–‹‘•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͻǢͳʹͶȋͷȌǣͳͷʹͻǦͶͶǤ ͳͳͳǤ ƒ”Š‹ŽŽǡƒ†‡”ǡ›ƒ Ǥ•–—†›‘ˆ—‹ƒš‹ƒŽ–‡•‹‘‘–Š‡•—’‡”ˆ‹ ‹ƒŽ†‡”ƒŽ ‹ ”‘˜ƒ• —Žƒ–—”‡Ǥ  ˜‡•–‡”ƒ–‘ŽǤͳͻͺͶǢͺʹȋͷȌǣͷͳͳǦͶǤ ͳͳʹǤ —––‹‰ǡƒŽŽƒ–›‡ǡŠƒ™ǡ‘˜‡”•‡ Ǥ”‹–‹ ƒŽ Ž‘•‹‰’”‡••—”‡ǡŽ‘ ƒŽ’‡”ˆ—•‹‘’”‡••—”‡ǡ ƒ†–Š‡ˆƒ‹Ž‹‰•‹ˆŽƒ’ǤŽƒ•–—”‰ǤͳͻͺʹǢͺȋ͸ȌǣͷͲͶǦͻǤ ͳͳ͵Ǥ ƒ‰ǡŠ—‰ǡ‡‡ǡ‡™ ǡ‘‰Ǥ˜ƒŽ—ƒ–‹‘‘ˆ–Š‡‡Žƒ–‹‘•Š‹’‡–™‡‡ Žƒ’‡•‹‘ ƒ†‹••—‡‡”ˆ—•‹‘‹ ’Žƒ–Ǧƒ•‡†”‡ƒ•–‡ ‘•–”— –‹‘•‹‰ƒ•‡”Ǧ••‹•–‡† †‘ ›ƒ‹‡ ”‡‡‰‹‘‰”ƒ’Š›Ǥ—”‰ ‘ŽǤʹͲͳͺǢʹͷȋͺȌǣʹʹ͵ͷǦͶͲǤ ͳͳͶǤ ‡Ž‹•ǡ‘‘”Žƒ†‡”ǡ˜ƒ†‡”Ž‡‹Œ ǡ˜ƒ‘‘”†‡ ǡ˜ƒ†‡” ‘”•–Ǥš›‰‡ƒ–‹‘ƒ† ‹ ”‘ ‹” —Žƒ–‹‘†—”‹‰•‹•–”‡– Š‹‰‹—†‡”‹‡†ƒ†‘—†‡”‹‡†•‹ǤŽƒ•–‡ ‘•–” —”‰ǤʹͲͲ͵ǢͳͳʹȋͷȌǣͳʹͻͷǦ͵ͲͳǤ ͳͳͷǤ ™ƒ•‘Ǥ‘’ƒ”‹•‘‘ˆ‹‹–‡†ƒ† —ŽŽ‹••‡ –‹‘„†‘‹‘’Žƒ•–›•‹‰ƒ•‡” Ž—‘”‡• ‡ ‡ ƒ‰‹‰–‘˜ƒŽ—ƒ–‡‡”ˆ—•‹‘‘ˆ–Š‡„†‘‹ƒŽ‹ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͷǢͳ͵͸ȋͳȌǣ͵ͳ‡ǦͶ͵‡Ǥ ͳͳ͸Ǥ ƒ›”ǡ ‘Žǡ ‘ˆ–‡”ǡ‡ ‡”ǡˆ‡‹ˆˆ‡”ǡ—ŠŽ„ƒ—‡”Ǥˆˆ‡ –•‘ˆƒ‡•–Š‡–‹ ƒ„†‘‹‘’Žƒ•–›‘ ƒ„†‘‹ƒŽ™ƒŽŽ’‡”ˆ—•‹‘ǣƒ“—ƒ–‹–ƒ–‹˜‡‡˜ƒŽ—ƒ–‹‘ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͶǢͳͳͶȋ͸Ȍǣͳͷͺ͸ǦͻͶǤ ͳͳ͹Ǥ ‘‘•–ƒ‡‹ƒ ǡ ƒ””‹•ǡ ƒ”ƒ• ǡƒ”–‘ ǡ‡‡Ž Ǥ‘’ƒ”‹•‘‘ˆ‹‹–‡†Ǧ†‡”‹‹‰ ‹’‘ƒ„†‘‹‘’Žƒ•–›ƒ†”ƒ†‹–‹‘ƒŽ„†‘‹‘’Žƒ•–›•‹‰ƒ•‡” Ž—‘”‡• ‡ ‡ ƒ‰‹‰Ǥ‡•–Š‡– —”‰ ǤʹͲͳͶǢ͵ͶȋͷȌǣ͹ͶͳǦ͹Ǥ ͳͳͺǤ ‹”œƒ„‡‹‰‹ǡ‹Ž•‘ ǡ ‹• Š‡” ǡƒ•–ƒǡƒ Š™ƒŽƒǡ‘˜ƒ Š ǡ‡–ƒŽǤ”‡†‹ –‹‰ƒ† ƒƒ‰‹‰†‘‘”Ǧ•‹–‡™‘—† ‘’Ž‹ ƒ–‹‘•‹ƒ„†‘‹ƒŽŽ›„ƒ•‡†ˆ”‡‡ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ǣ ‹’”‘˜‡†‘—– ‘‡•™‹–Š‡ƒ”Ž›”‡‘’‡”ƒ–‹˜‡ Ž‘•—”‡ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͷǢͳ͵ͷȋͳȌǣͳͶǦʹ͵Ǥ ͳͳͻǤ ‡ƒ”ŽǤ—‹ˆ›‹‰–Š‡‘”›‘ˆ–Š‡†‡Žƒ›’Š‡‘‡‘ǦǦ”‡ ‘˜‡”›ˆ”‘–Š‡Š›’‡”ƒ†”‡‡”‰‹ •–ƒ–‡Ǥ Žƒ•–—”‰ǤͳͻͺͳǢ͹ȋʹȌǣͳͲʹǦͳʹǤ ͳʹͲǤ Šƒ”ǡƒ›Ž‘” ǤŠ‡†‡Žƒ›’Š‡‘‡‘ǣ–Š‡•–‘”›—ˆ‘Ž†•ǤŽƒ•–‡ ‘•–”—”‰Ǥ ͳͻͻͻǢͳͲͶȋ͹ȌǣʹͲ͹ͻǦͻͳǤ

96 96 ͳʹͳǤ ƒ„•–ǡƒ‡”‡”ǡ”—‰‡”ǡ ƒ‰‡”ǡ ‡”ƒǤƒ• —Žƒ”ƒ” Š‹–‡ –—”‡‹ˆ”‡‡ˆŽƒ’•ǣ ƒŽ›•‹•‘ˆ˜‡••‡Ž‘”’Š‘Ž‘‰›ƒ†‘”’Š‘‡–”›‹—”‹‡ˆ”‡‡ˆŽƒ’•Ǥ‹ ”‘˜ƒ• ‡•Ǥ ʹͲͳͺǢͳͳͺǣͳʹͺǦ͵͸Ǥ ͳʹʹǤ ””ƒœ‘’‡œ ǡ—ƒ”‡œ‹‡–‘ǡƒ”–Š‡ ƒ” ‹ƒǡ‘Œ‘”–‡‰ƒ Ǥ˜ƒŽ—ƒ–‹‘‘ˆƒ‰‹‘‰‡‡•‹•‹ †‡Žƒ›‡†•‹ˆŽƒ’•—•‹‰ƒ‘‘ Ž‘ƒŽƒ–‹„‘†›ˆ‘”–Š‡˜ƒ• —Žƒ”‡†‘–Š‡Ž‹—Ǥ” Žƒ•–—”‰Ǥ ͳͻͻͷǢͶͺȋ͹ȌǣͶ͹ͻǦͺ͸Ǥ ͳʹ͵Ǥ ‡ƒŽ ǡ ‡™‹––ǡƒ”–‹ǡ”ƒ•Š‡”ǡƒ ƒ†ƒǤ”‡‘’‡”ƒ–‹˜‡ƒ†‘•–‘’‡”ƒ–‹˜‡ ••‡••‡–‘ˆ‡ –—•„†‘‹‹•—• Ž‡‹œ‡ƒ† — –‹‘ˆ‘ŽŽ‘™‹‰  Žƒ’—”‰‡”›ǤŽƒ•– ‡ ‘•–”—”‰ǤʹͲͳͺǢͳͶͳȋͷȌǣͳʹ͸ͳǦ͹ͲǤ ͳʹͶǤ ‹ǡ—›ƒ‰ǡ‹—Ǥ‡˜‡”ƒŽ’‹‹‘•‘”‡‘’‡”ƒ–‹˜‡ƒ†‘•–‘’‡”ƒ–‹˜‡••‡••‡–‘ˆ‡ –—• „†‘‹‹•—• Ž‡‹œ‡ƒ† — –‹‘ˆ‘ŽŽ‘™‹‰  Žƒ’—”‰‡”›ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲͳͻǢͳͶ͵ȋ͵Ȍǣ͸ͷͷ‡Ǧ͸‡Ǥ ͳʹͷǤ ‡ƒŽ ǡ ‡™‹––ǡƒ”–‹ǡ”ƒ•Š‡”ǡƒ ƒ†ƒǤ‡’Ž›ǣ”‡‘’‡”ƒ–‹˜‡ƒ†‘•–‘’‡”ƒ–‹˜‡ ••‡••‡–‘ˆ‡ –—•„†‘‹‹•—• Ž‡‹œ‡ƒ† — –‹‘ˆ‘ŽŽ‘™‹‰  Žƒ’—”‰‡”›ǤŽƒ•– ‡ ‘•–”—”‰ǤʹͲͳͻǢͳͶ͵ȋ͵Ȍǣ͸ͷ͸‡Ǧ͹‡Ǥ ͳʹ͸Ǥ ƒ”˜‡›ǡƒŽƒ˜ƒ–‹ǡ ‡‰ǡ—–Ž‡”Ǥ„†‘‹ƒŽ†‘‘”Ǧ•‹–‡‘—– ‘‡•ˆ‘”‡†‹ƒŽ˜‡”•—•Žƒ–‡”ƒŽ †‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›„”ƒ Š’‡”ˆ‘”ƒ–‘”Šƒ”˜‡•–ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͳǢͳʹ͹ȋ͸ȌǣʹͳͻͺǦ ʹͲͷǤ ͳʹ͹Ǥ ‡‡Ǧǡƒ” Ǧǡ— Ǧ Ǥ ’ƒ –‘ˆ‡ –—•—• Ž‡ Œ—”›†—”‹‰‡”ˆ‘”ƒ–‘”‹••‡ –‹‘‘ — –‹‘ƒŽ‘‘”‘”„‹†‹–›ƒˆ–‡”‡‡’ ˆ‡”‹‘”’‹‰ƒ•–”‹ ‡”ˆ‘”ƒ–‘” Žƒ’”‡ƒ•–‡ ‘•–”— –‹‘Ǥ Žƒ•–‡ ‘•–”—”‰ Ž‘„’‡ǤʹͲͳͻǢ͹ȋͳͲȌǣ‡ʹͶͺͶǦ‡Ǥ ͳʹͺǤ ‘œ‡ǡ•Š–‘ǡ—””ƒ›ǡƒ›Ž‘” Ǥ˜‘‹†‹‰†‡‡”˜ƒ–‹‘‘ˆ”‡ –—•ƒ„†‘‹‹•‹  ˆŽƒ’Šƒ”˜‡•–ǣ–Š‡‹’‘”–ƒ ‡‘ˆ‡†‹ƒŽ”‘™’‡”ˆ‘”ƒ–‘”•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͺǢͳʹʹȋ͵Ȍǣ͹ͳͲǦ͸Ǥ ͳʹͻǤ —–Ž‡”ǡŽ‘ œƒǡ‡‹••‹•ǡ ‡”› ǡ —–‡” ǡ‘‘† ǡ‡–ƒŽǤ ƒ –‘”•–Šƒ–’”‡†‹ –†‡‡’ ‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’†‘‘”•‹–‡Š‡”‹ƒƒ†„—Ž‰‡Ǥ Žƒ•–—”‰ ƒ†—”‰Ǥ ʹͲͳͺǢͷʹȋ͸Ȍǣ͵͵ͺǦͶʹǤ ͳ͵ͲǤ ƒ‹Ž‡› ǡƒ‹–Ǧ›”ǡ‘‰ǡ‘ŒƒŽŽƒŽǡŠƒ‰ǡ—›ƒ‰ǡ‡–ƒŽǤŠ‡•‹‰Ž‡†‘‹ƒ–‡†‹ƒŽ ”‘™’‡”ˆ‘”ƒ–‘” ˆŽƒ’‹„”‡ƒ•–”‡ ‘•–”— –‹‘ǣ–Š”‡‡Ǧ†‹‡•‹‘ƒŽ’‡”ˆ‘”ƒ•‘‡ƒ† Ž‹‹ ƒŽ ”‡•—Ž–•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͲǢͳʹ͸ȋ͵Ȍǣ͹͵ͻǦͷͳǤ ͳ͵ͳǤ  ƒŠ‘ ǡ— ǡ‹•‡„‡”‰Ǥ—• Ž‡‡†‡ƒǤ  ‘‡–‰‡‘ŽǤʹͲͳͲǢͳͻͶȋͶȌǣʹͺͶǦͻʹǤ ͳ͵ʹǤ ƒ ǡƒ‰ǡ‘‰ǡ‡‡ ǡ‹ǡ‘ Ǥ‘Ž—‡ Šƒ‰‡‹–Š‡”‡ –—•ƒ„†‘‹‹•—• Ž‡ ƒˆ–‡”†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’Šƒ”˜‡•–Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰Ǥ ʹͲͳͺǢ͹ͳȋͻȌǣͳ͵ͳͲǦ͸Ǥ ͳ͵͵Ǥ —––‡”ǡ‡„•–‡” ǡ ƒ‰‡ǡ‹– Š‡ŽŽǤ”‡–”‘•’‡ –‹˜‡ ‘’ƒ”‹•‘‘ˆƒ„†‘‹ƒŽ—• Ž‡ •–”‡‰–Šˆ‘ŽŽ‘™‹‰„”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Šƒˆ”‡‡‘” ˆŽƒ’Ǥ” Žƒ•–—”‰Ǥ ʹͲͲͲǢͷ͵ȋ͹Ȍǣͷ͹ͺǦͺ͵Ǥ ͳ͵ͶǤ ƒ••ƒǡ‡‡ǡ—š‡Š‘ˆ‡” ǡ Š‡—ˆŽ‡”ǡš‡”Ǥȏ›‘•‘‘‰”ƒ’Š‹ ‡˜ƒŽ—ƒ–‹‘‘ˆ”‡ –—• ƒ„†‘‹‹•—• Ž‡ˆ— –‹‘ƒˆ–‡” ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ȐǤ ƒ† Š‹”‹”‘ Š‹”Žƒ•–Š‹”Ǥ ʹͲͲʹǢ͵Ͷȋ͸Ȍǣ͵ͺ͸ǦͻͶǤ ͳ͵ͷǤ ‘†‡ǡ—† ǡ ”‹†„‡”‰ǡƒ‡•‹‘Ž†Ǧƒ•‘‡ǡŽ„‡”‰ Ǥ„†‘‹ƒŽ•–”‡‰–Šƒˆ–‡”„”‡ƒ•– ”‡ ‘•–”— –‹‘—•‹‰ƒˆ”‡‡ƒ„†‘‹ƒŽˆŽƒ’Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͲ͹Ǣ͸ͲȋͷȌǣͷͳͻǦʹ͵Ǥ ͳ͵͸Ǥ †ƒ ǡ‘‹‘ƒǡƒ”—ƒ™ƒǡ—ƒ‰ƒǡƒ‘ Š‹ ǡ—‰ƒ™ƒ”ƒǡ‡–ƒŽǤ„†‘‹ƒŽ‘”„‹†‹–›ƒˆ–‡” •‹‰Ž‡Ǧ˜‡”•—•†‘—„Ž‡Ǧ’‡†‹ Ž‡††‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’—•‡Ǥ Žƒ•–‡ ‘•–”‡•–Š‡– —”‰ǤʹͲͳ͸Ǣ͸ͻȋͻȌǣͳͳ͹ͺǦͺ͵Ǥ ͳ͵͹Ǥ ‘––‡”‘ǡ‡ˆƒ— Š‡—” ǡ ƒ†Š—Žǡƒ—Ž‘ǡ‘ŽŽ‹•ǡƒ–‹‡”‹ǤŽ‡ –”‘›‘‰”ƒ’Š‹ ƒ••‡••‡–‘ˆ ”‡ –—•ƒ„†‘‹‹•—• Ž‡ˆ— –‹‘ƒˆ–‡”†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’•—”‰‡”›ǤŽƒ•– ‡ ‘•–”—”‰ǤʹͲͲͶǢͳͳ͵ȋͳȌǣͳͷ͸Ǧ͸ͳǤ ͳ͵ͺǤ ‡Ž„‡” ǡ‡Ž•‘ ǡ ‘•‘– ǡ ‘Ž†•–‡‹ ǡ‡”‰‡›ǡ‘ƒ†ǡ‡–ƒŽǤ’”‘•’‡ –‹˜‡•–—†› ‘’ƒ”‹‰ –Š‡ˆ— –‹‘ƒŽ‹’ƒ –‘ˆ ǡ ǡƒ†—• Ž‡Ǧ•’ƒ”‹‰ˆ”‡‡ˆŽƒ’•‘–Š‡ƒ„†‘‹ƒŽ™ƒŽŽǣ ’ƒ”– Ǥ—‹Žƒ–‡”ƒŽ”‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͲǢͳʹ͸ȋͶȌǣͳͳͶʹǦͷ͵Ǥ ͳ͵ͻǤ ƒŠƒ„‡†‹ƒǡƒŠƒ„‡†‹ƒ ǤŽ‘•‹‰–Š‡‰ƒ’ˆ‘”’ƒ–‹‡–•™‹–Š”‡ –—•ƒ„†‘‹‹•†‹ƒ•–ƒ•‹•Ǥ —”•‹‰ǤʹͲͳͺǢͶͺȋͳȌǣͶͻǦͷʹǤ ͳͶͲǤ ƒŠƒ„‡†‹ƒǤƒƒ‰‡‡––”ƒ–‡‰‹‡•ˆ‘”‹ƒ•–ƒ•‹•‡ –‹Ǥ‡‹Žƒ•–—”‰ǤʹͲͳͺǢ͵ʹȋ͵ȌǣͳͶ͹ǦͷͶǤ ͳͶͳǤ ˜§”†„‘”‰ǡƒ•‰ƒƒ”†Ǥ‘‘”Ǧ•‹–‡‘”„‹†‹–›ƒˆ–‡”’‡†‹ Ž‡†„”‡ƒ•–”‡ ‘•–”— –‹‘ǣƒ ‘’ƒ”‹•‘‘ˆ–™‘†‹ˆˆ‡”‡––›’‡•‘ˆ‡•ŠǤƒŽ•‘ˆ’Žƒ•–‹ •—”‰‡”›ǤʹͲͳ͵Ǣ͹ͳȋͷȌǣͶ͹͸ǦͺͲǤ ͳͶʹǤ ƒ–Šǡ––ƒŽ‹ǡ—ƒ• ǡ ‘Ž†Ž—•–ǡŠƒ‰ ǡŠ‡˜”‡Ž ǤŠ‡ƒ„†‘‹ƒŽŽ‹‡ƒƒŽ„ƒǣƒƒƒ–‘‘Ǧ ”ƒ†‹‘Ž‘‰‹ ƒ†„‹‘‡ Šƒ‹ ƒŽ•–—†›Ǥ—”‰ƒ†‹‘Žƒ–Ǥͳͻͻ͸ǢͳͺȋͶȌǣʹͺͳǦͺǤ ͳͶ͵Ǥ ”ƒ—ƒǤ‹ƒ•–ƒ•‹•”‡ –‹ǣ Ž‹‹ ƒŽƒƒ–‘›ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͺǢͳʹʹȋͷȌǣͳͷ͸ͶǦͻǤ

97 97 ͳͶͶǤ ƒ”Ž•–‡†–ǡ‡––‡”••‘ǡ–ƒ”ǡ–”‹‰ƒ”†Ǥ„†‘‹‡ŽŽ”‡–—•†‹ƒ•–ƒ•ƒ‰‡ˆ—–‹‘‡ŽŽƒ„‡•˜¡”Ǥ ƒƒ”–‹†‹‰‡ǤʹͲͳͺǢͳͳͷǤ ͳͶͷǤ ‘—„‘˜ƒǡ†‡ŽǡƒŽƒ• ƒ‘˜ƒǦ’”‹‰”‘˜ƒ ǡ‘Žƒ”ǡ”‹œ ǡ‘„‡•‘˜ƒǤ‹ƒ•–ƒ•‹•‘ˆ”‡ –—• ƒ„†‘‹‹•—• Ž‡•‹Ž‘™„ƒ ’ƒ‹’ƒ–‹‡–•Ǥ ƒ —• —Ž‘•‡Ž‡–‡Šƒ„‹ŽǤʹͲͳͺǢ͵ͳȋͳȌǣͳͲ͹ǦͳʹǤ ͳͶ͸Ǥ —ƒ”••‘ǡ–ƒ”ǡƒŠŽ•–”ƒ†ǡ–”‹‰ƒ”†Ǥ‘””‡Žƒ–‹‘„‡–™‡‡ƒ„†‘‹ƒŽ”‡ –—•†‹ƒ•–ƒ•‹• ™‹†–Šƒ†ƒ„†‘‹ƒŽ—• Ž‡•–”‡‰–ŠǤ‹‰—”‰ǤʹͲͳͷǢ͵ʹȋʹȌǣͳͳʹǦ͸Ǥ ͳͶ͹Ǥ ƒ‰ǡ—ǡŠ‡ ǡ—ǡƒ‰ Ǥ‘‡•†‹ƒ•–ƒ•‹•”‡ –‹ƒ„†‘‹‹•™‡ƒ‡’‡Ž˜‹ ˆŽ‘‘”ˆ— –‹‘ǫ ”‘••Ǧ•‡ –‹‘ƒŽ•–—†›Ǥ –”‘‰›‡ ‘Ž ǤʹͲͳͻǤ ͳͶͺǤ Þǡ ‹Ž†‡ ǡ‡ˆŒ‘”†ǡ’‡”•–ƒ† ǡ‰ŠǤ‡Ž˜‹ ˆŽ‘‘”—• Ž‡ˆ— –‹‘ǡ’‡Ž˜‹ ˆŽ‘‘” †›•ˆ— –‹‘ƒ††‹ƒ•–ƒ•‹•”‡ –‹ƒ„†‘‹‹•ǣ”‘•’‡ –‹˜‡ ‘Š‘”–•–—†›Ǥ‡—”‘—”‘Ž”‘†›Ǥ ʹͲͳ͹Ǣ͵͸ȋ͵Ȍǣ͹ͳ͸ǦʹͳǤ ͳͶͻǤ ‡”ƒ†‡•†ƒ‘–ƒ ǡƒ• ‘ƒŽ ǡƒ”‹–ƒ ǡÞǤ”‡˜ƒŽ‡ ‡ƒ†”‹•ˆƒ –‘”•‘ˆ†‹ƒ•–ƒ•‹•”‡ –‹ ƒ„†‘‹‹•ˆ”‘Žƒ–‡’”‡‰ƒ ›–‘͸‘–Š•’‘•–’ƒ”–—ǡƒ†”‡Žƒ–‹‘•Š‹’™‹–ŠŽ—„‘Ǧ’‡Ž˜‹ ’ƒ‹Ǥ ƒŠ‡”ǤʹͲͳͷǢʹͲȋͳȌǣʹͲͲǦͷǤ ͳͷͲǤ ‡Œƒ‹ǡ ”ƒ™Ž‡› ǡŠ‹‡Ž†•ǡ˜ƒ†‡ƒ–‡”ǡƒ›Ž‘” Ǥ‡Žƒ–‹‘•Š‹’„‡–™‡‡†‹ƒ•–ƒ•‹• ‘ˆ–Š‡”‡ –—•ƒ„†‘‹‹•—• Ž‡ȋȌƒ†—• —Ž‘•‡Ž‡–ƒŽ†›•ˆ— –‹‘•ǡ’ƒ‹ƒ†“—ƒŽ‹–›‘ˆŽ‹ˆ‡ǣƒ •›•–‡ƒ–‹ ”‡˜‹‡™ǤŠ›•‹‘–Š‡”ƒ’›ǤʹͲͳͻǢͳͲͷȋͳȌǣʹͶǦ͵ͶǤ ͳͷͳǤ ƒ†‡‰Š‹ǡƒŽƒ–ƒǤ‡”•‹•–‡–‡”‘ƒ•‹„†‘‹ƒŽ ”‡‡ Žƒ’‘‘”‹–‡•ˆ–‡” ‘•–ƒ•–‡ –‘›”‡ƒ•–‡ ‘•–”— –‹‘—”‰‡”›ǣƒ•‡‡’‘”–•ƒ†‹–‡”ƒ–—”‡‡˜‹‡™Ǥ’Žƒ•–›Ǥ ʹͲͳ͵Ǣͳ͵ǣ‡ʹͶǤ ͳͷʹǤ ƒœœƒ‘ǡǤ ƒ–Š—”ƒǡƒ••‘‘ǡŽ‹ǡ ƒ›™‘‘†ǡ ‹‰—•Ǥ‡†— ‹‰ƒ„†‘‹ƒŽ•‡”‘ƒƒˆ–‡”  ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ǡ‘—– ‘‡•‹͹ʹ͸’ƒ–‹‡–•ǤŽƒ•–‹ ƒ†‡ ‘•–”— –‹˜‡—”‰‡”›Ǥ ʹͲͳ͸Ǣͳ͵͹ǣͳǤ ͳͷ͵Ǥ ‘”ƒ†‹ǡ—””ƒ–ǡ Žƒ•• ǡ•‘—‹ǡ‘‘†ǡ‘•‡Ǥ ˆŽƒ’Ž‡ƒ†•–‘ƒ‹ ”‡ƒ•‡‹ƒ„†‘‹ƒŽ •‡”‘ƒ”ƒ–‡• ‘’ƒ”‡†–‘ ˆŽƒ’ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ—”‘’‡ƒ ‘—”ƒŽ‘ˆŽƒ•–‹ —”‰‡”›Ǥ ʹͲͳͳǢ͵Ͷǣͺ͹ǦͻͳǤ ͳͷͶǤ ‘‘—ǡ‘Šƒǡœ‹œ‹ǡ‘ ‹ǡ”‹ Ž‡›ǡƒŽƒ–ƒǤ‘‘”•‹–‡‘”„‹†‹–›‹ ˆ”‡‡ ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘•ǣ ‘’ƒ”‹•‘‘ˆ—‹Žƒ–‡”ƒŽǡ„‹Žƒ–‡”ƒŽǡƒ†„‹’‡†‹ Ž‡†•—”‰‹ ƒŽ’”‘ ‡†—”‡ –›’‡•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳ͹Ǣ͹ͲȋͳͳȌǣͳͷͲͷǦͳ͵Ǥ ͳͷͷǤ ƒŠƒ„‡†‹ƒǤ Š‹‡˜‹‰‹†‡ƒŽ†‘‘”•‹–‡ƒ‡•–Š‡–‹ •™‹–Šƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ Žƒ† —”‰ǤʹͲͳͷǢͶȋʹȌǣͳͶͷǦͷ͵Ǥ ͳͷ͸Ǥ ‹• ‘–‹ ǡ‘ƒ•‡ŽŽ‹ ǡ‘†ƒǡƒ”‘‡Ǧ†‡•‹ǡƒŽ‰ƒ”‡ŽŽ‘Ǥ‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”› ’‡”ˆ‘”ƒ–‘”ˆŽƒ’†‘‘”Ǧ•‹–‡ Ž‘•—”‡™‹–Š ƒ—ŽƒǦƒ••‹•–‡†ǡŽ‹‹–‡†—†‡”‹‹‰ǡƒ†’”‘‰”‡••‹˜‡ Š‹‰ŠǦ–‡•‹‘•—–—”‡•˜‡”•—••–ƒ†ƒ”†ƒ„†‘‹‘’Žƒ•–›ǣ ‘’Ž‹ ƒ–‹‘•ǡ•‡•‹–‹˜‹–›ǡƒ† ‘•‡–‹  ‘—– ‘‡•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͷǢͳ͵ͷȋͳȌǣͳǦͳʹǤ ͳͷ͹Ǥ ƒŠƒ„‡†‹ƒǡ‘‡Ǥ‘™‡”ƒ„†‘‹ƒŽ„—Ž‰‡ƒˆ–‡”†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’ ȋ Ȍ„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŽƒ•–—”‰ǤʹͲͲͷǢͷͶȋʹȌǣͳʹͶǦͻǤ ͳͷͺǤ ‘šǡ ‘ǡ‡—‰ǡƒ•Šƒ‘”ǡ‡‘šǡƒƒ‡‡ǡ‡–ƒŽǤ‘’ƒ”‹•‘‘ˆ—– ‘‡• ˆ‘ŽŽ‘™‹‰—–‘Ž‘‰‘—•”‡ƒ•–‡ ‘•–”— –‹‘•‹‰–Š‡ ƒ†‡†‹ Ž‡† Žƒ’•ǣͳʹǦ‡ƒ” Ž‹‹ ƒŽ‡–”‘•’‡ –‹˜‡–—†›ƒ†‹–‡”ƒ–—”‡‡˜‹‡™ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳ͸Ǣͳ͵ͺȋͳȌǣͳ͸ǦʹͺǤ ͳͷͻǤ ƒ”˜‡›ǡ— Š‡Žǡ‘ ƒŒǡƒ•‡› ǡ͵”†ǡ ”ƒ› ǡ ‡”ƒ†‡œ ǡ‡–ƒŽǤ ƒ†’‡†‹ Ž‡† ˆŽƒ’•ǣƒ ‘’ƒ”‹•‘‘ˆ‘—– ‘‡•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲ͸Ǣͳͳ͹ȋ͸Ȍǣͳ͹ͳͳǦͻǢ†‹• —••‹‘ʹͲǦͳǤ ͳ͸ͲǤ ›ƒ•ǡ‹ ‹•‘ǡ ƒ•–‡Œ‹ƒ ǡƒ–•‘ ǡƒŽ‹‘ǡ”‹•‡”ƒǤ‹•ˆƒ –‘”•ˆ‘”ƒ„†‘‹ƒŽ †‘‘”Ǧ•‹–‡‘”„‹†‹–›‹ˆ”‡‡ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͺǢͳʹͳȋͷȌǣͳͷͳͻǦʹ͸Ǥ ͳ͸ͳǤ ƒǡ•‡‰ǡ†‡”•‘Ǧƒ ǡƒŽ‹‘ǡ”‹•‡”ƒǡ ‡•–‡Œ‹ƒ Ǥ  Ž—•‹‘‘ˆ‡•Š‹†‘‘”Ǧ •‹–‡”‡’ƒ‹”‘ˆˆ”‡‡ƒ†—• Ž‡Ǧ•’ƒ”‹‰ˆ”‡‡ˆŽƒ’•›‹‡Ž†•”ƒ–‡•‘ˆƒ„†‘‹ƒŽ ‘’Ž‹ ƒ–‹‘• ‘’ƒ”ƒ„Ž‡–‘–Š‘•‡‘ˆ ˆŽƒ’”‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲͳͲǢͳʹ͸ȋʹȌǣ͵͸͹Ǧ͹ͶǤ ͳ͸ʹǤ ‡ŽŽƒ”‘ ‡ ǡ‡ŽŽƒ”‘ ‡ ǡŽ—ǡ—ŽŽ‹˜ƒǡ”ƒŠƒ ǡ‹•‡ǡ‡–ƒŽǤ›–ŠǦ—•–‹‰–Š‡   Žƒ’ƒ†ƒ –”‘†— –‹‘–‘–Š‡„†‘‹ƒŽ‡”ˆ‘”ƒ–‘”š Šƒ‰‡ȋȌ”‡ƒ•– ‡ ‘•–”— –‹‘‡ Š‹“—‡ǣ‹‰Ž‡Ǧ—”‰‡‘‡–”‘•’‡ –‹˜‡‡˜‹‡™ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲͳͻǢͳͶ͵ȋͶȌǣͻͻʹǦͳͲͲͺǤ ͳ͸͵Ǥ —•‹ ǡŽƒ••‡ ǡ‡ŽŽǡƒ‘ ǡ ƒ”–Š›ǡ ‘––ǡ‡–ƒŽǤ‡ƒ•—”‹‰ƒ†ƒƒ‰‹‰’ƒ–‹‡– ‡š’‡ –ƒ–‹‘•ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘ǣ‹’ƒ –‘“—ƒŽ‹–›‘ˆŽ‹ˆ‡ƒ†’ƒ–‹‡–•ƒ–‹•ˆƒ –‹‘Ǥš’‡”–‡˜ Šƒ”ƒ ‘‡ ‘—– ‘‡•‡•ǤʹͲͳʹǢͳʹȋʹȌǣͳͶͻǦͷͺǤ ͳ͸ͶǤ ƒ‹ ǡ‡‡ǡ ‡‘ ǡ‹ǡ›‘ ǡƒ‰ ǡ‡–ƒŽǤ‘‘”•‹–‡‘”„‹†‹–›ˆ‘ŽŽ‘™‹‰ ˆŽƒ’ˆ‘” „”‡ƒ•–”‡ ‘•–”— –‹‘‹•‹ƒ’ƒ–‹‡–•ǣ •‹–†‹ˆˆ‡”‡–ǫ‹ ”‘•—”‰‡”›ǤʹͲͳͷǢ͵ͷȋͺȌǣͷͻ͸Ǧ͸ͲʹǤ ͳ͸ͷǤ Žƒ••‘ǡ›ƒ ǡ˜‡••‘ ǡ‡Žƒ†‡”Ǥ‘‹‰‹ ”‡ƒ•‡•†‘‘”•‹–‡ ‘’Ž‹ ƒ–‹‘•‹„”‡ƒ•– ”‡ ‘•–”— –‹‘™‹–Š ˆŽƒ’Ǥ Žƒ•–—”‰ ƒ†—”‰ǤʹͲͳ͸ǢͷͲȋ͸Ȍǣ͵͵ͳǦͷǤ

98 98 ͳ͸͸Ǥ ‹†‡„Žƒ––ǡ ”—‡Š‡”œǡ ƒ”Šƒ†‹ Ǥ•›•–‡ƒ–‹ ”‡˜‹‡™‘ˆ†‘‘”•‹–‡ƒ‡•–Š‡–‹ ƒ† ‘’Ž‹ ƒ–‹‘• ƒˆ–‡”†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ Žƒ†—”‰ǤʹͲͳͻǢͺȋͶȌǣ͵ͺͻǦͻͺǤ ͳ͸͹Ǥ ‘› ‡ǡ—”’Š›ǡ—”’Š›ǡ‡ŽŽ› ǡ‘””‹•‘Ǥ ƒ”ƒ”•ǣ”‡ˆ‡”‡ ‡•‹”‡ƒ•–—”‰‡”›Ǥ ” ŠŽƒ•–—”‰ǤʹͲͳͷǢͶʹȋͷȌǣͷͻ͸Ǧ͸ͲͲǤ ͳ͸ͺǤ Šƒ ǡƒ‰ǡ ƒ ǡ‹ǡ‘ Ǥ•‡‘ˆ–”‹ –ƒ–‹‡–‡Ž‡ –‹‘”‹–‡”‹ƒ–‘ Š‹‡˜‡ ‹‰‹ˆ‹ ƒ–—”‰‹ ƒŽ—– ‘‡•ˆ”‘ƒ‘™  Žƒ’”‡ƒ•–‡ ‘•–”— –‹‘Ǥ ‡ ‘•–”‹ ”‘•—”‰Ǥ ʹͲͳͻǢ͵ͷȋͺȌǣ͸ʹʹǦ͵ͲǤ ͳ͸ͻǤ ‹–ƒǡ‹–•—ƒ™ƒǡ‘—‘–‘ ǡ—”‹›ƒƒǡ—„‘–ƒǡ‹”ƒǡ‡–ƒŽǤ‘™Ǧ”‹•‡• ƒ”†‡‡’‹ˆ‡”‹‘” ‡’‹‰ƒ•–”‹ ƒ”–‡”›’‡”ˆ‘”ƒ–‘”ˆŽƒ’ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ‹ ”‘•—”‰‡”›ǤʹͲͳͷǢ͵ͷȋ͸ȌǣͶͷͳǦ͸Ǥ ͳ͹ͲǤ ‹–ƒǤ‹ˆˆ‡”‡ ‡•„‡–™‡‡‘™  Žƒ’ƒ†‘™Ǧ‹•‡ ƒ”  Žƒ’ˆ‘””‡ƒ•–‡ ‘•–”— –‹‘Ǥ Žƒ•–‡ ‘•–”—”‰ǤʹͲͳ͸Ǣͳ͵ͺȋʹȌǣ͵͸ͷ‡Ǧ͸‡Ǥ ͳ͹ͳǤ ‘”‡”ǡŽƒ˜‹ǡ‡ˆƒ‹˜”‡ ǡ‘” ǡ‡‰ǡ—•ƒŽ‹•ǡ‡–ƒŽǤ‡†— ‹‰‘•–‘’‡”ƒ–‹˜‡ „†‘‹ƒŽ—Ž‰‡ ‘ŽŽ‘™‹‰‡‡’ ˆ‡”‹‘”’‹‰ƒ•–”‹ ‡”ˆ‘”ƒ–‘” Žƒ’”‡ƒ•–‡ ‘•–”— –‹‘™‹–Š Žƒ›‘‘ˆ‹Žƒ‡–‘Ž›ǦͶǦ ›†”‘š›„—–›”ƒ–‡‹‘•›–Š‡–‹ ‡•ŠǤ ‡ ‘•–”‹ ”‘•—”‰Ǥ ʹͲͳ͹Ǣ͵͵ȋͳȌǣͺǦͳͺǤ ͳ͹ʹǤ ‡ƒ„›Ǥ‡ƒ•‘•™Š›™‘‡™Š‘Šƒ˜‡ƒ•–‡ –‘›†‡ ‹†‡–‘Šƒ˜‡‘”‘––‘Šƒ˜‡„”‡ƒ•– ”‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰ǤͳͻͻͺǢͳͲͳȋ͹ȌǣͳͺͳͲǦͺǤ ͳ͹͵Ǥ ƒ”™‡”ǡƒ††‡ǡ‡”–• Š— ǡŠ‹–ƒ‡”ǤŠ‡’•› Š‘Ž‘‰›‘ˆ ‘•‡–‹ •—”‰‡”›ǣƒ”‡˜‹‡™ ƒ†”‡ ‘ ‡’–—ƒŽ‹œƒ–‹‘ǤŽ‹•› Š‘Ž‡˜ǤͳͻͻͺǢͳͺȋͳȌǣͳǦʹʹǤ ͳ͹ͶǤ †‡”‹–‘ ǡƒŠƒ• ǡƒ”„‘•ƒǡ‹‹ ǡ‹—”ƒǡ ƒ”ƒŠǡ‡–ƒŽǤ„†‘‹‘’Žƒ•–›ƒ†‹–• ‡ˆˆ‡ –‘„‘†›‹ƒ‰‡ǡ•‡ŽˆǦ‡•–‡‡ǡƒ†‡–ƒŽŠ‡ƒŽ–ŠǤŽƒ•–—”‰ǤʹͲͳͲǢ͸ͷȋͳȌǣͷǦͳͲǤ ͳ͹ͷǤ ‘Ž–‘ǡ”—œ‹•›ǡƒ•Š ǡ‡”•‹‰ Ǥ‡ƒ•—”‹‰‘—– ‘‡•‹’Žƒ•–‹ •—”‰‡”›ǣ„‘†›‹ƒ‰‡ ƒ†“—ƒŽ‹–›‘ˆŽ‹ˆ‡‹ƒ„†‘‹‘’Žƒ•–›’ƒ–‹‡–•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲ͵ǢͳͳʹȋʹȌǣ͸ͳͻǦʹͷǢ†‹• —••‹‘ ʹ͸Ǧ͹Ǥ ͳ͹͸Ǥ ƒƒ• ǡŠƒ’‹‘ǡ‡ ‘”Ǥ‘–‹˜ƒ–‹‰ˆƒ –‘”•ˆ‘”•‡‡‹‰ ‘•‡–‹ •—”‰‡”›ǣƒ•›–Š‡•‹•‘ˆ–Š‡ Ž‹–‡”ƒ–—”‡ǤŽƒ•–—”‰—”•ǤʹͲͲͺǢʹͺȋͶȌǣͳ͹͹ǦͺʹǤ ͳ͹͹Ǥ ˜‘‘‡•–ǡ˜ƒŽ‡ ǡ‘ŽŽ‡„‘”‰ǡ‘ƒŽ† Ǥ•› Š‘•‘ ‹ƒŽˆƒ –‘”•’”‡†‹ –‹‰–Š‡‘–‹˜ƒ–‹‘–‘ —†‡”‰‘ ‘•‡–‹ •—”‰‡”›ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲ͸Ǣͳͳ͹ȋͳȌǣͷͳǦ͸ʹǢ†‹• —••‹‘͵ǦͶǤ ͳ͹ͺǤ –—‡”œǡ‹œƒ ǡ‹‡”ƒǡ‹œŽ Ǥ•› Š‘•‘ ‹ƒŽ‹’ƒ –‘ˆƒ„†‘‹‘’Žƒ•–›Ǥ„‡•—”‰Ǥ ʹͲͲͺǢͳͺȋͳȌǣ͵ͶǦͺǤ ͳ͹ͻǤ ‘’™‘‘†ǡ Ž‡– Š‡” ǡ‡‡ǡŽ ŠƒœƒŽǤ„‘†›‹ƒ‰‡• ƒŽ‡ˆ‘”—•‡™‹–Š ƒ ‡”’ƒ–‹‡–•Ǥ—”  ƒ ‡”ǤʹͲͲͳǢ͵͹ȋʹȌǣͳͺͻǦͻ͹Ǥ ͳͺͲǤ Š‘‰ǡ — ǡƒ‰Š‡”ǡ‘ǡᦤ‡‹ŽŽǡ—–Ž‡”ǡ‡–ƒŽǤ‘’ƒ”‹•‘‘ˆ•› Š‘Ž‘‰‹ ƒŽ‡•’‘•‡ǡ ‘†› ƒ‰‡ǡ‡š—ƒŽ‹–›ǡƒ†—ƒŽ‹–›‘ˆ‹ˆ‡„‡–™‡‡ ‡†‹ƒ–‡ƒ†‡Žƒ›‡†—–‘Ž‘‰‘—•‹••—‡ ”‡ƒ•–‡ ‘•–”— –‹‘ǣ”‘•’‡ –‹˜‡‘‰Ǧ‡”—– ‘‡–—†›ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲͳ͸Ǣͳ͵ͺȋͶȌǣ͹͹ʹǦͺͲǤ ͳͺͳǤ –‘ˆƒ ǡ‡ƒ˜‹ǡƒ‹‡‹ǡŽˆ‘”†Ǥ‡––‡”•‡šˆ”‘–Š‡‹ˆ‡ǫ‹–‹ƒ–‡Ž‘‘ƒ––Š‡ ‡ˆˆ‡ –•‘ˆ ‘•‡–‹ •—”‰‡”›‘•‡š—ƒŽ’”ƒ –‹ ‡•Ǥ‡•–Š‡–—”‰ ǤʹͲͲ͸Ǣʹ͸ȋͳȌǣͳʹǦ͹Ǥ ͳͺʹǤ ‘’‹‡ ǡ–‡”—‹Ž‡ǡ‹ƒǡ—”‡ƒ—ǡ‹„„‡Ǥ ’ƒ –‘ˆ†‡Žƒ›‡†‹’Žƒ–ƒ† ˆŽƒ’ „”‡ƒ•–”‡ ‘•–”— –‹‘‘„‘†›‹ƒ‰‡ƒ†•‡š—ƒŽ•ƒ–‹•ˆƒ –‹‘ǣƒ’”‘•’‡ –‹˜‡ˆ‘ŽŽ‘™Ǧ—’•–—†›Ǥ •› Š‘‘ ‘Ž‘‰›ǤʹͲͳͶǢʹ͵ȋͳȌǣͳͲͲǦ͹Ǥ ͳͺ͵Ǥ †‡”‹–‘ ǡƒŠƒ• ǡ—••‘Žƒ”‘ǡŠ‹›‘ǡƒ”„‘•ƒǡ ‡””‡‹”ƒǤˆˆ‡ –•‘ˆ ƒ„†‘‹‘’Žƒ•–›‘ˆ‡ƒŽ‡•‡š—ƒŽ‹–›ǣƒ’‹Ž‘–•–—†›Ǥ ‡š‡†ǤʹͲͳʹǢͻȋ͵ȌǣͻͳͺǦʹ͸Ǥ ͳͺͶǤ ‘„‘Ǧ—‡ ƒ ǡƒ”–‹Ǧ•’‹‘•ƒǡƒ’‹‡–”‘Ǧ”‡•’‘ǡ‘†”‹‰—‡œǦ‘””‡‰‘ǡƒ”‘ƒǦ ‘””‡• Ǥ‡š—ƒŽ†›•ˆ— –‹‘‹’ƒ‹•Š™‘‡™‹–Š„”‡ƒ•– ƒ ‡”Ǥ‘‡Ǥ ʹͲͳͺǢͳ͵ȋͺȌǣ‡ͲʹͲ͵ͳͷͳǤ ͳͺͷǤ ‹ƒ•ǡ”‘—™‡Žǡ Šƒ•‡‹ǡ˜ƒ†‡ ”‹ˆ–ǡ‘—ƒǡ‹––ǡ‡–ƒŽǤ‹• —••‹‰ •‡š—ƒŽ‹–›‹–Š‡ˆ‹‡Ž†‘ˆ’Žƒ•–‹ ƒ†”‡ ‘•–”— –‹˜‡•—”‰‡”›ǣƒƒ–‹‘ƒŽ•—”˜‡›‘ˆ —””‡–’”ƒ –‹ ‡‹ –Š‡‡–Š‡”Žƒ†•Ǥ—” Žƒ•–—”‰ǤʹͲͳͺǢͶͳȋ͸Ȍǣ͹Ͳ͹ǦͳͶǤ ͳͺ͸Ǥ ‹ƒ• ǡ˜ƒ†‡ ”‹ˆ–ǡ‘—ƒǡ—•‹ ǡ—ŽŽ‡†‡” Ǥ‡š—ƒŽ‹–›ǡƒ–‘’‹ –Šƒ–•—”‰‡‘• •Š‘—Ž††‹• —••™‹–Š™‘‡„‡ˆ‘”‡”‹•Ǧ”‡†— ‹‰ƒ•–‡ –‘›ƒ†„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ”‡ƒ•–Ǥ ʹͲͳͻǢͶ͵ǣͳʹͲǦʹǤ ͳͺ͹Ǥ ‡‡•‡ ǡ‘”‹ ‡ǡ‡ƒ Šǡ‘”–‡”ǡ—Ž•› ǡƒŽ›ǡ‡–ƒŽǤƒ–‹‡–Ǧ’”‘˜‹†‡” ‘—‹ ƒ–‹‘ ƒ„‘—–•‡š—ƒŽ ‘ ‡”•‹ ƒ ‡”ǣƒ•›•–‡ƒ–‹ ”‡˜‹‡™Ǥ ƒ ‡”—”˜‹˜ǤʹͲͳ͹ǢͳͳȋʹȌǣͳ͹ͷǦͺͺǤ ͳͺͺǤ ”ƒƒ•–ƒ†ǡ—†•‡ǡ ƒ •‘ǡ–Š‡‹ǡ”‹’’ ǡސ•‡–ŠǤ—ƒŽ‹–›‘ˆŽ‹ˆ‡ǡ’ƒ–‹‡– •ƒ–‹•ˆƒ –‹‘ƒ† ‘•‡–‹ ‘—– ‘‡ƒˆ–‡”†‡Žƒ›‡†„”‡ƒ•–”‡ ‘•–”— –‹‘—•‹‰ ˆŽƒ’ǣƒͳͲ›‡ƒ”•̵ ˆ‘ŽŽ‘™Ǧ—’•—”˜‡›Ǥ Žƒ•–—”‰ ƒ†—”‰ǤʹͲͳͻǢͷ͵ȋʹȌǣͳͳͻǦʹͶǤ ͳͺͻǤ  —‰ŠǤ –‡””ƒ–‡””‡Ž‹ƒ„‹Ž‹–›ǣ–Š‡ƒ’’ƒ•–ƒ–‹•–‹ Ǥ‹‘ Š‡‡†ȋƒ‰”‡„ȌǤʹͲͳʹǢʹʹȋ͵Ȍǣʹ͹͸ǦͺʹǤ

99 99 ͳͻͲǤ ƒ‡”†–ƒ–‹•–‹ •Ǥ‘Š‡̵•ƒ’’ƒǤȏ ‡••†ƒ–‡ʹͲͳͻǦͳͲǦͲͺȐǤ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣ Š––’•ǣȀȀ•–ƒ–‹•–‹ •ǤŽƒ‡”†Ǥ ‘Ȁ’”‡‹—Ȁ•’••Ȁ Ȁ ‘Š‡•Ǧƒ’’ƒǦ‹Ǧ•’••Ǧ͵Ǥ’Š’ ͳͻͳǤ ‘’‘˜‹ ǡŠ‘ƒ• Ǥ••‡••‹‰‘„•‡”˜‡”˜ƒ”‹ƒ„‹Ž‹–›ǣƒ—•‡”̵•‰—‹†‡Ǥƒ”†‹‘˜ƒ• ‹ƒ‰Š‡”Ǥ ʹͲͳ͹Ǣ͹ȋ͵Ȍǣ͵ͳ͹ǦʹͶǤ ͳͻʹǤ ’ƒœ‘ƒ‡œǡ‘•‡Ž ǡ—”„‡”‰‡” ǡ—•Š‡–•‘˜ƒǡ ‘••Žǡ‹– Š‡ŽŽǡ‡–ƒŽǤƒ•‡”‘’’Ž‡” ‹ƒ‰‡”ȋ Ȍ• ƒ‡”ƒ†‹–”ƒ†‡”ƒŽ‹Œ‡ –‹‘ˆ‘”‹˜‹˜‘’Šƒ”ƒ ‘Ž‘‰›‹Š—ƒ•‹ ‹ ”‘ ‹” —Žƒ–‹‘ǣ”‡•’‘•‡•–‘ƒ ‡–›Ž Š‘Ž‹‡ǡ‡†‘–Š‡Ž‹Ǧͳƒ†–Š‡‹””‡’‡ƒ–ƒ„‹Ž‹–›Ǥ” Ž‹ Šƒ”ƒ ‘ŽǤʹͲͲͷǢͷͻȋͷȌǣͷͳͳǦͻǤ ͳͻ͵Ǥ ƒ”–Ž‡–– ǡ ”‘•–Ǥ‡Ž‹ƒ„‹Ž‹–›ǡ”‡’‡ƒ–ƒ„‹Ž‹–›ƒ†”‡’”‘†— ‹„‹Ž‹–›ǣƒƒŽ›•‹•‘ˆ‡ƒ•—”‡‡–‡””‘”•‹ ‘–‹—‘—•˜ƒ”‹ƒ„Ž‡•ǤŽ–”ƒ•‘—†„•–‡– ›‡ ‘ŽǤʹͲͲͺǢ͵ͳȋͶȌǣͶ͸͸Ǧ͹ͷǤ ͳͻͶǤ  ”—Ǧ ƒ”†‡”Ǥƒ’Ž‡•‹œ‡ƒ†’‘™‡” ƒŽ —Žƒ–‹‘•ƒ†‡•‹’Ž‡Ǥ –‡”ƒ–‹‘ƒŽ ‘—”ƒŽ‘ˆ Š‡”ƒ’›ƒ†‡Šƒ„‹Ž‹–ƒ–‹‘ǤʹͲͳͲǢͳ͹ǣͳͲǦͶǤ ͳͻͷǤ  Š‹†– ǡ‘ǡ ‘ŽŽ‡•–‡‹Ǥ‡•‡ƒ” Š‡ Š‹“—‡•ƒ†‡‹’Ž‡ǣƒ’Ž‡‹œ‡•–‹ƒ–‹‘ƒ† ‘™‡”ƒŽ —Žƒ–‹‘Ǥ  ˜‡•–‡”ƒ–‘ŽǤʹͲͳͺǢͳ͵ͺȋͺȌǣͳ͸͹ͺǦͺʹǤ ͳͻ͸Ǥ ‹†Š‘Ž†–ǡƒ‹†‹ƒǡސ•‡–ŠǤ‹ ”‘ ‹” —Žƒ–‘”›‡˜ƒŽ—ƒ–‹‘‘ˆ†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”› ’‡”ˆ‘”ƒ–‘”ˆŽƒ’•™‹–ŠŽƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘‹ƒ‰‹‰‹„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ Žƒ•–—”‰ ƒ† —”‰ǤʹͲͳͳǢͶͷȋ͵ȌǣͳͶ͵Ǧ͹Ǥ ͳͻ͹Ǥ †‘Ž•‡ ǡ”‘‘‰ ǡŠ‘”ˆ‹ ǡ‹†ƒǤƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘‹ƒ‰‹‰‘ˆ–Š‡”ƒ†‹ƒŽˆ‘”‡ƒ” ˆŽƒ’ǣƒ Ž‹‹ ƒŽ•–—†›Ǥ ƒ† Žƒ•–‡ ‘•–”—”‰ ƒ†—”‰ǤʹͲͲ͸ǢͶͲȋʹȌǣͳͲͳǦͷǤ ͳͻͺǤ ސ•‡–Šǡ‹†Š‘Ž†–Ǥ‹ ”‘ ‹” —Žƒ–‹‘‹•‹‰Ž‡ƒ†—Ž–‹’Ž‡Ǧ„ƒ•‡†’‡”ˆ‘”ƒ–‘”ˆŽƒ’•‹ƒ ‡š’‡”‹‡–ƒŽ‘†‡Ž‘ˆ”ƒ–•Ǥ ƒ† Žƒ•–‡ ‘•–”—”‰ ƒ†—”‰ǤʹͲͲ͹ǢͶͳȋʹȌǣͶͻǦͷʹǤ ͳͻͻǤ ƒŽŽ‘  ǤŠ›•‹‘Ž‘‰‹ ƒŽ•–—†‹‡•—•‹‰Žƒ•‡”‘’’Ž‡”ˆŽ‘™‡–”›–‘ ‘’ƒ”‡„Ž‘‘†ˆŽ‘™–‘–Š‡œ‘‡• ‘ˆ–Š‡ˆ”‡‡ˆŽƒ’ǤŽƒ•–—”‰ǤʹͲͲͳǢͶ͹ȋ͵ȌǣʹʹͻǦ͵͵Ǥ ʹͲͲǤ ‘Žǡƒ›”ǡ ‘ˆ–‡”ǡ‹‘˜‹ Ǥ‡”ˆ—•‹‘œ‘‡•‘ˆ–Š‡ ˆŽƒ’”‡˜‹•‹–‡†ǣƒ Ž‹‹ ƒŽ•–—†›Ǥ Žƒ•–‡ ‘•–”—”‰ǤʹͲͲ͸Ǣͳͳ͹ȋͳȌǣ͵͹ǦͶ͵Ǥ ʹͲͳǤ ‘‘‹ ǡ‡„ƒ–• ǡ‘‡ šǡ˜ƒ†‡” —Ž•–Ǥ•–—†›‘ˆ’‡”ˆ—•‹‘‘ˆ–Š‡†‹•–ƒŽˆ”‡‡ǦˆŽƒ’ —•‹‰Žƒ•‡”‘’’Ž‡”ˆŽ‘™‡–”›Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͲͺǢ͸ͳȋ͵ȌǣʹͺʹǦͺǤ ʹͲʹǤ †‡‡‡”†ǡ‹Žƒ†ǡ‡” ‡” Ǥ‡”ˆ—•‹‘†›ƒ‹ •‘ˆˆ”‡‡ ƒ† ˆŽƒ’•†—”‹‰–Š‡ˆ‹”•– ’‘•–‘’‡”ƒ–‹˜‡™‡‡‘‹–‘”‡†™‹–Š†›ƒ‹ ‹ˆ”ƒ”‡†–Š‡”‘‰”ƒ’Š›ǤŽƒ•–—”‰Ǥ ʹͲͲͻǢ͸ʹȋͳȌǣͶʹǦ͹Ǥ ʹͲ͵Ǥ —––‘ǡ ‘ƒ‹†‹• ǡ‘”›•œǡ‘•‡ǡ Ž‹– ǡ‘„‹•‘ǡ‡–ƒŽǤ‘™‡”ˆƒ‹Ž—”‡ǣ™Š›•ƒŽŽ •ƒ’Ž‡•‹œ‡—†‡”‹‡•–Š‡”‡Ž‹ƒ„‹Ž‹–›‘ˆ‡—”‘• ‹‡ ‡Ǥƒ–‡˜‡—”‘• ‹ǤʹͲͳ͵ǢͳͶȋͷȌǣ͵͸ͷǦ͹͸Ǥ ʹͲͶǤ ‘”ƒŽ† ǡƒ†‡ ǡ ‹‰—•ǤŠ‡‹ ”‡ƒ•‡†”‹•‘ˆƒ†˜‡”•‡‘—– ‘‡•‹„‹Žƒ–‡”ƒŽ†‡‡’‹ˆ‡”‹‘” ‡’‹‰ƒ•–”‹ ƒ”–‡”›’‡”ˆ‘”ƒ–‘”ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ ‘’ƒ”‡†–‘—‹Žƒ–‡”ƒŽ”‡ ‘•–”— –‹‘ǣƒ •›•–‡ƒ–‹ ”‡˜‹‡™ƒ†‡–ƒǦƒƒŽ›•‹•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳͶǢ͸͹ȋʹȌǣͳͶ͵Ǧͷ͸Ǥ ʹͲͷǤ ƒ—”‡–ǡ‹•–”‡––ƒ ǡ‘––‹‰‹‘Ž‹ǡƒŠ‡Žǡ ‘—Œ‘ǡ‹ ‘Žƒ• ǡ‡–ƒŽǤ Š‘‰”ƒ’Š‹ ‡ƒ•—”‡‡–‘ˆ •‹–Š‹ ‡••‹ƒ†—Ž–•„›Š‹‰Šˆ”‡“—‡ ›—Ž–”ƒ•‘—†–‘ƒ••‡••–Š‡ƒ’’”‘’”‹ƒ–‡‹ ”‘‡‡†Ž‡Ž‡‰–Š ˆ‘”‹–”ƒ†‡”ƒŽ†‡Ž‹˜‡”›‘ˆ˜ƒ ‹‡•Ǥƒ ‹‡ǤʹͲͲ͹Ǣʹͷȋ͵ͶȌǣ͸Ͷʹ͵Ǧ͵ͲǤ ʹͲ͸Ǥ ƒ‹•Š‹ǡƒƒŒ‹ƒ ǡ‹ƒ„‡ǡ‹•‘Ǥ‰‹‘‰”ƒ’Š‹ •–—†›‘ˆ–Š‡•—„†‡”ƒŽ’Ž‡š—•ǣƒ ’”‡Ž‹‹ƒ”›”‡’‘”–Ǥ ƒ† Žƒ•–‡ ‘•–”—”‰ ƒ†—”‰ǤʹͲͲͲǢ͵ͶȋʹȌǣͳͳ͵Ǧ͸Ǥ ʹͲ͹Ǥ ‹‘• Ǥƒ†ƒ”•‹–Š‡ƒƒ–‘‹ ƒŽ•–—†›‘ˆ–Š‡„Ž‘‘†•—’’Ž›‘ˆ–Š‡•‹Ǥ” Žƒ•–—”‰Ǥ ͳͻͺͷǢ͵ͺȋʹȌǣͳͻ͹ǦʹͲ͹Ǥ ʹͲͺǤ ”ƒ˜‡”ƒ ǡ Š‡ Š‡” Ǥ‘–‘—”ƒ’’‹‰‘ˆ–Š‡ —–ƒ‡‘—•‹ ”‘˜ƒ• —Žƒ–—”‡„› ‘’—–‡”‹œ‡† Žƒ•‡”‘’’Ž‡”˜‡Ž‘ ‹‡–”›Ǥ  ˜‡•–‡”ƒ–‘ŽǤͳͻͻͳǢͻ͹ȋ͸ȌǣͳͲͳ͵ǦͺǤ ʹͲͻǤ ƒ”†‡ŽŽǡ”ƒ˜‡”ƒ ǡ‹Ž˜‡”ƒ ǡ‹Ž••‘ Ǥ’ƒ–‹ƒŽŠ‡–‡”‘‰‡‡‹–›‹‘”ƒŽ•‹’‡”ˆ—•‹‘ ”‡ ‘”†‡†™‹–ŠŽƒ•‡”‘’’Ž‡”‹ƒ‰‹‰ƒ†ˆŽ‘™‡–”›Ǥ‹ ”‘˜ƒ• ‡•ǤͳͻͻͶǢͶͺȋͳȌǣʹ͸Ǧ͵ͺǤ ʹͳͲǤ ”•–”‘‰ǤŠ‡–‘—•‡–Š‡‘ˆ‡””‘‹ ‘””‡ –‹‘Ǥ’Š–ŠƒŽ‹ Š›•‹‘Ž’–ǤʹͲͳͶǢ͵ͶȋͷȌǣͷͲʹǦͺǤ ʹͳͳǤ ›”ǡ‹ƒ”†ǡ—„‘‹•ǡ‘”‹Ǥ‡Ž‹ƒ„‹Ž‹–›‘ˆ˜—Ž˜ƒ”„Ž‘‘†’‡”ˆ—•‹‘‹™‘‡™‹–Š’”‘˜‘‡† ˜‡•–‹„—Ž‘†›‹ƒ—•‹‰Žƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘‹ƒ‰‹‰ƒ†Žƒ•‡”•’‡ Ž‡‹ƒ‰‹‰Ǥ‹ ”‘˜ƒ• ‡•Ǥ ʹͲͳͺǢͳʹͳǣͳǦ͸Ǥ ʹͳʹǤ Š‡ǡ‡ ǡƒ‰ǡŠƒ‘ ǡ‹ǡ —Ǥ‡Žƒ–‹‘•Š‹’„‡–™‡‡–Š‡„Ž‘‘†’‡”ˆ—•‹‘˜ƒŽ—‡• †‡–‡”‹‡†„›Žƒ•‡”•’‡ Ž‡‹ƒ‰‹‰ƒ†Žƒ•‡”‘’’Ž‡”‹ƒ‰‹‰‹‘”ƒŽ•‹ƒ†’‘”–™‹‡ •–ƒ‹•ǤŠ‘–‘†‹ƒ‰‘•‹•Š‘–‘†›Š‡”ǤʹͲͳ͸Ǣͳ͵ǣͳǦͻǤ ʹͳ͵Ǥ ŽŽ‡ ǡ ‘™‡ŽŽǤ‹ ”‘˜ƒ• —Žƒ”‹ƒ‰‹‰ǣ–‡ Š‹“—‡•ƒ†‘’’‘”–—‹–‹‡•ˆ‘” Ž‹‹ ƒŽ’Š›•‹‘Ž‘‰‹ ƒŽ ‡ƒ•—”‡‡–•ǤŠ›•‹‘Ž‡ƒ•ǤʹͲͳͶǢ͵ͷȋ͹ȌǣͻͳǦ”ͳͶͳǤ ʹͳͶǤ ‡›‡† ƒˆƒ”‹ǡ Šƒ™ƒ–ǡƒ‡‹ŽŽ‡ǡŠƒˆ‹‰Š‹Ǥ‡Žƒ–‹˜‡‹†‡š‡•‘ˆ —–ƒ‡‘—•„Ž‘‘† ’‡”ˆ—•‹‘‡ƒ•—”‡†„›”‡ƒŽǦ–‹‡Žƒ•‡”‘’’Ž‡”‹ƒ‰‹‰ȋ Ȍ‹Š‡ƒŽ–Š›˜‘Ž—–‡‡”•Ǥ‹ ”‘˜ƒ• ‡•Ǥ ʹͲͳͶǢͻͶǣͳǦ͸Ǥ

100 100 ʹͳͷǤ ¤”†‡ŽŽǤƒ•‡”‘’’Ž‡”‡”ˆ—•‹‘ ƒ‰‹‰Ǧ‡–Š‘†‘Ž‘‰›ƒ†‹’’Ž‹ ƒ–‹‘•Ǥ‹Ú’‹‰ǡ ™‡†‡Ǥǣ‹Ú’‹‰‹˜‡”•‹–›ǢͳͻͻͶǤ ʹͳ͸Ǥ ‹Ž••‘ ǡ‡Žƒ†ǡ„‡”‰Ǥ˜ƒŽ—ƒ–‹‘‘ˆƒŽƒ•‡”‘’’Ž‡”ˆŽ‘™‡–‡”ˆ‘”‡ƒ•—”‡‡–‘ˆ –‹••—‡„Ž‘‘†ˆŽ‘™Ǥ ”ƒ•‹‘‡†‰ǤͳͻͺͲǢʹ͹ȋͳͲȌǣͷͻ͹Ǧ͸ͲͶǤ ʹͳ͹Ǥ ”‘›Ž‡• ǡ Š—‡‡ǡƒ–‡Žǡƒ‹Žǡ”‘›Ž‡• ǡ‡ŽŽ‘Ǥ‡ˆ‹‹‰–Š‡ƒ–‘›‘ˆ–Š‡ ‡†‹‘—• –‡”•‡ –‹‘•‘ˆ–Š‡‡ –—•„†‘‹‹•—• Ž‡ƒ†Š‡‹”Ž‹‹ ƒŽ ’Ž‹ ƒ–‹‘•‹ — –‹‘ƒŽ—• Ž‡‡—”‘–‹œƒ–‹‘ǤŽƒ•–—”‰ǤʹͲͳͺǢͺͲȋͳȌǣͷͲǦ͵Ǥ ʹͳͺǤ Š‡–œ‡Žǡ —ƒ‰ǤŠ‡˜ƒ• —Žƒ”ƒƒ–‘›‘ˆ–Š‡–‡†‹‘—•‹–‡”•‡ –‹‘•‘ˆ–Š‡”‡ –—•ƒ„†‘‹‹• —• Ž‡ǤŽƒ•–‡ ‘•–”—”‰Ǥͳͻͻ͸ǢͻͺȋͳȌǣͺ͵ǦͻǤ ʹͳͻǤ Š‘‰ǡƒ‘ǡ‡”•–‡‹ǡ‘™‡›ǡ˜ƒ• Ǥ ‹‰ŠǦˆ”‡“—‡ ›—Ž–”ƒ•‘—†ǣƒ—•‡ˆ—Ž–‘‘Žˆ‘” ‡˜ƒŽ—ƒ–‹‰–Š‡ƒ„†‘‹ƒŽ™ƒŽŽˆ‘ŽŽ‘™‹‰ˆ”‡‡ƒ† ˆŽƒ’•—”‰‡”›ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲͲ͸Ǣͳͳ͹ȋͶȌǣͳͳͳ͵ǦʹͲǤ ʹʹͲǤ —”ƒǡ‘ŽŽ—‘‰Ž—ǡ—”›‹Žƒœǡ‘”— —‘‰Ž—Ǥ”‡˜ƒŽ‡ ‡‘ˆ†‹ƒ•–ƒ•‹•”‡ –‹ƒ„†‘‹‹•‹–Š‡ ’‘’—Žƒ–‹‘‘ˆ›‘—‰—Ž–‹’ƒ”‘—•ƒ†—Ž–•‹—”‡›Ǥ ‹‡‘Ž‘ŽǤʹͲͳͳǢͺʹȋͳͳȌǣͺͳ͹ǦʹͳǤ ʹʹͳǤ ‘‹••‘ƒ—Ž– ǡŽƒ• Šƒ Ǥ  ‹†‡ ‡‘ˆ†‹ƒ•–ƒ•‹•”‡ –‹ƒ„†‘‹‹•†—”‹‰–Š‡ Š‹Ž†„‡ƒ”‹‰›‡ƒ”Ǥ Š›•Š‡”ǤͳͻͺͺǢ͸ͺȋ͹ȌǣͳͲͺʹǦ͸Ǥ ʹʹʹǤ ’‡”•–ƒ† ǡ‡ˆŒ‘”†ǡ ‹Ž†‡ ǡŽŽ•–”‘Ǧ‰ŠǡÞǤ‹ƒ•–ƒ•‹•”‡ –‹ƒ„†‘‹‹•†—”‹‰ ’”‡‰ƒ ›ƒ†ͳʹ‘–Š•ƒˆ–‡” Š‹Ž†„‹”–Šǣ’”‡˜ƒŽ‡ ‡ǡ”‹•ˆƒ –‘”•ƒ†”‡’‘”–‘ˆŽ—„‘’‡Ž˜‹ ’ƒ‹Ǥ ” ’‘”–•‡†ǤʹͲͳ͸ǢͷͲȋͳ͹ȌǣͳͲͻʹǦ͸Ǥ ʹʹ͵Ǥ ƒ‡•ǡ ”ƒ ‘Žǡ—ƒ‹ƒ Ǥ’’”‡ ‹ƒ–‹‘‘ˆ‘•–’ƒ”–—Šƒ‰‡•‘ˆ–Š‡‡ –—•—• Ž‡•‹ ”‹ƒ”›ƒ†‡’‡ƒ–‡†„†‘‹‘’Žƒ•–›ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͻǢͳͶͶȋʹȌǣͳͻ͹‡ǦʹͲͶ‡Ǥ ʹʹͶǤ ƒ‡”†–ƒ–‹•–‹ •Ǥ‹Ž ‘š‘‹‰‡†Ǧƒ‡•–Ǥȏ ‡••†ƒ–‡ʹͲͳͻǦͳͲǦͲͺȐǤ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣ Š––’•ǣȀȀ•–ƒ–‹•–‹ •ǤŽƒ‡”†Ǥ ‘Ȁ’”‡‹—Ȁ•’••Ȁ™•”–Ȁ™‹Ž ‘š‘Ǧ•‹‰‡†Ǧ”ƒǦ–‡•–Ǧ‹Ǧ•’••Ǥ’Š’Ǥ ʹʹͷǤ ‡‡ǡ— ‡ǡ ”‡‡ƒ–Ž‡ǡ‘”‡ Ǥ’Š–ŠƒŽ‹ •–ƒ–‹•–‹ •‘–‡ͻǣ’ƒ”ƒ‡–”‹ ˜‡”•—•‘Ǧ ’ƒ”ƒ‡–”‹ ‡–Š‘†•ˆ‘”†ƒ–ƒƒƒŽ›•‹•Ǥ” ’Š–ŠƒŽ‘ŽǤʹͲͳ͸ǢͳͲͲȋ͹Ȍǣͺ͹͹ǦͺǤ ʹʹ͸Ǥ ƒ‡”†–ƒ–‹•–‹ •ǤƒǦŠ‹–‡›‡•–Ǥȏ ‡••†ƒ–‡ʹͲͳͻǦͳͲǦͲͺȐǤ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣ Š––’•ǣȀȀ•–ƒ–‹•–‹ •ǤŽƒ‡”†Ǥ ‘Ȁ’”‡‹—Ȁ•’••Ȁ™—–ȀƒǦ™Š‹–‡›Ǧ–‡•–Ǧ‹Ǧ•’••Ǧ͵Ǥ’Š’ ʹʹ͹Ǥ ƒ‡”†–ƒ–‹•–‹ •Ǥ‡ƒ”•‘̵•”‘†— –Ǧ‘‡–‘””‡Žƒ–‹‘Ǥȏ ‡••†ƒ–‡ʹͲͳͻǦͳͲǦͲͺȐǤ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣ Š––’•ǣȀȀ•–ƒ–‹•–‹ •ǤŽƒ‡”†Ǥ ‘Ȁ’”‡‹—Ȁ•’••Ȁ’ Ȁ’‡ƒ”•‘Ǧ ‘””‡Žƒ–‹‘Ǧ‹Ǧ•’••Ǥ’Š’Ǥ ʹʹͺǤ ”•–”‘‰ǤŠ‘—Ž†‡ƒ”•‘̵• ‘””‡Žƒ–‹‘ ‘‡ˆˆ‹ ‹‡–„‡ƒ˜‘‹†‡†ǫ’Š–ŠƒŽ‹ Š›•‹‘Ž’–Ǥ ʹͲͳͻǢ͵ͻȋͷȌǣ͵ͳ͸Ǧʹ͹Ǥ ʹʹͻǤ Žƒ•‡”ǡƒ‹‡”Ǥ‘†›†›•‘”’Š‹ †‹•‘”†‡”ƒ†–Š‡Ž‹’‘•— –‹‘’ƒ–‹‡–Ǥ‡”ƒ–‘Ž—”‰Ǥ ʹͲͲͷǢ͵ͳȋͷȌǣͷͷͻǦ͸ͲǢ†‹• —••‹‘͸ͳǤ ʹ͵ͲǤ ƒ”™‡”ǡƒ††‡ǡ‡”–• Š— ǡŠ‹–ƒ‡”Ǥ‘†›‹ƒ‰‡†‹••ƒ–‹•ˆƒ –‹‘ƒ†„‘†› †›•‘”’Š‹ †‹•‘”†‡”‹ͳͲͲ ‘•‡–‹ •—”‰‡”›’ƒ–‹‡–•ǤŽƒ•–‡ ‘•–”—”‰ǤͳͻͻͺǢͳͲͳȋ͸Ȍǣͳ͸ͶͶǦͻǤ ʹ͵ͳǤ Ž–Š—„ƒ‹–‹Ǥ ˆ‘”ƒ–‹‘„‹ƒ•‹Š‡ƒŽ–Š”‡•‡ƒ” Šǣ†‡ˆ‹‹–‹‘ǡ’‹–ˆƒŽŽ•ǡƒ†ƒ†Œ—•–‡–‡–Š‘†•Ǥ  —Ž–‹†‹• ‹’ ‡ƒŽ–Š ǤʹͲͳ͸ǢͻǣʹͳͳǦ͹Ǥ ʹ͵ʹǤ —ŠŽǡƒ•‰ƒƒ”†ǡ̵‘‘”ǡŠ”‹•–‡•‡ǡƒ Šƒ”‹ƒ‡Ǥ‡”•‘ƒŽ‹–›”ƒ‹–•ƒ•”‡†‹ –‘”•‘ˆ —ƒŽ‹–›‘ˆ‹ˆ‡ƒ†‘†› ƒ‰‡ƒˆ–‡””‡ƒ•–‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰ Ž‘„’‡Ǥ ʹͲͳ͹ǢͷȋͷȌǣ‡ͳ͵ͶͳǦ‡Ǥ ʹ͵͵Ǥ ˜‘‘‡•–ǡ˜ƒŽ‡ ǡ‘ƒŽ† ǡ‘ŽŽ‡„‘”‰ǤŠ‡‡ˆˆ‡ –•‘ˆ ‘•‡–‹ •—”‰‡”›‘„‘†›‹ƒ‰‡ǡ •‡ŽˆǦ‡•–‡‡ǡƒ†’•› Š‘Ž‘‰‹ ƒŽ’”‘„Ž‡•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͲͻǢ͸ʹȋͳͲȌǣͳʹ͵ͺǦͶͶǤ ʹ͵ͶǤ ”ƒ‰‰ǡ ‘•‡ǡ”‹˜ƒ•–ƒ˜ƒǤƒ–‹‡–•ƒ–‹•ˆƒ –‹‘ˆ‘ŽŽ‘™‹‰ƒ„†‘‹‘’Žƒ•–›ǣƒ ‡š’‡”‹‡ ‡Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͲ͹Ǣ͸ͲȋͳȌǣ͹ͷǦͺǤ ʹ͵ͷǤ ”ƒœ‡” ǡ ‘Ž†™›Ǥ„†‘‹‘’Žƒ•–›ƒ••‡••‡†„›•—”˜‡›ǡ™‹–Š‡’Šƒ•‹•‘ ‘’Ž‹ ƒ–‹‘•Ǥ Žƒ•–‡ ‘•–”—”‰Ǥͳͻ͹͹ǢͷͻȋͶȌǣͷͳ͵Ǧ͹Ǥ ʹ͵͸Ǥ ‡”‘‰ƒ–‹•ǡ‘””‘™ ǡ ‡––‹‰ ǡ‡ƒǡ‹ƒ•‡–•›ǡ ŠƒŽ‡ǡ‡–ƒŽǤŠ‡’”‡˜ƒŽ‡ ‡‘ˆ ’•› Š‹ƒ–”‹ †‹•‘”†‡”•ƒ‘‰ ƒ ‡”’ƒ–‹‡–•Ǥ ƒƒǤͳͻͺ͵ǢʹͶͻȋ͸Ȍǣ͹ͷͳǦ͹Ǥ ʹ͵͹Ǥ ‡ Š‡”‡”ǡƒƒŽ‹ǡƒ—Žǡ—ǡ—”‹‡ŽǡƒŠ‘”•– ǡ‡–ƒŽǤ”‡˜ƒŽ‡ ‡‘ˆ’•› Š‹ƒ–”‹  ‘‘”„‹†‹–‹‡•ƒ‘‰™‘‡—†‡”‰‘‹‰ˆ”‡‡–‹••—‡ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ —”‰ ‘ŽǤ ʹͲͳ͹Ǣͳͳ͸ȋ͹ȌǣͺͲ͵ǦͳͲǤ ʹ͵ͺǤ ‹‡””‹•ƒ”†ǡƒ ‹— Šƒǡƒ ‹‹ ǡƒ–Š‡Ž‘–ǡƒ‡ŽŽ‡ǡ‘–ƒƒǤ‘†›‹ƒ‰‡ƒ† ’•› Š‘Ž‘‰‹ ƒŽ†‹•–”‡••‹™‘‡™‹–Š„”‡ƒ•– ƒ ‡”ǣƒ ”‡ Š‘Ž‹‡•—”˜‡›‘’ƒ–‹‡–•̵ ’‡” ‡’–‹‘•ƒ†‡š’‡ –ƒ–‹‘•Ǥ”‡ƒ•–ƒ ‡”ǤʹͲͳͺǢʹͷȋ͵Ȍǣ͵Ͳ͵ǦͺǤ ʹ͵ͻǤ –‘‡ ǡ‡ŽŽ‘ ǡ‹‘–‘•ǡ‡›‡”ǡ‡„ƒ‹ǡƒ›‡ǡ‡–ƒŽǤƒ–‹‡–Ǧ‡Žƒ–‡†‹• ƒ –‘”•ˆ‘” ‘”•‡‡†„†‘‹ƒŽ‡ŽŽǦ‡‹‰ƒˆ–‡”—–‘Ž‘‰‘—•”‡ƒ•–‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲʹͲǢͳͶͷȋ͵ȌǣͶ͹ͷ‡ǦͺͲ‡Ǥ ʹͶͲǤ Š‘‹ǡƒǤ ƒ–ƒŽ‘‰‘ˆ„‹ƒ•‡•‹“—‡•–‹‘ƒ‹”‡•Ǥ”‡˜Š”‘‹ ‹•ǤʹͲͲͷǢʹȋͳȌǣͳ͵Ǥ

101 101 ʹͶͳǤ ‡‹•‡„‡”‰ ǡ‹ŽŽ‹ƒ•ǦŠ‹ŽŽ‹‰ˆ‘”†Ǥ”‡ƒ “—‹‡• ‡–ƒ†‡š–”‡‡”‡•’‘•‡•–›Ž‡•”‡Žƒ–‡†–‘Ž‘™ ‹–‡ŽŽ‹‰‡ ‡ƒ†‡†— ƒ–‹‘ǫ‡”•‘ƒŽ‹–›ƒ† †‹˜‹†—ƒŽ‹ˆˆ‡”‡ ‡•ǤʹͲͲͺǢͶͶǣͳͷ͵ͻǦͷͲǤ ʹͶʹǤ ‘˜‡ǡ ‡‡”‡Ǥ‡•’‘•‡„‹ƒ•‹•—”˜‡›•‘ˆ‡–ƒŽŠ‡ƒŽ–Šǣƒ‡’‹”‹ ƒŽ‹˜‡•–‹‰ƒ–‹‘Ǥ ‡”‹ ƒ ‘—”ƒŽ‘ˆ‘ ‹‘Ž‘‰›Ǥͳͻ͹͹Ǣͺʹȋ͸ȌǣͳʹͺͻǦ͵ͳ͹Ǥ ʹͶ͵Ǥ ‘ “—›– ǡŽ‘†‡‡Žǡ‡’›’‡”‡ ǡƒ‡‹Œ’‡ǡƒ‡•ǡ‘•–”‡› ǡ‡–ƒŽǤ‡––‡” ‘•‡–‹ ”‡•—Ž–•ƒ† ‘’ƒ”ƒ„Ž‡“—ƒŽ‹–›‘ˆŽ‹ˆ‡ƒˆ–‡”•‹Ǧ•’ƒ”‹‰ƒ•–‡ –‘›ƒ†‹‡†‹ƒ–‡ ƒ—–‘Ž‘‰‘—•„”‡ƒ•–”‡ ‘•–”— –‹‘ ‘’ƒ”‡†–‘„”‡ƒ•– ‘•‡”˜ƒ–‹˜‡–”‡ƒ–‡–Ǥ” Žƒ•–—”‰Ǥ ʹͲͲ͵Ǣͷ͸ȋͷȌǣͶ͸ʹǦ͹ͲǤ ʹͶͶǤ Ž†‡”ƒǡ‹Ž‹• ǡ‘™‡”› ǡ‹ǡƒ˜‹• Ǥ‡–‡”‹ƒ–•‘ˆ’ƒ–‹‡–•ƒ–‹•ˆƒ –‹‘‹ ’‘•–ƒ•–‡ –‘›„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͲǢͳͲ͸ȋͶȌǣ͹͸ͻǦ͹͸Ǥ ʹͶͷǤ ƒŽƒ›ǡŠ—‰Ǥ ‘™–‘—•‡‘—– ‘‡•“—‡•–‹‘ƒ‹”‡•ǣ’‡ƒ”Ž•ƒ†’‹–ˆƒŽŽ•ǤŽ‹Žƒ•–—”‰Ǥ ʹͲͳ͵ǢͶͲȋʹȌǣʹ͸ͳǦͻǤ ʹͶ͸Ǥ ‡ƒ”•ǡŠ—‰Ǥ‰—‹†‡–‘‹–‡”’”‡–‹‰ƒ•–—†›‘ˆ’ƒ–‹‡–Ǧ”‡’‘”–‡†‘—– ‘‡•ǤŽƒ•–‡ ‘•–” —”‰ǤʹͲͳʹǢͳʹͻȋͷȌǣͳʹͲͲǦ͹Ǥ ʹͶ͹Ǥ Žƒ’Šƒ ǡ—•Šƒ ǡŠ—‰Ǥ•›•–‡ƒ–‹ ”‡˜‹‡™‘ˆƒ’’Ž›‹‰’ƒ–‹‡–•ƒ–‹•ˆƒ –‹‘‘—– ‘‡• ‹’Žƒ•–‹ •—”‰‡”›ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͲǢͳʹͷȋ͸Ȍǣͳͺʹ͸Ǧ͵͵Ǥ ʹͶͺǤ Ž‡˜‡Žƒ†Ž‹‹ Ǥ ‘•–‡”‹‰ƒ‘•‹–‹˜‡‡ŽˆǦ ƒ‰‡Ǥȏ ‡••†ƒ–‡ʹͲͳͻǦͳͲǦͳͲȐǤ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣ Š––’•ǣȀȀ›Ǥ Ž‡˜‡Žƒ† Ž‹‹ Ǥ‘”‰ȀŠ‡ƒŽ–ŠȀƒ”–‹ Ž‡•ȀͳʹͻͶʹǦˆ‘•–‡”‹‰ǦƒǦ’‘•‹–‹˜‡Ǧ•‡ŽˆǦ‹ƒ‰‡Ǥ ʹͶͻǤ ƒ‡”†–ƒ–‹•–‹ •Ǥ ‘‘†ƒƒ†”—•ƒŽ̵• ƒƒǤȏ ‡••†ƒ–‡ʹͲͳͻǦͳͲǦͳ͵ȐǤ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣ Š––’•ǣȀȀ•–ƒ–‹•–‹ •ǤŽƒ‡”†Ǥ ‘Ȁ’”‡‹—Ȁ•’••Ȁ‰‰Ȁ‰‘‘†ƒǦƒ†Ǧ”—•ƒŽ•Ǧ‰ƒƒǦ‹Ǧ•’••Ǥ’Š’Ǥ ʹͷͲǤ ƒ‡”†–ƒ–‹•–‹ •Ǥ ‹•Š‡”̵•šƒ –‡•–ȋʹšʹ‡•–‘ˆ †‡’‡†‡ ‡ȌǤȏ ‡••†ƒ–‡ʹͲͳͻǦͳͳǦͳͲȐǤ ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣŠ––’•ǣȀȀ•–ƒ–‹•–‹ •ǤŽƒ‡”†Ǥ ‘Ȁ’”‡‹—Ȁ•’••Ȁˆ‡–ʹšʹȀˆ‹•Š‡”•Ǧ‡šƒ –Ǧ–‡•–Ǧ‹Ǧ•’••Ǥ’Š’Ǥ ʹͷͳǤ ƒ”‡”Ǥ‡•–‹‰ƒ••‘ ‹ƒ–‹‘™‹–Š ‹•Š‡”̵•šƒ ––‡•–Ǥ  ƒŽƒ‡’”‘† ‡ƒŽ–Šƒ”‡Ǥ ʹͲͳ͵Ǣ͵ͻȋͶȌǣʹͺͳǦͶǤ ʹͷʹǤ –ƒ–‹•–‹ •‘Ž—–‹‘•Ǥ ‹•Š‡”šƒ –‡•–Ǥȏ ‡••†ƒ–‡ʹͲͳͻǦͳͲǦͳͳȐǤ˜ƒ‹Žƒ„Ž‡ˆ”‘ǣ Š––’•ǣȀȀ™™™Ǥ•–ƒ–‹•–‹ ••‘Ž—–‹‘•Ǥ ‘Ȁˆ‹•Š‡”Ǧ‡šƒ –Ǧ–‡•–ȀǤ ʹͷ͵Ǥ ›†‡”•‡ǡ”ƒ†Šƒǡ‡ Šƒ—†Š—”‹ǡƒƒ‡ǤŠ‘‹ ‡‘ˆ–‡•–ˆ‘”ƒ••‘ ‹ƒ–‹‘‹•ƒŽŽ•ƒ’Ž‡ —‘”†‡”‡†”š –ƒ„Ž‡•Ǥ–ƒ–‡†ǤʹͲͲ͹Ǣʹ͸ȋʹ͵ȌǣͶ͵ʹͺǦͶ͵Ǥ ʹͷͶǤ ‘††‹‘––ǡƒ•• ǤŠ‡†‹ŽŽƒ–‘–ƒŽ†‡•‹‰•—”˜‡›‡–Š‘†Ǥƒ ƒŠ›•‹ ‹ƒǤͳͻͺ͸Ǣ͵ʹǣʹ͵͸͸Ǧ ͺǤ ʹͷͷǤ ”ƒ—‰ƒŽ‹• ǡ‘‘• ǡŽƒœƒǤ‡•–’”ƒ –‹ ‡•ˆ‘”•—”˜‡›”‡•‡ƒ” Š”‡’‘”–•ǣƒ•›‘’•‹•ˆ‘”ƒ—–Š‘”• ƒ†”‡˜‹‡™‡”•Ǥ Šƒ”†— ǤʹͲͲͺǢ͹ʹȋͳȌǣͳͳǤ ʹͷ͸Ǥ Šƒ‰ǡ ‡†‘ǡ‹˜‡”ƒǡ—ŽŽǡ‹ Šƒ”†•‘ǡ—Ǥ‘•–Š‘ ’‘™‡”ƒƒŽ›•‹•ǣ‹•‹–ƒ‹ˆ‘”ƒ–‹˜‡ ƒ†‡ƒ‹‰ˆ—ŽƒƒŽ›•‹•ǫ ‡•› Š‹ƒ–”ǤʹͲͳͻǢ͵ʹȋͶȌǣ‡ͳͲͲͲ͸ͻǤ ʹͷ͹Ǥ Ǥ‘”Ž†‡†‹ ƒŽ••‘ ‹ƒ–‹‘‡ Žƒ”ƒ–‹‘‘ˆ ‡Ž•‹‹ǣ‡–Š‹ ƒŽ’”‹ ‹’Ž‡•ˆ‘”‡†‹ ƒŽ”‡•‡ƒ” Š ‹˜‘Ž˜‹‰Š—ƒ•—„Œ‡ –•Ǥ ƒƒǤʹͲͳ͵Ǣ͵ͳͲȋʹͲȌǣʹͳͻͳǦͶǤ ʹͷͺǤ ‘Ž• ǡ ‘ˆˆƒǡ‘ƒ‹ǡ‘š Ǥ —–‡”ƒ†‹ƒ–‹‘‡ˆˆ‡ –•‘ —–ƒ‡‘—•‹ ”‘˜ƒ• —Žƒ–—”‡ǣ ‡˜ƒŽ—ƒ–‹‘™‹–ŠƒŽƒ•‡”‘’’Ž‡”’‡”ˆ—•‹‘‘‹–‘”Ǥƒ†‹‘Ž‘‰›ǤͳͻͺͺǢͳ͸ͻȋʹȌǣͷͷ͹Ǧ͸ͲǤ ʹͷͻǤ ˜ƒ•ǡ‘„Ž‹‰ǡƒ‰‰•ƒ’’‘”– ǡ ‘—•–‘ ǡ‹‡”•Ž‡›ǡ‹Ž‹•‘Ǥ –†‘‡•̵– ‘•– ƒ›–Š‹‰Œ—•––‘ƒ•ǡ†‘‡•‹–ǫŠ‡‡–Š‹ •‘ˆ“—‡•–‹‘ƒ‹”‡Ǧ„ƒ•‡†”‡•‡ƒ” ŠǤ ‡†–Š‹ •Ǥ ʹͲͲʹǢʹͺȋͳȌǣͶͳǦͶǤ ʹ͸ͲǤ †ƒ ǡ‘‹‘ƒǡƒ”—ƒ™ƒǡ—ƒ‰ƒǡ—‰ƒ™ƒ”ƒǤ‘’ƒ”‹•‘‘ˆƒ„†‘‹ƒŽ™ƒŽŽ‘”„‹†‹–› „‡–™‡‡‡†‹ƒŽƒ†Žƒ–‡”ƒŽ”‘™Ǧ„ƒ•‡††‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’Ǥ Žƒ•–‡ ‘•–” ‡•–Š‡–—”‰ǤʹͲͳͷǢ͸ͺȋͳͳȌǣͳͷͷͲǦͷǤ ʹ͸ͳǤ ’‘•–‘Ž‹†‡• ǡƒ‰ƒ”ƒ‹•ǡ‘••‘ Ǥ”‡•‡”˜‹‰–Š‡‹–‡”ƒŽƒƒ”›ƒ”–‡”›ǣ‡†Ǧ–‘Ǧ•‹†‡ ‹ ”‘˜ƒ• —Žƒ”ƒ”–‡”‹ƒŽƒƒ•–‘‘•‹•ˆ‘” ƒ† ˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–” —”‰ǤʹͲͳͳǢͳʹͺȋͶȌǣʹʹͷ‡Ǧ͵ʹ‡Ǥ ʹ͸ʹǤ ̵‡‹ŽŽǡ—‰ŠƒŽǡƒ‰‰ƒˆǡ‹•‹‡™•‹ǡŠ‘‰ǡ ‘ˆ‡”Ǥ•–”— –—”‡†’ƒ–Š™ƒ›ˆ‘” ƒ ‡Ž‡”ƒ–‡†’‘•–‘’‡”ƒ–‹˜‡”‡ ‘˜‡”›”‡†— ‡•Š‘•’‹–ƒŽ•–ƒ›ƒ† ‘•–‘ˆ ƒ”‡ˆ‘ŽŽ‘™‹‰‹ ”‘˜ƒ• —Žƒ” „”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Š‘—–‹ ”‡ƒ•‡† ‘’Ž‹ ƒ–‹‘•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰Ǥ ʹͲͳͻǢ͹͵ȋͳȌǣͳͻǦʹ͸Ǥ ʹ͸͵Ǥ ‹Œ—•‘˜‹ ǡ”‡’ǡ ‡‹‡”ǡ‘ŽŽǡ• Š™ƒ†‡ǡ‡‹†Ž‡” ǡ‡–ƒŽǤ‘Ž‘”‘’’Ž‡” —Ž–”ƒ•‘—†ƒ† ‘’—–‡†–‘‘‰”ƒ’Š‹ ƒ‰‹‘‰”ƒ’Š›ˆ‘”’‡”ˆ‘”ƒ–‘”ƒ’’‹‰‹ ˆŽƒ’„”‡ƒ•– ”‡ ‘•–”— –‹‘”‡˜‹•‹–‡†ǣ ‘Š‘”–•–—†›Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳͻǢ͹ʹȋͳͲȌǣͳ͸͵ʹǦͻǤ ʹ͸ͶǤ Žƒ••‘ǡ˜‡••‘ ǡƒŽǡƒ••‡Ž‹—• ǡ‡Žƒ†‡”Ǥ”‡‘’‡”ƒ–‹˜‡ƒ‰‹‘‰”ƒ’Š›˜‡”•—• ‘’’Ž‡”—Ž–”ƒ•‘—†ƒ’’‹‰‘ˆƒ„†‘‹ƒŽ’‡”ˆ‘”ƒ–‘”‹ „”‡ƒ•–”‡ ‘•–”— –‹‘•ǣ ”ƒ†‘‹œ‡†’”‘•’‡ –‹˜‡•–—†›Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳͷǢ͸ͺȋ͸Ȍǣ͹ͺʹǦ͸Ǥ

102 102 ʹ͸ͷǤ ‹ƒǡƒŽ‰ƒ”‡ŽŽ‘ǡƒ”‘‡Ǧ†‡•‹ǡ‹ƒŽ†‹ǡ‘‘‘ǤŽƒ‹‰„”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Š†‡‡’ ‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›’‡”ˆ‘”ƒ–‹‰˜‡••‡Ž•ǣ—Ž–‹†‡–‡ –‘”ƒ‰‹‘‰”ƒ’Š›˜‡”•—• ‘Ž‘”‘’’Ž‡” Ǥƒ†‹‘Ž‘‰›ǤʹͲͳͲǢʹͷͷȋ͵Ȍǣͻ͹ͻǦͺ͹Ǥ ʹ͸͸Ǥ —‡Ž‹ǡ ‘‘‰‡˜‡‡ǡ Š—Ž–œ‡‘‘Ž ǡŽ”‹ Š Ǥ‡™ƒ† ‘˜ƒ–‹˜‡‡–Š‘†‘ˆ ”‡‘’‡”ƒ–‹˜‡Ž›Žƒ‹‰ƒ†”‘Œ‡ –‹‰ƒ• —Žƒ”ƒ–‘›‹  Žƒ’”‡ƒ•–‡ ‘•–”— –‹‘ǣ ƒ†‘‹œ‡†‘–”‘ŽŽ‡†”‹ƒŽǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͻǢͳͶ͵ȋ͸Ȍǣͳͳͷͳ‡Ǧͺ‡Ǥ ʹ͸͹Ǥ ‘––‡”ǡ‹ŽŽ•ǡƒ™–Š‘”ǡ‹Ž•‘ǡŽƒœ‡„› Ǥš’Ž‘”‹‰‹ˆ‘”ƒ–‹‘’”‘˜‹•‹‘‹”‡ ‘•–”— –‹˜‡ „”‡ƒ•–•—”‰‡”›ǣ“—ƒŽ‹–ƒ–‹˜‡•–—†›Ǥ”‡ƒ•–ǤʹͲͳͷǢʹͶȋ͸Ȍǣ͹͵ʹǦͺǤ ʹ͸ͺǤ ”†ƒǦƒ‰‡” ǡ‹Ž‹• ǡ—•‹ ǡ‹ ǡ ƒ‹ŽŽ ǡ‹ ǡ‡–ƒŽǤ‘’Ž‹ ƒ–‹‘•ƒ†ƒ–‹‡–Ǧ ‡’‘”–‡†—– ‘‡•ƒˆ–‡”„†‘‹ƒŽŽ›ƒ•‡†”‡ƒ•–‡ ‘•–”— –‹‘ǣ‡•—Ž–•‘ˆ–Š‡ƒ•–‡ –‘› ‡ ‘•–”— –‹‘—– ‘‡•‘•‘”–‹—–—†›ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͺǢͳͶͳȋʹȌǣʹ͹ͳǦͺͳǤ ʹ͸ͻǤ Š‡˜”ƒ›Ǥ”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Š•—’‡”ˆ‹ ‹ƒŽ‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›ˆŽƒ’•ǣƒ’”‘•’‡ –‹˜‡ ‘’ƒ”‹•‘™‹–Šƒ† ˆŽƒ’•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͶǢͳͳͶȋͷȌǣͳͲ͹͹Ǧͺ͵Ǣ†‹• —••‹‘ͺͶǦͷǤ ʹ͹ͲǤ ƒ›Ž‘” ǡƒ‹‡ŽǤŠ‡ƒƒ–‘›‘ˆ•‡˜‡”ƒŽˆ”‡‡ˆŽƒ’†‘‘”•‹–‡•ǤŽƒ•–‡ ‘•–”—”‰Ǥ ͳͻ͹ͷǢͷ͸ȋ͵ȌǣʹͶ͵Ǧͷ͵Ǥ ʹ͹ͳǤ ”‡‰‘”‹ ǡ Ž‹•ǡ‹Ž‘–‹  ǡ”†ƒǡ–‹”ǡ”‡œǤ‡Žƒ›‹‰–Š‡•—’‡”ˆ‹ ‹ƒŽ‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹  ƒ”–‡”›ˆŽƒ’ǣƒ•‘Ž—–‹‘–‘–Š‡’”‘„Ž‡‘ˆ–Š‡•ƒŽŽ ƒŽ‹„”‡‘ˆ–Š‡†‘‘”ƒ”–‡”›Ǥ Žƒ•–‡ ‘•–” ‡•–Š‡–—”‰ǤʹͲͳͳǢ͸ͶȋͻȌǣͳͳͺͳǦ͸Ǥ ʹ͹ʹǤ ‘”‘‡‘• ǡ ‡ŽŽ‡”ǡ‘‹‡•‘• ǡ˜”ƒǤ ˜‡”•—• ”–‡”‹ƒŽ‘’Ž‹ ƒ–‹‘•ǣ‘Š‘”– –—†›ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͳͷǢͳ͵ͷȋͷȌǣͺͲʹ‡Ǧ͹‡Ǥ ʹ͹͵Ǥ ‡Ž„‡” ǡƒ”ƒ ǡ”‹•–‘Žǡ‘ƒ†ǡ‡‰ƒǡ—ǡ‡–ƒŽǤŠ‡ƒ†Ǧ–‘ǦŠ‡ƒ† ‘’ƒ”‹•‘„‡–™‡‡ –Š‡—• Ž‡Ǧ•’ƒ”‹‰ˆ”‡‡ƒ†–Š‡ ˆŽƒ’•ǣ‹•–Š‡”ƒ–‡‘ˆˆŽƒ’Ž‘••™‘”–Š–Š‡‰ƒ‹‹ ƒ„†‘‹ƒŽ™ƒŽŽˆ— –‹‘ǫŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͺǢͳʹʹȋʹȌǣ͵ͶͺǦͷͷǤ ʹ͹ͶǤ —–Ž‡”ǡ—Ǥ„†‘‹ƒŽ’‡”ˆ‘”ƒ–‘”˜•Ǥ—• Ž‡•’ƒ”‹‰ˆŽƒ’•ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ Žƒ† —”‰ǤʹͲͳͷǢͶȋ͵ȌǣʹͳʹǦʹͳǤ ʹ͹ͷǤ ‘•Š‹ƒ ǡ ƒ‰ƒ™ƒǡƒƒ‘–‘ǡ‘”‹‰— Š‹Ǥ‡™‹ ”‘•—”‰‹ ƒŽ„”‡ƒ•–”‡ ‘•–”— –‹‘—•‹‰ ˆ”‡‡’ƒ”ƒ—„‹Ž‹ ƒŽ’‡”ˆ‘”ƒ–‘”ƒ†‹’‘•ƒŽˆŽƒ’•ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲͲͲǢͳͲ͸ȋͳȌǣ͸ͳǦͷǤ ʹ͹͸Ǥ  Š‘‡ŽŽ‡”ǡƒ—‡”ǡ —”—Ž—‘‰Ž—ǡ —••Ž ǡ––‘Ǧ Š‘‡ŽŽ‡”ǡ‹œƒǦƒ–œ‡” ǡ‡–ƒŽǤ‘†‹ˆ‹‡†ˆ”‡‡ ’ƒ”ƒ—„‹Ž‹ ƒŽ’‡”ˆ‘”ƒ–‘”ˆŽƒ’ǣ–Š‡‡š–Ž‘‰‹ ƒŽ•–‡’‹„”‡ƒ•–”‡ ‘•–”— –‹‘ǤŽƒ•–‡ ‘•–”—”‰Ǥ ʹͲͲ͵Ǣͳͳͳȋ͵ȌǣͳͲͻ͵ǦͺǢ†‹• —••‹‘ͻǦͳͲͳǤ ʹ͹͹Ǥ ‘Šƒǡƒ‘•ǡ ƒ„ƒǡ Š—’„ƒ Š ǡ ‘‡†‡ ǡƒŽŽƒǡ‡–ƒŽǤ‘†‹ˆ‹‡†ƒ‡•–Š‡–‹  ƒ„†‘‹‘’Žƒ•–›ƒ’’”‘ƒ Š‹’‡”ˆ‘”ƒ–‘”ˆ”‡‡ǦˆŽƒ’„”‡ƒ•–”‡ ‘•–”— –‹‘ǣ ’ƒ –‘ˆ†”ƒ‹ˆ”‡‡†‘‘” •‹–‡‘’ƒ–‹‡–‘—– ‘‡•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳͷǢ͸ͺȋ͸ȌǣͺͲͲǦͻǤ ʹ͹ͺǤ ƒ‰ƒ”ƒ”ǡƒŠ‹ƒ‹ǡŠ‡‰ǡ‡‡ǡ‡‘–‹ƒǡƒ‹–Ǧ›”Ǥ‘Ǧ†”ƒ‹  Žƒ’‘‘”Ǧ•‹–‡ Ž‘•—”‡•‹‰ƒ”„‡†”‘‰”‡••‹˜‡‡•‹‘—–—”‡•ǤŽƒ•–‡ ‘•–”—”‰ Ž‘„’‡ǤʹͲͳ͸ǢͶȋͶȌǣ‡͸͹ʹǤ ʹ͹ͻǤ ‹ƒ‰ ǡ—••‡Ž†‘”’ ǡ˜ƒ ŠƒŽ™›ǡ ƒ”‹•™ƒ›ǡ‘‘†ǡ‘•‡ǡ‡–ƒŽǤ—‹‰„ƒ”„‡† •—–—”‡“—‹Ž–‹‰”‡†— ‡•ƒ„†‘‹ƒŽ†”ƒ‹ƒ‰‡‹’‡”ˆ‘”ƒ–‘”Ǧ„ƒ•‡†„”‡ƒ•–”‡ ‘•–”— –‹‘Ǥ Žƒ•– ‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳ͸Ǣ͸ͻȋͳȌǣͶʹǦ͹Ǥ ʹͺͲǤ ƒ‰ǦǡŠƒ‰ Š‹‡Ǧ ǡŠ‡Ǧǡ •—Ǧ ǡ•ƒ‹ǦǤŽ‘•‡†‹ ‹•‹‘‡‰ƒ–‹˜‡’”‡••—”‡–Š‡”ƒ’› ˆ‘ŽŽ‘™‹‰ƒ„†‘‹‘’Žƒ•–›ƒˆ–‡”„”‡ƒ•–”‡ ‘•–”— –‹‘™‹–Š†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ’‡”ˆ‘”ƒ–‘”ˆŽƒ’•Ǥ –‘—† ǤʹͲͳͻǣͳͲǤͳͳͳͳȀ‹™ŒǤͳ͵ʹ͹͵Ǥ ʹͺͳǤ —ŽŽ‡”ǦŽ‘‘ˆǡ†‡ƒƒ– ǡ —‡Ž‹ǡ‡–‡”• ǡŽ”‹ Š ǤŠ‡‡ˆˆ‡ –‘ˆ’‘•–‘’‡”ƒ–‹˜‡ Ž‘•‡†‹ ‹•‹‘‡‰ƒ–‹˜‡’”‡••—”‡–Š‡”ƒ’›‘–Š‡‹ ‹†‡ ‡‘ˆ†‘‘”•‹–‡™‘—††‡Š‹• ‡ ‡‹ „”‡ƒ•–”‡ ‘•–”— –‹‘’ƒ–‹‡–•ǣŠ‹• ‡ ‡˜‡–‹‘–—†›ȋȌǡ’‹Ž‘–”ƒ†‘‹œ‡† ‘–”‘ŽŽ‡†–”‹ƒŽǤ ‹••—‡‹ƒ„‹Ž‹–›ǤʹͲͳͺǢʹ͹ȋͶȌǣʹ͸ʹǦ͸Ǥ ʹͺʹǤ ƒ†ƒ† ǡ „”ƒŠ‹ǡ‹ ǡ‡‡Ǥ—‰‡–‡† ˆŽƒ’ˆ‘”‹ ”‘˜ƒ• —Žƒ”„”‡ƒ•–”‡ ‘•–”— –‹‘ ƒˆ–‡”’”‹‘”Ž‹‰ƒ–‹‘‘ˆ„‹Žƒ–‡”ƒŽ†‡‡’‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”‹‡•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰Ǥ ʹͲͳ͵Ǣ͸͸ȋ͸ȌǣͺͶͷǦ͹Ǥ ʹͺ͵Ǥ –”‘—œƒǡƒ‹Žƒ”–Š‡Ž‡›ǡƒŒ‘—Ž‡–ǡ‡Ž Š‡–ǡƒ••‡›ƒ”ǡ–ŽƒǤ†‘• ‘’‹  ˆŽƒ’ †‹••‡ –‹‘ȋ‡ Ȍǣ‡š’‡”‹‡–ƒŽ ƒ†ƒ˜‡”‹ •–—†›Ǥ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰Ǥ ʹͲͳ͹Ǣ͹ͲȋͺȌǣͳͳͶͻǦͷͳǤ ʹͺͶǤ ‡‹–‰ƒ••‡”ǡ”ǡ‡—–œ• Š ǡ Š‘‡ŽŽ‡”Ǥ‡†— –‹‘‘ˆ–Š‡ ˆŽƒ’†‘‘”•‹–‡‘”„‹†‹–› –Š”‘—‰Šƒ‹‹ƒŽŽ›‹˜ƒ•‹˜‡’‡†‹ Ž‡Šƒ”˜‡•–™‹–Š ƒ ‘„̵•Žƒ††‡”‹ ‹•‹‘•Ǥ Žƒ•–‡ ‘•–”‡•–Š‡– —”‰ǤʹͲͳͺǢ͹ͳȋ͸Ȍǣͻ͵ͳǦ͵Ǥ ʹͺͷǤ –”—ǡƒ”ˆƒ–‹ǡ‡›ƒ”‹‡ǡ‹••‹•–”ƒ‘ǡŽŠƒ•Šƒ ǡ‹ƒ”‡‹š ǡ‡–ƒŽǤ‘„‘–‹ Ǧƒ••‹•–‡†  ˆŽƒ’Šƒ”˜‡•–ǣˆ‡ƒ•‹„‹Ž‹–›•–—†›‘ ƒ†ƒ˜‡”‹ ‘†‡ŽǤ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳͺǢ͹ͳȋʹȌǣʹͷͻǦ ͸ͳǤ

103 103 ʹͺ͸Ǥ —†Žƒ’ƒŽŽ‹ǡ‰—Ž‡›‡ǡ ‘––ǡ‡œ‹‰‡”ǡŽ ǡƒ˜ƒƒǡ‡–ƒŽǤ‘„‘–‹ Ǧƒ••‹•–‡††‡‡’ ‹ˆ‡”‹‘”‡’‹‰ƒ•–”‹ ƒ”–‡”›’‡”ˆ‘”ƒ–‘”ˆŽƒ’ƒ„†‘‹ƒŽŠƒ”˜‡•–ˆ‘”„”‡ƒ•–”‡ ‘•–”— –‹‘ǣ ƒ•‡ ”‡’‘”–Ǥ‹ ”‘•—”‰‡”›ǤʹͲͳͺǢ͵ͺȋ͸Ȍǣ͹ͲʹǦͷǤ ʹͺ͹Ǥ ƒ‡†ǡ ƒ†‹ Ǥ‡’Ž›–‘–Š‡†‹–‘”ǣ‘„‘–‹ Ǧƒ••‹•–‡† ˆŽƒ’Šƒ”˜‡•–ǣˆ‡ƒ•‹„‹Ž‹–› •–—†›‘ ƒ†ƒ˜‡”‹ ‘†‡ŽǤ Žƒ•–‡ ‘•–”‡•–Š‡–—”‰ǤʹͲͳͺǢ͹ͳȋͺȌǣͳʹͳ͸Ǧ͵ͲǤ ʹͺͺǤ ‡Ž„‡” ǤŠ‡‘„‘–‹   Žƒ’ǤŽƒ•–‡ ‘•–”—”‰ǤʹͲʹͲǢͳͶͷȋʹȌǣ͵ͶͲǦ͵Ǥ

104 104 I

ORIGINAL ARTICLE Breast Microcirculatory Evaluation of the Abdominal Skin in Breast Reconstruction with Deep Inferior Epigastric Artery Perforator Flap

Christoffer Aam Ingvaldsen, MS*† Background: No studies have assessed the perfusion of the undermined Kim Alexander Tønseth, MD, abdominal skin in breast reconstruction with deep inferior epigastric ar- PhD*†‡ tery perforator flap. A greater understanding of the procedure’s impact Are Hugo Pripp, MSc, PhD§ on the perfusion of the abdominal skin can be valuable in predicting areas Tyge Tind Tindholdt, MD, susceptible to necrosis. PhD*† Methods: Microcirculatory changes were monitored in the abdominal skin of 20 consecutive patients undergoing breast reconstruction with a deep inferior epigastric artery perforator flap. Quantitative mapping was per- formed with laser Doppler perfusion imaging at 7 set intervals. Measure- ments were taken and recorded within 4 standardized zones covering the skin between the xiphoid process and the upper incisional boundary of the flap (zones 1–4; cranial to caudal). Results: Before commencing surgery, a significantly higher perfusion was registered in zones 3 and 4 when compared with zone 1. After undermin- ing the abdominal skin, the perfusion in zones 1–3 increased significantly. After the abdominal closure, the perfusion dropped in all 4 zones and only the perfusion level in zone 1 remained significantly higher than preopera- tive mean. Postoperatively, the perfusion of each zone stabilized at a signifi- cantly higher level compared with preoperative values. No tissue necrosis was observed in any of the zones. Conclusions: Although perforators are divided during undermining of the abdominal skin, there seems to be a reactive hyperemia that exceeds the blood supply delivered by the perforators. Thus, due to microcirculatory mechanisms, the undermining of the abdomen during the procedure does not seem to pres- ent any great risk of tissue necrosis. (Plast Reconstr Surg Glob Open 2016;4:e616; doi: 10.1097/GOX.0000000000000602; Published online 10 February 2016.)

From the *Department of Plastic and Reconstructive Surgery, he integument can be divided into vascular Oslo University Hospital, Oslo, Norway; †Institute for territories based on the arterial inflow. Each Surgical Research, Oslo University Hospital, Oslo, Norway; Tterritory has a source artery, which supplies ‡Faculty of Medicine, University of Oslo, Oslo, Norway; and a certain block of skin and underlying structures. §Oslo Centre of Biostatistics and Epidemiology, Research These composite units are called angiosomes or per- Support Services, Oslo University Hospital, Oslo, Norway. forasomes.1–3 Such vascular territories are intercon- Presented at the 90th Annual Congress of the Norwegian nected either by true anastomotic vessels without Society of Plastic Surgery, October 23rd, 2014, Oslo, Norway. change in caliber or by connections with reduced Received for publication July 19, 2015; accepted December 22, 4–6 2015. caliber called choke anastomotic vessels. A sub- Copyright © 2016 The Authors. Published by Wolters stantial work has been conducted to map these units Kluwer Health, Inc. on behalf of The American Society of through ink injection, dissection, perforator map- Plastic Surgeons. All rights reserved. This is an open-access ping, and radiographic analysis in fresh cadavers.7,8 article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 Disclosure: The authors have no financial interest (CCBY-NC-ND), where it is permissible to download and to declare in relation to the content of this article. The share the work provided it is properly cited. The work cannot Article Processing Charge was paid for by the Publishing be changed in any way or used commercially. Fund (University of Oslo). DOI: 10.1097/GOX.0000000000000602

www.PRSGlobalOpen.com 1 PRS Global Open • 2016

This knowledge is of major importance in terms of Table 1. Patient Details (N = 20) preoperative planning and establishing the surgical Age at examination (yr) 53.5 (6.4) (43.9–65.7) approach in perforator flap reconstructions. BMI (kg/m2) 25.0 (2.8) (21.6–30.9) At present, the deep inferior epigastric artery Coexisting conditions, n (%) perforator (DIEAP) flap is the most commonly used None 15 (75) Hypertension 1 (5) perforator flap in breast reconstruction due to a Asthma 2 (10) wide array of advantages. The procedure does, how- Other 2 (10) ever, have a detrimental impact on the structure and Smoking, n (%) 3 (15) 9,10 Adjuvant therapy, n (%) function of the abdominal wall. Chemotherapy 8 (40) When harvesting the flap, one leaves behind a Radiotherapy 9 (45) sizable abdominal donor defect. To close the defect, Axillary node dissections, n (%) 9 (45) Time between mastectomy and 2.8 (2.3) (0.5–11.8) the integument cranial to the DIEAP flap has to be reconstruction (yr) extensively undermined and mobilized. This process Data are described as means (SD) (min–max) or number of patients includes ligation of the perforators in the respective (%). BMI indicates body mass index; SD, standard deviation. area. Both high tension and the loss of perforator vessels to the skin might reduce the local microcircu- tors on one side were dissected from the level of the lation and hereby pose a threat to the wound healing. anterior rectus fascia to the entrance of the inferior Previously, it has been shown that comparable high epigastric vessels. The circulatory capacity of the larg- tension when closing the wound can lead to reduced est perforators was tested by clamping remaining per- microcirculation11,12 and poor wound healing.13 forators for 15 minutes. If the chosen perforator(s) Most DIEAP surgeons have witnessed varying de- seemed to be satisfactory, transection of perforators grees of circulatory instability in the harvested flap, was done, and the flap was transferred to the recipient as well as the donor area throughout the postopera- area. Microanastomosis was performed end-to-end to tive phase. The purpose of this study was to perform the inframammary vessels in all cases. a quantitative perfusion study of the undermined Concurrent to the flap insetting, the donor defect abdominal skin to obtain more knowledge on per- was closed by the other team of surgeons. The un- fusion dynamics. Laser Doppler perfusion imaging dermining of the abdominal skin was performed to (LDPI) was used to evaluate this. the level of xiphoid and along the costal margin. No infiltration was used, and no liposuction was done PATIENTS AND METHODS in the donor flap. Nor were any progressive tension sutures used to promote the adherence between the Study Design donor flap and the abdominal wall; however, the op- In a prospective clinical study, microcirculatory erating bed was jack-knifed to prevent tension. changes in the undermined abdominal skin were The patients were returned to horizontal position evaluated applying LDPI in women undergoing before scans. Additionally, all postoperative mea- breast reconstruction with a DIEAP flap. The study surements were completed in a horizontal position. was registered and published in the ClinicalTrials. Heating blankets were used intraoperatively to cover gov database (ID number: NCT0248184), and the the lower extremities. research protocol was approved by the local Ethical Committee (REK Sør; reference no. S-07071a). LDPI Measurements LDPI is an extension of laser Doppler flowmetry Patients and was developed to generate a color-coded perfu- Twenty women consecutively undergoing second- sion image in a large area of skin.15,16 LDPI has been ary, unilateral breast reconstruction with a DIEAP increasingly used in skin research and the assessment flap were identified and recruited to participate in of cutaneous microcirculation.17 In plastic surgery, it the study. The patients were informed about the has been used to evaluate the depth and healing of risks and benefits and gave written consent before burn wounds,18,19 and it has been proven to be an participation. All smokers stopped smoking 4 weeks applicable, clinical tool in assessing and monitoring before surgery. Patient details are listed in Table 1. pressure sores, free flaps, and perforator flaps.20–24 An LDPI machine (PIM 3, Perimed AB, Järfälla, Surgery Sweden) was used to monitor the microcirculatory A standard DIEAP flap procedure as described by changes in the abdominal skin. The technique works Blondeel et al14 was performed. Surgery was carried by the emission of a laser beam, which is then scat- out at the donor and recipient area by 2 teams of plas- tered and partly absorbed by the tissue. Light hitting tic surgeons simultaneously. Only the largest perfora- the moving blood cells undergoes a Doppler shift

2 Ingvaldsen et al. • Abdominal Skin Perfusion after DIEAP Flap Procedure

(while light hitting static objects is unchanged). The zones were standardized using 4 reference lines; A, a magnitude of the frequency shift reflects the num- vertical line from the xiphoid process to the caudal ber and velocity of the blood cells in the area be- boundary of the undermined skin; B, a horizontal ing studied, resulting in a quantitative measurement line dividing A in 2 halves; C, a vertical line through of cutaneous perfusion. The depth of the scans is the intersection of line B and the costal margin; D, 0.5−1 mm, depending on the tissue properties.25 a horizontal line parallel to the caudal boundary of Simultaneously, as the machine detects the the undermined skin (Fig. 2). reflected light, an internal mirror sequentially The zones were composed of 1 triangle (zone moves the laser beam stepwise between measure- 1) and 3 rectangles (zones 2−4). The triangle had ment points (perfusion sites). Detected light from typically fewer perfusion sites compared with the different perfusion sites is then processed to cre- remaining zones, with the smallest zone of 61 per- ate a color map of the scanned zones. In addition, fusion sites. All 4 zones were situated around the ab- a digital camera records a clinical photograph, dominal midline and did not include the outermost which corresponds closely with the blood perfu- areas of the undermined skin—covering “zone 1” of sion image. the 3 vascular territories of the abdomen described In our clinical setup, 7 scans were performed: by Huger.26 This was done knowingly to only get mea- (1) preoperative; (2) after raising the flap; (3) af- surements where the laser beam intersected the skin ter undermining; (4) after abdominal closure; (5) surface perpendicularly. postoperative day 1 (POD1); (6) postoperative day 3 The zones described were not marked directly (POD3); and (7) postoperative day 7 (POD7). on the patient before commencing surgery. Al- The distance from the laser head to the skin was ternatively, the perfusion zones were defined and set at 35 cm, and the resolution was placed at a low demarked on the digital, clinical photograph us- range. All scans were performed perpendicular to the ing the software, which includes the necessary geo- skin, under constant light, and temperature condi- metrical tools. The clinical photograph (intensity) tions (Fig. 1). The undermined abdominal skin was when viewed in the software was directly correlated left undisturbed at least 10 minutes before each scan. to the perfusion color map (perfusion), and the The perfusion was calculated using the software zones were automatically superimposed upon the LDPI win 3.1. latter (Fig. 2).

Perfusion Zones Statistical Analysis Four zones (zones 1–4; cranial to caudal) were Descriptive statistics are presented using means used to evaluate the perfusion of the donor flap. The (SD) and number of patients (percentage) if not otherwise stated. Because of repeated and clus- tered measurements, we used linear mixed models with a random intercept. Separate statistical mod- els for each of the 4 zones were conducted, and the 7 observation times (ie, preoperative to postopera- tive day 7) were assessed as a fixed factor. In addi- tion, separate statistical models for each of the 7 observation times were conducted, and the 4 zones were then assessed as a fixed factor. All pair wise comparison in the statistical models was done with the Bonferroni correction. We accepted P values of less than 0.05 as statistical significance. IBM SPSS Statistics 21 (IBM, Armonk, NY) was used for statis- tical analysis.

RESULTS No tissue necrosis, seromas, or hematomas were observed at the donor site following the abdominal closure. Fig. 1. Photograph taken intraoperatively after raising the Statistical data comparing the abdominal per- flap that illustrates the clinical setup with the LDPI machine fusion zones are listed in Table 2 and depicted in situated 35 cm above the abdomen. The 4 standardized Figure 3. The results are reported briefly according zones are marked directly on the patient. to the time of measurement in the following text:

3 PRS Global Open • 2016

Fig. 2. “Intensity” showing the 4 standardized zones and reference lines marked on a grayscale version of the clinical photo- graph seen in the software used. Zones 1–4 made by the geometrical tools offered. “Perfusion” showing the 4 zones being automatically superimposed upon the color-coded LDPI perfusion map in the software.

Table 2. Microcirculatory Evaluation with Laser Doppler Perfusion Imaging of the Abdominal Zones 1–4 Shown in Mean Perfusion Units After After Raising After Abdominal Preoperative the Flap Undermining Closure POD1 POD3 POD7 Zone 1 Mean (SD) 37.2 (9.1) 46.8 (11.1) 88.7 (28.1) 52.5 (10.8) 70.2 (26.4) 58.9 (16.6) 61.2 (17.8) P value* 1 <0.01 0.04 <0.01 <0.01 <0.01 Zone 2 Mean (SD) 40.5 (11.1) 51.4 (12.8) 71.2 (20.6) 49.6 (12.3) 68.0 (15.1) 60.1 (18.1) 62.5 (16.9) P value† 0.34 0.13 <0.01 1.0 1.0 1.0 1.0 P value* 0.09 <0.01 0.33 <0.01 <0.01 <0.01 Zone 3 Mean (SD) 42.1 (12.2) 51.9 (11.8) 59.0 (17.3) 45.3 (18.3) 66.7 (22.2) 64.8 (20.9) 69.4 (17.2) P value† 0.03 0.06 <0.01 0.26 1.0 0.99 0.22 P value* 0.70 <0.01 1.0 <0.01 <0.01 <0.01 Zone 4 Mean (SD) 42.3 (10.2) 48.6 (9.9) 47.1 (15.7) 37.8 (12.3) 55.2 (17.5) 58.9 (15.4) 66.3 (14.0) P value† 0.03 1.0 <0.01 <0.01 <0.01 1.0 1.0 P value* 1.0 1.0 1.0 0.01 <0.01 <0.01 Bold numbers qualify as significant. All P values are adjusted correspondingly to Bonferroni correction for pair wise comparisons. SD indicates standard deviation. *P values comparing preoperative perfusion levels for each zone with perfusion levels at times indicated above. †P values comparing perfusion levels of zone 1 with perfusion levels of zones 2–4.

1. Preoperative: Mean perfusion increased succes- measurement. Only zone 1 remained with a sig- sively from zone 1 to zone 4. Zones 3 and 4 had sig- nificantly higher perfusion compared with pre- nificantly higher perfusion compared with zone 1. operative mean. Mean perfusion in zone 4 was 2. After raising the flap: All zones had an increase significantly lower than zone 1. of mean perfusion compared with preoperative 5. POD1: All zones had an increase of perfusion mean, but none of these were significant. Zone compared with previous measurement, and all 1 had insignificant perfusion compared with re- perfusion means were significantly higher com- maining zones. pared with their preoperative mean. Only mean 3. After undermining: Zones 1–3 had a significant perfusion in zone 4 was significantly lower than increase of mean perfusion compared with pre- zone 1. operative values (Fig. 4). Zone 4 had a decrease 6. POD3: Zones 1–3 had a decrease of perfusion of perfusion compared with previous measure- compared with previous measurements, but the ment, but the perfusion remained insignificant means were still significantly higher compared compared with the preoperative mean. Zone 1 with their preoperative mean. Zone 4 had an in- had significantly higher perfusion compared crease of perfusion and remained significantly with remaining zones. higher compared with preoperative mean. Zone 4. After abdominal closure: All zones had a de- 1 had insignificant perfusion mean compared crease of perfusion compared with previous with remaining zones.

4 Ingvaldsen et al. • Abdominal Skin Perfusion after DIEAP Flap Procedure

Fig. 3. Graph illustrating mean perfusion units for each zone at times indicated above. POD indicates postoperative day.

Fig. 4. Intraoperative perfusion maps with zones 1–4: after rising of the DIEAP flap (A) and after undermining of the abdominal skin (B).

7. POD7: All zones had an increase of perfusion com- Zone 1 had both the highest (after undermining) pared with previous measurement, and all perfu- and the lowest (preoperative) perfusion means of all sion means were significantly higher compared measurements performed. with preoperative mean. Zone 1 had insignificant In terms of the standardized zones described perfusion mean compared with remaining zones. above, the postsurgical location of umbilicus varied between patients. Seven of 20 (35%) patients was lo- The highest individual perfusion mean was found cated in zone 3, 1 of 20 (5%) in zone 4 and 12 of 20 after undermining in zones 1 and 2, and POD7 in (60%) partly in both zones 3 and 4. The umbilicus zones 3 and 4. The lowest individual perfusion mean had a higher number of perfusion units than the sur- was found preoperatively for zones 1–3 and after ab- rounding skin. Although the umbilicus had an im- dominal closure for zone 4. pact on the zone’s mean, we chose to not exclude

5 PRS Global Open • 2016 the umbilicus from the zonal perfusion mean (see significantly higher mean perfusion than zones 2–4 Discussion section). (Table 2). The perfusion dropped rather dramatically in all DISCUSSION zones after the abdominal closure. A comparable There is no prior research that addresses skin perfusion drop is described by Mayr et al29 in their perfusion in the donor site in DIEAP flap breast re- quantitative evaluation of perfusion changes in the construction. The purpose of the study was to gain abdominal wall after suturing of the abdominal flap information on perfusion dynamics in the under- during abdominoplasty. The observations are, addi- mined abdominal skin by assessing the microvascu- tionally, in accordance with Barnhill et al,11 who have lar impact of the procedure. previously shown that wound tension has a negative It was observed that the postsurgical location of effect on the superficial dermal microvasculature the umbilicus varied. The umbilicus had clearly a and leads to reduced microcirculation. greater perfusion compared with adjacent areas. It Postoperatively, there was generally an increase was, nevertheless, included in the zones’ mean per- and overall stabilization of perfusion in zones 1–4. fusion. It was included based on 2 observations: (1) Throughout the postoperative phase, all zones had a the umbilicus on the perfusion map was very irregu- significantly higher perfusion compared with preop- lar in terms of shape and perfusion level and had erative status. These consistently high postoperative rarely a defined, outer border and (2) the perfusion perfusion measurements indicate a postoperative maps often showed spots of higher perfusion sur- regeneration of vascular networks. Ribuffo et al30 rounding the umbilicus. These observations made have evaluated this vascular buildup by the use of it, first of all, difficult to define, which perfusion ar- duplex scanning, verifying the growth of new vessels eas that were related to the umbilicus and, thereby, in the abdominal wall after radical abdominoplasty should have been excluded. Second, it appeared in in 10 patients. The authors of the study describe that the postoperative phase as the umbilicus was improv- the initial reperfusion of the abdominal wall occurs ing the local perfusion, having spots of higher perfu- mainly from regrowth of the intercostal vessels— sion randomly spread in the most adjacent areas of most likely causing the significantly higher perfusion the undermined abdominal skin. Thus, the umbili- measurements in our postoperative data. cus might be a factor kick-starting the local reper- Our data illustrate that the perfusion of the donor fusion and angiogenesis. Further investigations are flap gets increasingly better the more cranially you needed to clarify the umbilicus’ role in the under- go from the harvested flap after the undermining. mined tissue. This stepwise decrease of perfusion in a cranial to Notably, our study uncovered several significant caudal fashion lasts until the first postoperative day. differences comparing the perfusion zones that were The area just above the cranial incision of the donor outlined in the clinical setup: defect (zone 4) is the most vulnerable in terms of low Significantly higher perfusion means were regis- perfusion, especially after closure of the abdominal tered in zones 3 and 4 compared with zone 1 even defect and the extra tension caused. Although sever- before commencing surgery. Consistent with pre- al zonal differences like this were observed, it seems, vious studies, this observation can be explained by however, like they do not have a clinical impact. the high occurrence of periumbilical perforators in In summary, the material provides a greater un- these most caudal zones.27,28 derstanding of the surgical impact of DIEAP flap After the undermining, we expected the perfu- reconstruction on abdominal skin perfusion. Our sion to drop—especially in the zones being furthest study did not find any contraindications of under- away from underlying perforators (zones 3 and 4). mining larger areas of skin to achieve successful, sur- These zones are to a greater extent provided by the gical closure. subdermal plexus alone compared with more cranial zones. Although this seems logical, we did instead ob- Christoffer Aam Ingvaldsen serve a significant increase of perfusion in zones 1–3 Department of Plastic and Reconstructive Surgery and only a minimal reduction in zone 4 after under- Oslo University Hospital—Rikshospitalet mining (Fig. 4). The latter reduction was, moreover, Postboks 4950 Nydalen insignificant compared with preoperative mean. In 0424 Oslo, Norway fact, the perfusion in none of the 4 zones dropped E-mail: [email protected]/[email protected] below the preoperative mean after the undermining. An increase of perfusion in zones 1–3 could be ACKNOWLEDGMENT explained by a reactive hyperemia—being more We thank Perimed AB (Järfälla, Sweden) for their pronounced cranially in the donor flap; zone 1 had assistance with the laser Doppler perfusion imager.

6 Ingvaldsen et al. • Abdominal Skin Perfusion after DIEAP Flap Procedure

REFERENCES 16. Essex TJ, Byrne PO. A laser Doppler scanner for imaging 1. Schmidt M, Tinhofer I, Duscher D, et al. Perforasomes of blood flow in skin. J Biomed Eng. 1991;13:189–194. the upper abdomen: an anatomical study. J Plast Reconstr 17. Keymel S, Sichwardt J, Balzer J, et al. Characterization of Aesthet Surg. 2014;67:42–47. the non-invasive assessment of the cutaneous microcircu- 2. Saint-Cyr M, Wong C, Schaverien M, et al. The perfora- lation by laser Doppler perfusion scanner. Microcirculation. some theory: vascular anatomy and clinical implications. 2010;17:358–366. Plast Reconstr Surg. 2009;124:1529–1544. 18. Cho JK, Moon DJ, Kim SG, et al. Relationship between 3. Wong C, Saint-Cyr M, Mojallal A, et al. Perforasomes healing time and mean perfusion units of laser Doppler of the DIEP flap: vascular anatomy of the lateral versus imaging (LDI) in pediatric burns. Burns 2009;35: medial row perforators and clinical implications. Plast 818–823. Reconstr Surg. 2010;125:772–782. 19. Park YS, Choi YH, Lee HS, et al. The impact of laser 4. Taylor GI, Chubb DP, Ashton MW. True and ‘choke’ anas- Doppler imaging on the early decision-making process tomoses between perforator angiosomes: part i. anatomi- for surgical intervention in adults with indeterminate cal location. Plast Reconstr Surg. 2013;132:1447–1456. burns. Burns 2013;39:655–661. 5. Chubb DP, Taylor GI, Ashton MW. True and ‘choke’ 20. Thorfinn J, Sjöberg F, Lidman D. Perfusion of buttock anastomoses between perforator angiosomes: part II. dy- skin in healthy volunteers after long and short repetitive namic thermographic identification. Plast Reconstr Surg. loading evaluated by laser Doppler perfusion imager. 2013;132:1457–1464. Scand J Plast Reconstr Surg Hand Surg. 2007;41:297–302. 6. Taylor GI, Chubb DP, Ashton MW. True and ‘choke’ anas- 21. Tønseth KA, Tindholdt TT. Microcirculation in single tomoses between perforator angiosomes: part i. anatomi- and multiple-based perforator flaps in an experimen- cal location. Plast Reconstr Surg. 2013;132:1447–1456. tal model of rats. Scand J Plast Reconstr Surg Hand Surg. 7. Taylor GI, Corlett RJ, Dhar SC, et al. The anatomical (an- 2007;41:49–52. giosome) and clinical territories of cutaneous perforating 22. Tindholdt TT, Saidian S, Pripp AH, et al. Monitoring arteries: development of the concept and designing safe microcirculatory changes in the deep inferior epigastric flaps. Plast Reconstr Surg. 2011;127:1447–1459. artery perforator flap with laser Doppler perfusion imag- 8. Taylor GI, Palmer JH. The vascular territories (angio- ing. Ann Plast Surg. 2011;67:139–142. somes) of the body: experimental study and clinical ap- 23. Tindholdt TT, Saidian S, Tønseth KA. Microcirculatory plications. Br J Plast Surg. 1987;40:113–141. evaluation of deep inferior epigastric artery perforator 9. Tønseth KA, Günther A, Brabrand K, et al. flaps with laser Doppler perfusion imaging in breast re- Ultrasonographic evaluation of the rectus abdominis construction. J Plast Surg Hand Surg. 2011;45:143–147. muscle after breast reconstruction with the DIEP flap. 24. Schlosser S, Wirth R, Plock JA, et al. Application of a new Ann Plast Surg. 2005;54:483–486. laser Doppler imaging system in planning and monitor- 10. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The do- ing of surgical flaps. J Biomed Opt. 2010;15:036023. nor site morbidity of free DIEP flaps and free TRAM flaps 25. Instruments P. Pim3 Technical Specifications. for breast reconstruction. Br J Plast Surg. 1997;50:322–330. 26. Huger WE Jr. The anatomic rationale for abdominal li- 11. Barnhill RL, Bader DL, Ryan TJ. A study of uniaxial ten- pectomy. Am Surg. 1979;45:612–617. sion on the superficial dermal microvasculature. J Invest 27. Heitmann C, Felmerer G, Durmus C, et al. Anatomical Dermatol. 1984;82:511–514. features of perforator blood vessels in the deep in- 12. Tønseth K, Hokland B. Evaluation of microcirculation ferior epigastric perforator flap. Br J Plast Surg. and wound-closing tension after undermining the skin. 2000;53:205–208. A study in a porcine model using laser Doppler perfusion 28. Kikuchi N, Murakami G, Kashiwa H, et al. Morphometrical imaging. Eur J Plast Surg. 2004: 27: 295–97. study of the arterial perforators of the deep inferior 13. Hunt TK, Hopf H, Hussain Z. Physiology of wound heal- epigastric perforator flap. Surg Radiol Anat. 2001;23: ing. Adv Skin Wound Care. 2000;13(2 Suppl):6–11. 375–381. 14. Blondeel PN, Landuyt KHV, Monstrey SJ. Surgical- 29. Mayr M, Holm C, Höfter E, et al. Effects of aesthetic ab- technical aspects of the free DIEP flap for breast recon- dominoplasty on abdominal wall perfusion: a quantitative struction. Oper Tech Plast Reconstruct Surg. 1999: 6: 27–37. evaluation. Plast Reconstr Surg. 2004;114:1586–1594. 15. Bornmyr S, Mårtensson A, Svensson H, et al. A new device 30. Ribuffo D, Marcellino M, Barnett GR, et al. Breast recon- combining laser Doppler perfusion imaging and digital struction with abdominal flaps after abdominoplasties. photography. Clin Physiol. 1996;16:535–541. Plast Reconstr Surg. 2001;108:1604–1608.

7

II

ORIGINAL ARTICLE Breast Donor-Site Morbidity After DIEAP Flap Breast Reconstruction—A 2-Year Postoperative Computed Tomography Comparison

Christoffer Aam Ingvaldsen, MD*† Gerhard Bosse, MD‡ Background: The study was undertaken to provide a more complete picture of do- Georg Karl Mynarek, MD‡ nor-site morbidity following the deep inferior epigastric artery perforator (DIEAP) Thomas Berg, MD, PhD*† flap harvest in breast reconstruction. Most studies evaluating this subject have been Tyge Tind Tindholdt, MD, PhD*† performed using ultrasonography. Computed tomography (CT) might provide Kim Alexander Tønseth, MD, valuable information. PhD*†§ Methods: In 14 patients who were reconstructed with a DIEAP flap, donor-site morbidity was assessed by comparing routine preoperative CT abdomen with CT abdomen performed 2 years postoperatively. The anteroposterior diameter and transverse diameter (TD) of the rectus muscle were measured bilaterally within 4 standardized zones. Diastasis recti abdominis (DRA) was measured in the same zones. The abdominal wall was assessed for hernias, bulging, and seromas. Results: The operated rectus muscle had a significantly increased anteroposterior diameter in 2 zones and decreased TD in 1 zone compared with preoperative mea- surements. Comparing the operated and nonoperated rectus muscles, the former had a significantly decreased TD in 1 zone. Supraumbilical DRA was significantly decreased with surgery, whereas infraumbilical DRA was significantly increased. No new hernias or bulging were found. Two patients had seroma formation in the abdominal wall. Conclusions: Symmetry of the 2 hemiabdomens is well preserved after DIEAP flap harvest; however, significant changes to the rectus muscles and DRA were ob- served. Hernia formation does not seem to be a postoperative complication of importance. The study indicates that DIEAP flaps result in limited donor-site mor- bidity, which for most patients does not outweigh the benefits of free perforator flap breast reconstruction. (Plast Reconstr Surg Glob Open 2017;5:e1405; doi: 10.1097/ GOX.0000000000001405; Published online 25 July 2017.)

INTRODUCTION and aesthetic defects at the donor-site.2–6 Moreover, the The deep inferior epigastric artery perforator (DIEAP) growing trend toward bilateral breast reconstruction flap is currently the first choice for both unilateral and has made it necessary to preserve the integrity of the ab- bilateral autogenous breast reconstruction.1 Its benefit of dominal wall.7 Most of the strength and stability of the ab- minimizing donor-site morbidity is ever more relevant as dominal wall is derived from the paired rectus abdominis increasingly emphasis is put on reducing the functional muscles and the anterior and posterior rectus sheaths. The harvest of an abdominal flap implicitly violates the From the *Department of Plastic and Reconstructive Surgery, integrity of these structures, which may result in asymme- Rikshospitalet, Oslo University Hospital, Norway; †Institute for try, bulging, and hernia formation.5 Several studies have Surgical Research, Oslo University Hospital, Norway; ‡Department shown, however, that the DIEAP flap reduces the donor- of Radiology, Rikshospitalet, Oslo University Hospital, Norway; site morbidity compared with other free flaps harvested and §Faculty of Medicine, University of Oslo, Norway. from the abdomen.3,4,6,8 Man et al.4 reported half the risk Received for publication December 21, 2016; accepted May 16, of abdominal bulging and hernias comparing DIEAP 2017. flaps to free transverse rectus abdominis myocutaneous Copyright © 2017 The Authors. Published by Wolters Kluwer Health, flaps. Furthermore, 2 meta-analyses evaluating abdominal Inc. on behalf of The American Society of Plastic Surgeons. This is bulging and hernia formation demonstrated that these an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the Disclosure: The authors have no financial interest to work provided it is properly cited. The work cannot be changed in declare in relation to the content of this article. The Article any way or used commercially without permission from the journal. Processing Charge was paid for by the authors. DOI: 10.1097/GOX.0000000000001405

www.PRSGlobalOpen.com 1 PRS Global Open • 2017 complications are reduced in DIEAP flap reconstructions muscle dissection was performed in a longitudinal, fascia- compared with transverse rectus abdominis myocutane- sparing manner, and all segmental motor branches of the ous flap.3,4 intercostal nerves were carefully preserved. Inevitably, With regard to the postoperative changes to the paired some small motor nerves were disrupted during the dis- rectus bellies, the literature is more conflicting. Some stud- section of intramuscular perforators. Such severed nerves ies have reported that the morphological and functional were not repaired by microsurgical coaptation due to their changes to the rectus muscles are minimal,9,10 whereas oth- size. Nine patients had 1 perforator, whereas the remain- ers have reported significant differences concerning con- ing 5 patients had 2 perforators included in the flap. Eight tractility6,8,11 and structure.12 flaps were based on medial perforators, 4 flaps on lateral The aim of this study was to further assess the donor- perforators, and the remaining 2 flaps had 1 perforator site morbidity following the DIEAP flap breast reconstruc- from each row. In all cases, the muscle was split longitudi- tion. We wanted to evaluate the long-term effects of the nally from the level of the perforator and as far inferiorly flap harvest on the abdominal wall with a focus on the rec- as necessary to divide the pedicle safely. A single myotomy tus muscles, hernia, and diastasis recti abdominis (DRA). was made and no rectus muscle was divided. Among the 5 No previous studies have assessed if there are dimensional flaps with 2 perforators, however, 1 dissection required 2 changes of the DRA—also called abdominal separation. myotomies, and the rectus muscle was partially divided in We chose to use computed tomography (CT) in assess- 2 cases. If the chosen perforator(s) appeared to be satis- ing the abdominal wall. This modality enables the scru- factory, the pedicle was transected and the flap was trans- pulous evaluation of structural components (directly or ferred to the recipient site. No anterior rectus fascia was indirectly) affected. As most previous anatomical studies harvested. Microanastomosis was performed end-to-end have been performed by the use of ultrasonography,6,10,12 to the internal mammary vessels in all cases. Concurrent we believe that the use of CT provides complementary in- to the flap replacement on the thorax, the donor defect formation to the discussion. was closed by the second team of surgeons. By using the fascia-sparing technique, primary fascial closure was rou- METHODS tinely achieved with polydioxanone (PDS 0) running su- ture. There was no use of synthetic or bioprosthetic mesh This prospective clinical study included 14 women to reinforce the fascia. Since no fascia was removed, no who underwent secondary unilateral breast reconstruc- tightening of the contralateral anterior rectus sheath for tion with a DIEAP flap. All patients had undergone mas- symmetrizing the umbilicus was performed. Upon intra- tectomy as a result of cancer. Patient details are listed in operative evaluation, 1 patient had a supraumbilical and Table 1. The patients were informed about the risks and umbilical DRA of 27 and 51 mm, respectively. A DRA plica- benefits and gave written consent before participation. tion was performed in this patient. No DRA plication was The study was registered and published in the Clinical- performed in any other patients. The surgeons did not Trials.gov database (ID number: NCT02563977), and the perform progressive tension sutures to promote the ad- research protocol was approved by the local Ethical Com- herence between the donor flap and the abdominal wall; mittee (REK; reference no. S-07071a) however, the operating bed was jack-knifed to prevent ten- sion. Two 18 French drains were placed in the donor-site Surgical Technique and later removed when the production volume of each A standard DIEAP flap procedure as described by drain was less than 30 cc per day. Blondeel et al.13 was performed. Surgery was carried out at the donor and recipient site by 2 teams of plastic surgeons Preoperative CT Angiography of the Abdominal Wall simultaneously. The presumed best perforator was dissect- Per standard protocol, all DIEAP flap patients un- ed from the level of the anterior rectus fascia to the en- derwent preoperative CT angiography to delineate the trance of the deep inferior epigastric vessels on 1 side. The topography of the perforators. The scans covered the abdominal wall from the second lumbar vertebra to the Table 1. Patient Details (N = 14) pubic symphysis. They were performed in supine position, and the patient was instructed not to contract the abdomi- Age at reconstruction (y), 53.2 (4.6) (45.3–59.5) Preoperative BMI (kg/m2), 25.6 (2.7) (21.1–30.3) nal muscles. The scans were contrast enhanced with 90 cc Previous surgery to the abdomen, n (%) iomeprol (Iomeron 350 mg Iodine/ml, Bracco Imaging, None, 11 (78) Milano, Italy) and with 50 cc saline flush at a flow rate of Cesarean section, 2 (14) Laparoscopy, 2 (14) 5.5 cc/sec. Laparotomy, 0 (0) Smoking, n (%) Two Year Postoperative CT of the Abdominal Wall Nonsmoker, 9 (64) Former smoker, 4 (28) The postoperative CT scans were performed as close Stopped smoking minimum 6 weeks before reconstruction, 1 (7) to 2 years after the breast reconstruction as possible. Mean Adjuvant therapy, n (%) follow-up time was 23.5 months (range, 19–26). These Chemotherapy, 12 (85) Radiotherapy, 12 (85) scans covered more of the abdominal wall—starting from Hormone, 11 (78) the xiphoid process to pubic symphysis. We chose to extend Data are described as means (SD) (minimum–maximum) or number of the postoperative scan length to be able to assess the most patients (percentages). cranial aspects of the abdominal wall. Postoperative CT

2 Ingvaldsen et al. • Donor-Site Morbidity after DIEAP Flap Breast Reconstruction scans were noncontrast enhanced and acquired with the dial fascia end of the contralateral rectus belly. Figure 2 illus- same image parameters as preoperative scans to achieve trates preoperative and postoperative measurements of APD, identical image sets. Iodine contrast media enhancement TD, DRA, and fat layer in all 4 zones of the same patient. was found avoidable, due to the relatively high attenuation Figures 3, 4 are the anterior abdominal wall of the 2 zones of difference (Hounsfield units) between muscle and fat in greatest interest (zones B and C) in another patient. Further- CT scans done both with and without intravenous contrast more, the radiologists meticulously assessed the abdominal enhancement. Furthermore, iodine contrast media en- wall for other signs of donor-site morbidity such as hernias, hancement is generally low in both fat and muscle tissue— bulging, seromas, and hematomas. In some patients, the especially in CT angiography scans. Hence, there is little radiologists also reported skeletal metastasis, (unspecified) influence on the visualization and size of the evaluated liver lesions, and a splenic artery aneurysm. Such findings structures between the preoperative and the postopera- were carefully followed up with applicatory diagnostic tests tive CT scans. Based on these aspects, there was no indica- and reported to the patients and their general physicians/ tion for the use of contrast enhancement on postoperative oncologists. All additional findings are listed in Table 2. scans—potentially putting the patients at risk of its adverse effects. All scans were in the supine position, and each pa- Statistical Analysis tient was told not to contract the abdominal muscles. Descriptive statistics are presented using means (SD) and number of patients (percentage) if not otherwise stated. Com- CT Systems and Further Specifications parisons of related samples were performed with nonparamet- All 28 scans were done on multidetector CT systems. ric Wilcoxon Sign Rank test, whereas Mann-Whitney U test was The majority of the CT scans (24 of 28) were performed used to compare independent samples. Pearson’s correlation on a 64-row system (Light speed CT, GE Healthcare, Chi- tests were conducted to calculate the association between (1) cago). Four scans were performed on a 320-row CT system DRA and rectus muscle changes and (2) DRA changes and (Aquilion ONE, Toshiba Medical Systems, Japan) due to BMI/age. Body mass index (BMI) is defined as the body mass availability of machines. These 4 scans were performed on (kg) divided by the square of the body height (m). 4 different patients (3 preoperative scans and 1 postopera- The single patient who had a DRA plication done was tive scan). Scan parameters for the 64-row CT system were excluded from all analysis including DRA measurements. 64 × 0.625 mm, 120 kV, 250–750 mA, pitch 0.984, rotation We accepted P values of less than 0.05 as statistically signifi- time 0.5 sec, noise index 24, Adaptive Statistical Iterative Re- cant. IBM SPSS Statistics 21 (IBM, Armonk, N.Y.) was used construction 30%. Images were consecutively reconstructed for statistical analysis. with 2.5 mm axial, coronal, and sagittal and 1 mm axial (mul- tiplanar reconstruction) images. Scan parameters for the 320-row CT system were 80 × 0.5 mm, 120 kV, 100–580 mA, RESULTS rotation time 0.5 sec, SD 7.5, sure exposure 3D and Adap- Selections of results are listed in Tables 3–6. All data tive Iterative Dose Reduction 3D. Images were consecutively are calculated using the mean of the 2 numbers recorded reconstructed with 2 mm axial, coronal, and sagittal and by each radiologist. 1 mm axial (multiplanar reconstruction) images. Mean dose length product was 625.46 mGy-cm and mean effective dose Rectus Muscle Changes estimated to 11.26 mSv based on conversion factor 0.018. On postoperative CT, the operated rectus muscle had a significantly increased APD in zones B and C and de- Standardized Zones creased TD in zone D compared with preoperative mea- Four zones, named zones A–D, covering transverse sec- surements of the same rectus muscle (Tables 3, 4). There tions of the abdominal wall were standardized in the study. were no significant results comparing pre- and postopera- Zone A: 5 cm cranial to the umbilicus. Zone B: umbilical tive APD and TD of the nonoperated rectus muscle. For level. Zone C: central zone (midway between zones B and that reason, these data are not included in the article. D). Zone D: 5 cm cranial to the pubic symphysis. Figure 1 Comparing the operated and nonoperated rectus illustrates the location of each zone. muscles on the postoperative CT scans, the former had a significantly decreased TD in zone C (Table 5). Radiological Assessment The nonparametric Mann-Whitney U tests showed no Two full sets of measurement data were recorded sepa- significant results comparing APD and TD changes in rately by 2 consulting radiologists. They were blinded to the flaps based on either (1) 1 perforator versus 2 perforators numbers recorded by their colleague and the side of surgery or (2) medial row perforator versus lateral row perforator. (although microvascular clips left behind easily revealed the operated side). Findings in each hemiabdomen were re- DRA Changes corded according to the 4 standardized zones described and We found a significantly decreased DRA in zone A (su- illustrated below. The following 3 anatomical features were praumbilical) and significantly increased DRA in zones C measured bilaterally: (1) anteroposterior diameter (APD) of and D (infraumbilical). Data are listed in Table 6. the rectus muscle, (2) transverse diameter (TD) of the rectus muscle, and (3) fat layer thickness (largest anteroposterior Correlation Tests measurement). DRA was measured in the midline in each There was no statistically significant correlation be- zone—from the medial fascia end of 1 rectus belly to the me- tween (1) DRA and rectus muscle changes or (2) DRA

3 PRS Global Open • 2017

Fig. 1. Illustration of the 4 standardized zones. Zone A: 5 cm cranial to umbilicus. Zone B: umbilical level. Zone C: central zone (midway between zones B and D). Zone D: 5 cm cranial to pubic symphysis. changes and BMI/age. BMI and age, however, were strong- the seromas. Therefore, no further surgical management ly correlated where older patients had a significantly lower was initiated by the plastic surgeons. BMI (R = ˗0.76; P value = 0.003). DISCUSSION Other Abdominal Wall Changes To date, only 1 study has investigated the donor-site The fat layer thickness was decreased in all zones post- morbidity after DIEAP flap breast reconstruction using operatively, being significantly thinner in zones A–C on 8 both operated and nonoperated side. Comparing the postoperative CT. Blondeel et al. scanned 12 patients 1 postoperative fat layer of the 2 hemiabdomens, no signifi- year postoperatively to compare the cross-sectional areas cant differences were observed (Table 5). of the rectus muscles. All measurements were performed As listed in Table 2, 1 patient had both an umbilical and at the level of the umbilicus, which equals zone B outlined an epigastric hernia on the postoperative CT scan. These in our study. Their results demonstrated a minor change, hernias had, however, no interval change in the size of the whereby 10 of 12 patients had less than 5% atrophy on fascial defect or the hernia sac. Signs of incarceration or the operated side compared with the nonoperated side. strangulation were not noted, and the patient reported no Similarly, we did not detect any significant difference in discomfort. There was no radiographically apparent post- APD or TD of the operated rectus belly at the umbilical operative hernia among the remaining patients. level. Only the TD in zone C proved to be significantly dif- Two patients had ellipsoidal seromas in their abdomi- ferent between operated and nonoperated side (Fig. 4). nal wall 2 years postoperatively (Fig. 3). These patients This could be an indicator of localized muscle atrophy have not had any further surgery to the abdominal wall where the pedicle has been harvested. Zone C is in fact since the DIEAP flap reconstruction. They did not report situated right inferiorly to where the majority of domi- any abdominal asymmetry, pain, or discomfort related to nant perforators are located.14,15 Muscle atrophy would

4 Ingvaldsen et al. • Donor-Site Morbidity after DIEAP Flap Breast Reconstruction

Fig. 2. Preoperative (left) and postoperative (right) measurements of all 4 zones. Left being the operated side. Measure- ments in millimeters. A and B) Zone A. C and D) Zone B. E and F) Zone C. Note the increased postoperative APD on the operated side. G and H) Zone D.

5 PRS Global Open • 2017

Fig. 3. Preoperative (A) and postoperative (B) measurements in Zone B. Right being the operated side. Measurements in millimeters. Note: (1) the increased postoperative APD on the operated side and (2) the seroma covering most of the anterior surface of the operated muscle belly.

Fig. 4. Preoperative (A) and postoperative (B) measurements in Zone C. Right being the operated side. Measurements in millimeters. Note: (1) the increased postoperative APD on the operated side, (2) the smaller TD on operated side versus nonoperated side, and (3) the increased postoperative DRA.

Table 2. Additional Findings on Postoperative CT Scan (N = 14)

Additional Finding N Applicatory Diagnostic Testing Comment Seroma 2 None No surgery/aspiration needed Hernia 1 None Two hernias (epigastric and umbilical) on same patient. Unchanged from preoperative CT Liver lesion 2 Ultrasound with contrast Both hemangiomas Splenic artery aneurysm 1 CT with contrast No surgery needed Skeletal metastasis 1 CT-guided biopsy Reported to oncologist develop inferior to the perforator location when injury to increased APD might be secondary to impaired venous/ the nerve and muscle happens due to pedicle dissection lymphatic drainage and scar formation caused by the in- progression. Despite this finding, all remaining data listed tramuscular perforator dissection. Venous stasis is thought in Table 5 indicate otherwise well-preserved symmetry of to occur when the deep inferior epigastric vein, a rather the paired rectus muscles. When comparing the operat- large caliber vessel, is separated from the muscle belly. ed rectus belly on postoperative scans to the same rectus In accordance with our data, Lee et al.10 assessed the rec- belly on preoperative scans, the former had a significantly tus muscle using ultrasonography and concluded that the increased APD in zones B and C (Figs. 2–4). No similar resting muscle thickness (APD) was significantly increased significant change is seen on the nonoperated side. The at 1 month postoperatively (P = 0.01). They measured APD

6 Ingvaldsen et al. • Donor-Site Morbidity after DIEAP Flap Breast Reconstruction

Table 3. Anteroposterior Diameter of Operated Rectus Muscle (N=14)

Zone A Zone B Zone C Zone D Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Minimum 4.0 6.0 8.0 8.0 7.0 8.5 5.0 5.0 Maximum 11.5 11.5 11.0 13.5 12.5 14.5 13.0 15.5 Mean 8.5 9.1 9.3 10.0 10.2 11.2 9.7 9.3 SD 1.9 1.7 1.5 1.4 1.7 2.0 2.3 2.6 P* 0.508† 0.044† 0.038† 0.207† All data in millimeters. Significance was taken at p < 0.05. *P values comparing preoperative and postoperative measurements within each zone. †Values are statistically significant.

Table 4. Transverse Diameter of Operated Rectus Muscle (N=14)

Zone A Zone B Zone C Zone D Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Minimum 59.5 49.5 51.0 49.0 56.0 51.5 23.0 22.0 Maximum 94.5 82.0 82.5 80.5 82.5 83.5 63.5 54.5 Mean 69.5 67.1 66.0 64.7 68.6 65.7 47.9 44.5 SD 10.0 9.6 9.4 7.7 7.9 9.1 9.8 8.6 P* 0.116† 0.363† 0.064† 0.035† All data in millimeters. Significance was taken at p < 0.05. *P values comparing preoperative and postoperative measurements within each zone. †Values are statistically significant.

Table 5. Comparison of Operated and Nonoperated Side on Postoperative CT Scan (N=14)

Zone A Zone B APD TD Fat Layer APD TD Fat Layer Side* OS NOS OS NOS OS NOS OS NOS OS NOS OS NOS Mean 9.1 8.9 67.1 69.6 18.4 18.4 10.0 9.9 64.7 65.1 18.0 18.6 P value† 0.398 0.140 0.776 0.673 0.60 0.422

Zone C Zone D Side* OS NOS OS NOS OS NOS OS NOS OS NOS OS NOS Mean 11.2 11.1 65.7 70.4 13.9 13.4 9.3 9.6 44.5 46.2 20.9 20.8 P value† 0.906 0.048† 0.293 0.636 0.208 0.969 All data in millimeters. Significance was taken at p < 0.05. *Side: OS, operated side; NOS, nonoperated side. †P values comparing postoperative measurements of operated and nonoperated side within each zone. ‡Values are statistically significant.

Table 6. Diastasis Recti Abdominis (N=13)

Zone A Zone B Zone C Zone D Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Minimum 7.5 4.0 19.5 15.0 0.0 0.0 0.0 0.0 Maximum 38.0 32.5 41.5 36.5 20.0 23.0 10.5 16.5 Mean 23.0 19.5 29.0 27.5 8.2 11.8 1.8 5.3 SD 8.6 8.6 7.8 7.4 5.7 7.1 3.4 5.6 *P value 0.036† 0.382† 0.030† 0.032† All data in millimeters. Significance was taken at p < 0.05. *P values comparing preoperative and postoperative measurements within each zone. †Values are statistically significant. of the rectus belly at 1 standardized point (using bony resonance imaging would be more preferable in address- landmarks) almost equivalent to our zone C. The authors ing these issues. Magnetic resonance elastography and ul- of the study also speculate whether this can be attributed to trasound elastography are other usable alternatives. a postoperative edema of the muscle caused by damage of Although some of our data indicate morphological local blood flow and lymphatic drainage. Contrary to our changes to the rectus bellies postoperatively—possibly rep- data, the same study reports that the increased APD was resenting localized atrophy (reduced TD) and/or chronic resolved at 1 year follow-up (P = 0.54), suggesting a more edema (increased APD) on the operated side—they do not transient muscle edema as the cause. Whether or not the tell anything about rectus muscle function. This issue has operated rectus belly suffers from chronic edema and/or not been sufficiently addressed in our study. Futter et al.9 scar formation are subjects of further research. Magnetic used an isokinetic dynamometer to compare DIEAP flap

7 PRS Global Open • 2017 patients and no surgery controls reporting insignificant and plastic surgeons.21 Importantly, a DRA is not a true differences (although there was a trend of reconstructed hernia and is not associated with a risk of strangulation.22 patients having lower eccentric and isometric abdominal Blondeel et al.8 have demonstrated that despite having flexion strength). Bottero et al.11 showed an analogous abdominal bulging after the flap harvest, none of the pa- muscle function reduction through their electromyo- tients experienced subjective complaints. Based on these graphic analysis comparing the operated and nonoperated publications and personal clinical experience, we do not rectus muscles. At 15 months follow-up, the mean activ- believe that DRA changes play a major role in donor-site ity of the operated muscle was 70% of the nonoperated morbidity and abdominal wall functioning. We suggest, muscle. We believe that the morphological changes docu- however, that plastic surgeons should tell patients that a mented in our study, in concert with such postoperative DIEAP flap reconstruction might cause DRA changes and muscle function studies, indicate that DIEAP flap harvest possibly shifts to abdominal contour. In addition, if repair causes some muscle morbidity. The changes documented, is to be undertaken, abdominal wall protrusion (and not however, are probably not limiting the patient in terms of the DRA itself) should be the prime indicator.17 During activities of daily living and regular exercise. the preoperative consultation, one should also add the Despite not performing a plication of the linea alba positive fact that no hernias or bulging were observed during the abdominoplasty, the DIEAP flap procedure on the postoperative CT scans. This also counts for the seems to cause several significant changes to the DRA. As dehisced anterior sheath repaired and the traumatized listed in Table 6, there are significant changes in 3 of 4 muscle. Hernia formation does not seem be a frequent zones. postoperative complication of DIEAP flaps, which must In zone A, the DRA is decreased in size (Fig. 2). As be seen as a great advantage comparing the outcomes of mentioned, only 1 patient had a DRA plication done who other abdominally based perforator flaps.3,4,6,8 was subsequently excluded for the analysis. The authors In summary, the study does demonstrate significant hypothesize, therefore, that the decreased DRA might be changes to the donor-site. In our opinion, however, these caused by the longitudinal tension generated when clos- changes could be seen as minimal and of minor clinical ing the abdominal defect: To achieve an adequate closure, relevance. The study does, in other words, indicate that the upper abdominal panniculus is undermined and mo- DIEAP flaps result in limited donor-site morbidity, which bilized several centimeters caudally. Due to the ellipsoidal for most patients does not outweigh the benefits of free shape of the donor defect, the tension is greater in the perforator flap breast reconstruction. midline compared with the lateral corners. Consequently, the closure might cause the upper abdominal tissue to be Christoffer Aam Ingvaldsen, MD Department of Plastic and Reconstructive Surgery pulled both caudally and medially and the supraumbilical Rikshospitalet Oslo University Hospital DRA is thought to tighten. In contrast, the DRA in zones Norway C and D increased significantly (Fig. 4). Initially, we be- Email: [email protected] and [email protected] lieved that the decreased TD of the operated rectus belly in the same zones was a plausible explanation of these DRA changes. There was, nevertheless, no statistically ACKNOWLEDGMENTS significant correlation between the structural changes of We want to express our gratitude to Dr. William Winter (MD, operated rectus muscle and DRA. The results of our cor- PhD, Department of Radiology at Vanderbilt University Medical relation tests make muscle atrophy through iatrogenic de- Center, Nashville) and Dr. Adam Seruga (MD, Department of nervation less likely the cause of increased infraumbilical Radiology at John Hunter Hospital, Newcastle, Australia) for DRA. Due to the relatively low sample size of the study, valuable comments. such hypothesis should however not be totally ruled out (type II errors). REFERENCES Alternatively, one can imagine that there is less sup- 1. Healy C, Allen RJ, Sr. The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap. J Reconstr port in the myoaponeurotic system in the lower abdomen Microsurg. 2014;30:121–125. and that zones C and D cover areas that are more suscep- 2. Chang EI, Chang EI, Soto-Miranda MA, et al. Comprehensive tible to abdominal wall laxity. We believe that a number of analysis of donor-site morbidity in abdominally based free flap factors contribute in increasing the infraumbilical DRA as breast reconstruction. Plast Reconstr Surg. 2013;132:1383–1391. this is where the abdominal wall integrity is violated the 3. Egeberg A, Rasmussen MK, Sørensen JA. Comparing the donor- most. The statistical tests performed simply do not yield a site morbidity using DIEP, SIEA or MS-TRAM flaps for breast re- single, conceivable cause. constructive surgery: a meta-analysis. J Plast Reconstr Aesthet Surg. When assessing these DRA measurements, one needs 2012;65:1474–1480. to keep in mind whether the radiographically measurable 4. Man LX, Selber JC, Serletti JM. Abdominal wall following free changes are of any clinical significance. DRA is described TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg. 2009;124:752–764. as a weakening of the linea alba, which can contribute 16–18 5. Nahabedian MY, Dooley W, Singh N, et al. Contour abnormali- in bulging of the abdominal wall. There is, however, ties of the abdomen after breast reconstruction with abdomi- a lack of agreement on when diastasis is pathologic, and nal flaps: the role of muscle preservation. Plast Reconstr Surg. 16 there is no universal agreement about the definition. It 2002;109:91–101. is known to be a prevalent condition, especially postpar- 6. Seidenstuecker K, Legler U, Munder B, et al. Myosonographic tum,19,20 and is regularly evaluated and treated by general study of abdominal wall dynamics to assess donor site morbidity

8 Ingvaldsen et al. • Donor-Site Morbidity after DIEAP Flap Breast Reconstruction

after microsurgical breast reconstruction with a DIEP or an ms-2 mography angiogram: does the standard deep inferior epigastric TRAM flap. J Plast Reconstr Aesthet Surg. 2016;69:598–603. artery perforator flap design include the dominant perforator? 7. Zendejas B, Moriarty JP, O’Byrne J, et al. Cost-effectiveness of Ann Plast Surg. 2014;72:670–673. contralateral prophylactic mastectomy versus routine surveil- 15. Bailey SH, Saint-Cyr M, Wong C, et al. The single dominant me- lance in patients with unilateral breast cancer. J Clin Oncol. dial row perforator DIEP flap in breast reconstruction: three- 2011;29:2993–3000. dimensional perforasome and clinical results. Plast Reconstr Surg. 8. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor 2010;126:739–751. site morbidity of free DIEP flaps and free TRAM flaps for breast 16. Akram J, Matzen SH. Rectus abdominis diastasis. J Plast Surg reconstruction. Br J Plast Surg. 1997;50:322–330. Hand Surg. 2014;48:163–169. 9. Futter CM, Webster MH, Hagen S, et al. A retrospective com- 17. Brauman D. Diastasis recti: clinical anatomy. Plast Reconstr Surg. parison of abdominal muscle strength following breast re- 2008;122:1564–1569. construction with a free TRAM or DIEP flap. Br J Plast Surg. 18. Rath AM, Attali P, Dumas JL, et al. The abdominal linea alba: an 2000;53:578–583. anatomo-radiologic and biomechanical study. Surg Radiol Anat. 10. Lee SJ, Lim J, Tan WT, et al. Changes in the local morphology of 1996;18:281–288. the rectus abdominis muscle following the DIEP flap: an ultraso- 19. Sperstad JB, Tennfjord MK, Hilde G, et al. Diastasis recti abdomi- nographic study. Br J Plast Surg. 2004;57:398–405. nis during pregnancy and 12 months after childbirth: preva- 11. Bottero L, Lefaucheur JP, Fadhul S, et al. Electromyographic lence, risk factors and report of lumbopelvic pain. Br J Sports Med. assessment of rectus abdominis muscle function after deep 2016;50:1092–1096. inferior epigastric perforator flap surgery. Plast Reconstr Surg. 20. Fernandes da Mota PG, Pascoal AG, Carita AI, et al. Prevalence 2004;113:156–161. and risk factors of diastasis recti abdominis from late pregnancy 12. Tønseth KA, Günther A, Brabrand K, et al. Ultrasonographic to 6 months postpartum, and relationship with lumbo-pelvic evaluation of the rectus abdominis muscle after breast recon- pain. Man Ther. 201;20:200–205. struction with the DIEP flap. Ann Plast Surg. 2005;54:483–486. 21. Kulhanek J, Mestak O. Treatment of umbilical hernia and 13. Blondeel PN, Landuyt KHV, Monstrey SJ. Breast reconstruction recti muscles diastasis without a periumbilical incision. Hernia. surgical-technical aspects of the free DIEP flap for breast recon- 2013;17:527–530. struction. Operat Tech Plas Reconstr Surg 1999: 6: 27–37. 22. Hickey F, Finch JG, Khanna A. A systematic review on the 14. Saad A, Rebowe RE, Hogan ME, et al. Localization of the domi- outcomes of correction of diastasis of the recti. Hernia. nant deep inferior epigastric artery perforator by computed to- 2011;15:607–614.

9 ERRATUM

Donor-Site Morbidity After DIEAP Flap Breast Reconstruction—A 2-Year Postoperative Computed Tomography Comparison: Erratum

In the article by Ingvaldsen et al (Donor-Site Morbid- symbol. The corrected tables, as they should have ap- ity After DIEAP Flap Breast Reconstruction—A 2-Year peared, are shown here. Postoperative Computed Tomography Comparison. Plast REFERENCE Reconstr Surg Glob Open 2017;5(7):e1405. DOI: 10.1097/ Ingvaldsen CA, Bosse G, Mynarek GK, Berg T, Tindholdt TT, Tønseth KA. GOX.0000000000001405), in Tables 3, 4, and 6, some Donor-site morbidity after DIEAP flap breast reconstruction—a 2-year data were erroneously marked as significant. Also, in postoperative computed tomography comparison. Plast Reconstr Surg Table 5, a datum was marked with an incorrect footnote Glob Open 2017;5(7):e1405. DOI: 10.1097/GOX.0000000000001405

Table 3. Anteroposterior Diameter of Operated Rectus Muscle (N=14) Zone A Zone B Zone C Zone D Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Minimum 4.0 6.0 8.0 8.0 7.0 8.5 5.0 5.0 Maximum 11.5 11.5 11.0 13.5 12.5 14.5 13.0 15.5 Mean 8.5 9.1 9.3 10.0 10.2 11.2 9.7 9.3 SD 1.9 1.7 1.5 1.4 1.7 2.0 2.3 2.6 P* 0.508 0.044† 0.038† 0.207 All data in millimeters. Significance was taken at p < 0.05. *P values comparing preoperative and postoperative measurements within each zone. †Values are statistically significant. Table 4. Transverse Diameter of Operated Rectus Muscle (N=14) Zone A Zone B Zone C Zone D Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Minimum 59.5 49.5 51.0 49.0 56.0 51.5 23.0 22.0 Maximum 94.5 82.0 82.5 80.5 82.5 83.5 63.5 54.5 Mean 69.5 67.1 66.0 64.7 68.6 65.7 47.9 44.5 SD 10.0 9.6 9.4 7.7 7.9 9.1 9.8 8.6 P* 0.116 0.363 0.064 0.035† All data in millimeters. Significance was taken at p < 0.05. *P values comparing preoperative and postoperative measurements within each zone. †Values are statistically significant.

Table 5. Comparison of Operated and Nonoperated Side on Postoperative CT Scan (N=14) Zone A Zone B APD TD Fat Layer APD TD Fat Layer Side* OS NOS OS NOS OS NOS OS NOS OS NOS OS NOS Mean 9.1 8.9 67.1 69.6 18.4 18.4 10.0 9.9 64.7 65.1 18.0 18.6 P value† 0.398 0.140 0.776 0.673 0.60 0.422 Zone C Zone D Side* OS NOS OS NOS OS NOS OS NOS OS NOS OS NOS Mean 11.2 11.1 65.7 70.4 13.9 13.4 9.3 9.6 44.5 46.2 20.9 20.8 P value† 0.906 0.048‡ 0.293 0.636 0.208 0.969 All data in millimeters. Significance was taken at p < 0.05. *Side: OS, operated side; NOS, nonoperated side. †P values comparing postoperative measurements of operated and nonoperated side within each zone. ‡Values are statistically significant. Table 6. Diastasis Recti Abdominis (N=13) Zone A Zone B Zone C Zone D Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Minimum 7.5 4.0 19.5 15.0 0.0 0.0 0.0 0.0 Maximum 38.0 32.5 41.5 36.5 20.0 23.0 10.5 16.5 Mean 23.0 19.5 29.0 27.5 8.2 11.8 1.8 5.3 SD 8.6 8.6 7.8 7.4 5.7 7.1 3.4 5.6 *P value 0.036† 0.382 0.030† 0.032† All data in millimeters. Significance was taken at p < 0.05. *P values comparing preoperative and postoperative measurements within each zone. †Values are statistically significant.

www.PRSGlobalOpen.com 1 III

1 declare declare = 0.016) = 0.016) P Breast As such, the 1 and an increased 2,3 The increased risk of 4–6 = 0.009), and there was a trend = 0.009), and there was a trend P

The authors have no financial interest to The authors have no financial interest 3,7 = 0.003) than DIEAP patients. There was no sig- = 0.003) than DIEAP patients. There P Due to the differences in operative technique, unwant- The DIEAP flap abdominoplasty, however, varies in however, The DIEAP flap abdominoplasty, in relation to the content of this article. to the in relation The Article Processing Charge was paid for by the authors. Disclosure: ORIGINAL ARTICLE ORIGINAL risk of venous thromboembolism. proposed benefits of the DIEAP flap AP may not be as genuine as frequently suggested in literature and during ed aesthetic outcomes (eg, visible scar, lateral displace- ed aesthetic outcomes (eg, visible scar, ment of the umbilicus, and dog ears) are more commonly observed after DIEAP flap procedures. venous thromboembolism is suggested to be caused by the high intraabdominal pressure generated by rectus plica- tion, which is shown to interfere with lower extremity ve- nous return. several ways compared with the routine steps of an AP: several ways compared with the routine First, one does not usually perform liposuction due to Second, the extent of um- the risk of perforator injury. bilical surgery on the varies in DIEAP flaps depending need to incorporate paraumbilical perforators. Third, rectus plication is not frequently undertaken—being both time-consuming and associated with postoperative com- plications such as respiratory distress (Plast Reconstr Surg Glob Open 2018;6:e1876; doi: 10.1097/ (Plast Reconstr Surg Glob Open 2018;6:e1876; The dermolipectomy of the deep inferior epigastric artery The dermolipectomy perforator DIEAP flap patients were equally as satisfied with the abdo- DIEAP flap patients were equally Thirty-four patients reconstructed with a DIEAP flap (DIEAP group), reconstructed with a DIEAP flap Thirty-four patients The DIEAP group was significantly older compared with the AP group. older compared with the AP group. The DIEAP group was significantly = 0.085). No significant difference was found comparing outcomes con- = 0.085). No significant difference more altered body image ( = 0.044). AP patients had a significantly P P of DIEAP patients being more satisfied with the appearance of the abdomen with the appearance of the abdomen of DIEAP patients being more satisfied ( The DIEAP pain, scarring, and contour. cerning umbilicus, muscle function, health than the AP group postoperatively group was more worried about their ( in self-image, social relationships, being nificant difference regarding changes and overall satisfaction. naked with partner, Conclusion: men as AP patients. Background: as seen with abdomino- is designed to give an end result (DIEAP) flap procedure not routinely performed. This steps of an AP are, however, plasty (AP). Several these 2 procedures with patient-reported outcomes between study compared the abdomen. an emphasis on the Methods: complete 2 study-specific an AP (AP group) were asked to and 30 patients with covered abdominal outcomes, whereas the questionnaires. The first questionnaire second was concerned with general outcomes. Results: group and 66 % of the AP group answered Eighty-five percentage of the DIEAP the DIEAP group was significantly more the questionnaires. Postoperatively, ( satisfied with their bodies when dressed and increased sexual desire ( 8 August 2018.) GOX.0000000000001876; Published online MD*† PhD*† PhD*†‡ reported that having a simultaneous 1 INTRODUCTION

Tyge Tind Tindholdt, MD, Tind Tindholdt, Tyge Christoffer Aam Ingvaldsen, Christoffer Aam Ingvaldsen,

Kim Alexander Tønseth, MD, Kim Alexander Tønseth, Breast reconstruction with deep inferior epigastric arteryBreast reconstruction with deep inferior Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Copyright © 2018 The Authors. Published by Wolters Inc. on behalf of The American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Derivatives License 4.0 Commons Attribution-Non Commercial-No the it is permissible to download and share where (CCBY-NC-ND), cited. The work cannot be changed in it is properly work provided the journal. without permission from any way or used commercially From the *DepartmentFrom of Plastic and Reconstructive Surgery, Rikshospitalet, Oslo University Hospital, Norway; †Institute for Oslo University Hospital, Norway;Surgical Research, and ‡Faculty of Medicine, University of Oslo, Norway. Received for publication December 6, 2017; accepted May 30, 2018. DOI: 10.1097/GOX.0000000000001876 www.PRSGlobalOpen.com

Abdomen as Abdominoplasty Patients as Abdominoplasty Abdomen DIEAP Flap Patients Equally as Satisfied with the with as Satisfied Equally Patients Flap DIEAP AP was the main reason of choosing a DIEAP flap recon- struction in 40 % of their patient group. The secondary ben- efits of the AP are, in other words, of major importance in terms of the patients’ reconstruction preferences and goals. perforator (DIEAP) flap is commonly presented as a two- in-one procedure reflecting the abdominoplasty (AP) per- formed. Niddam et al.

'RZQORDGHG IURP KWWSVMRXUQDOVOZZFRPSUVJR E\ %K'0IH3+.DY](RXPW4I1DN-/K(=JEV,+R;0LK&\Z&;$:Q<4S,O4U+'\5O;J9=$V

Study Design The preoperative markings of the DIEAP flap varied The retrospective and questionnaire-based study com- slightly according to the location of key perforators, which pared patient-reported outcomes between DIEAP flap were planned to be incorporated. Most of the time the cra- and AP patients. Both groups underwent surgery with the nial incision was placed at the perimeter of or above the same department. umbilicus. The caudal incision was positioned in the su- We provided information regarding the scope of the prapubic crease—approximately 12–13 centimeters below study and obtained written consent from all participants. the cranial incision. The incisions were extended laterally The study was registered and published in the ClinicalTri- to the anterior superior iliac spine on both sides to make a als.gov database (ID number: NCT03209167). symmetric, elliptical flap in the hypogastrium. After dissecting the DIEAP flap with its perforators, Patients undermining of the upper abdominal panniculus was per- DIEAP Flap Patients (DIEAP Group) formed to the level of the xiphoid process and along the A group of 34 consecutive, unilateral DIEAP flap breast costal margin. We did not use any infiltration. Nor was any reconstructed patients were recruited to the study. All pa- liposuction done in the abdominal flap. Primary fascial clo- tients had undergone mastectomy due to breast cancer. sure was routinely achieved using polydioxanone suture Bilateral breast reconstructions and DIEAP flaps used in (PDS) 0 running suture. No fascia was harvested in any of nonbreast reconstructions were excluded. the patients, and no mesh was needed to reinforce the de- fect (except from 1 patient who had multiple fascia incisions AP Patients (AP Group) during the perforator dissection and consequently needed a A group of 30 patients who had undergone AP with polypropylene mesh to prevent hernia formation). Tighten- transposition of the umbilicus served as control group. All ing of the contralateral anterior sheath was not performed. patients had a lipocutaneous overhang of the abdomen None of the patients had a rectus plication done. The new with a minimum of 2 centimeters. umbilicus was externalized at a level equivalent to its natural The comparisons of baseline characteristics are shown position. A selective defatting at the exit-site was performed in Table 1. to achieve a natural umbilical depression. The donor defect was closed in 3 layers (Scarpa’s fascia, deep dermally and Surgical Technique intracutaneously), which is believed to reduce dermis ten- DIEAP Flap Breast Reconstruction sion and risk of wound disruption.11–13 The skin edges were A standard DIEAP flap procedure as described by approximated in a lateral-to-medial fashion, and pleating Blondeel et al.10 was performed. A 2-team approach (do- of the abdominal flap was performed to prevent dog ears. nor- and recipient-site) was carried out to reduce opera- Progressive tension sutures were not applied. Two closed- tive time. In the following text, we describe the abdominal system suction drains (18 French) were used. Compression wall surgery in detail: garment was used for 4—6 weeks postoperatively.

2 Ingvaldsen et al. • Abdominoplasty Outcomes in DIEAP Flap Reconstruction

Abdominoplasty Eighty-five percentage (29/34) of the DIEAP group The AP was performed in supine position under gen- and 66 % (20/30) of the AP group answered the question- eral anesthesia. Tumescent liposuction was performed in naires. most patients. The liposuction was routinely done in the Seventy-five percentage (15/20) of the AP group and flanks and upper abdomen, and in the lower abdomen 0% (0/29) of the DIEAP group had a liposuction done. (caudal to the flap) if this was found necessary. The mean removed fat volume in the AP group was 601 cc After completing the liposuction, the lower abdominal (SD, 287 cc; minimum 100 cc; maximum 1,000 mL). The segment was incised curvilinearly from the right anterior mean total flap weight in the AP group was 1,400 g (SD superior iliac spine to its contralateral counterpart. The 756 g; minimum 670 g; maximum 3,500 g). The mean total incision was placed 5–7 cm superior to the anterior com- flap weight in the DIEAP group was 1,038 g (SD, 308 g; missure and carried through to the level of deep fascia. minimum 410 g; maximum, 1,580 g). Like the DIEAP flap procedure, cranial undermining of One of the AP patients required a reoperation within 1 the panniculus was performed to the level of the xiphoid week, whereas none of the DIEAP patients needed a reop- process and along the costal margin. Meanwhile under- eration due to donor-site complication(s). The mean fol- mining the panniculus, the umbilicus was incised ovally low-up time was rather similar—being 2.4 years in DIEAP and its stalk freed. The excess panniculus was excised, group and 2.2 years in AP group. and the wound was closed temporarily with clamps. The In terms of abdominal outcomes (Table 2), no signifi- new umbilical position was marked and incised to fit the cant differences were found. Comparisons of the groups underlying umbilicus. The umbilical stalk was later identi- yielded insignificant P values concerning the appearance fied, pulled through the opening, and sutured in place. of the umbilicus, muscle function, pain, scarring, and Rectus plication was performed in a small number of pa- contour. There was, however, a trend of DIEAP patients tients who had a significant rectus diastasis with abdomi- being more satisfied with the overall appearance of the nal bulging preoperatively. The skin was closed in a similar abdomen (P = 0.085). Patients self scored their grade of fashion as in the DIEAP procedure. satisfaction from 1 to 10 (with 1 being “very dissatisfied” Finally, 2 closed-system suction drains (18 French) and 10 being “very satisfied”). The DIEAP group had an were placed under the flap. No progressive tension su- average score of 7.7, whereas the AP group had an average tures were used. Compression garment was used for 4–6 of 6.7. Similarly, 59 % (17/29) of the DIEAP patients were weeks postoperatively. more satisfied with the appearance of the abdomen after surgery compared with 50% (10/20) of the AP patients. Questionnaire These numbers did not, however, generate a significant P All patients received 2 study-specific questionnaires: value with ordinal test analysis. 1 of the questionnaires covered abdominal outcomes, In our comparisons of general outcomes (Table 3), whereas the second was concerned with general outcomes. DIEAP patients were more satisfied with their bodies when Both questionnaires had questions with dichotomous dressed (P = 0.009). Postoperatively, only 4% (1/29) of (“yes” or “no”), ordinal (eg, “less,” “unchanged,” “more”) the DIEAP patients were dissatisfied with her body when or numerical (eg, 1–10) answer alternatives. We piloted dressed, whereas dissatisfaction was noted among 35% the questionnaires in 5 patients. This acted as a control (7/20) of the AP patients. On the other hand, the DIEAP measure for language, understanding and difficulty in an- patients were significantly more worried about their health swering the various questions. Patients did not report any after surgery compared with the AP group (P = 0.031). AP misunderstanding. We sent nonrespondents a reminder. patients reported a significantly more altered body image (P = 0.016) and increased sexual desire (P = 0.003) after Statistical Analysis surgery. There was no significant difference regarding Descriptive statistics are presented using mean ± SD change of self-image, social relationships, being naked with and number (%). Ordinal data were compared using partner (meaning how the woman herself feels about be- Ordinal Test (Gamma). In addition, cross-tabulation was ing seen naked by partner), and overall satisfaction. Similar performed to conduct Fisher’s exact test (with Freeman- numbers of DIEAP flap and AP patients would have gone Halton Extension) as appropriate. Dichotomous data through the same operation again (97% versus 100%) and were analyzed using Mann-Whitney U test. Comparisons recommended the operation to other patients (93% versus of numerical data were done using independent t test and 95%). Moreover, the number of patients being overall satis- Mann-Whitney U test—primarily the latter due to low sam- fied with the operation (97% versus 85%) and preoperative ple size and lack of normality. We chose a 5% significance counseling (90% versus 79%) were insignificantly different. level. P values between 5% and 10% were interpreted as trends. The Statistical Package for the Social Sciences ver- sion 25.0 (IBM, Armonk, NY) was used. DISCUSSION This is the very first study that compared patient-report- RESULTS ed abdominoplasty outcomes between DIEAP flap and AP Table 1 lists the baseline characteristics of both groups. surgery. Overall, the data presented suggest equivalence There was an age difference of a decade between the mean between the procedures. Before drawing a conclusion, age within the DIEAP group (51.8 years; SD, 6.1) versus however, the following limitations with our study must be the mean age within the AP group (41.8 years; SD, 10.1). considered:

3 PRS Global Open • 2018

Table 2. Abdominal Outcomes

DIEAP Group AP Group Question (N = 29) (N = 20) P Satisfied with appearance of abdomen (0 = very dissatisfied, 10 = very satisfied) 7.7 ± 2.5 6.7 ± 2.7 0.085* Satisfied with appearance of umbilicus (0 = very dissatisfied, 10 = very satisfied) 7.6 ± 2.5 7.7 ± 1.6 0.58* Abdominal wall muscle function (0 = no reduced muscle function, 3.2 ± 2.9 2.2 ± 1.5 0.33* 10 = completely lost muscle function) Abdominal wall pain (0 = no pain, 10 = severe pain) 2.0 ± 1.4 1.6 ± 1.6 0.51* How blemishing is the scarring (0 = not blemishing, 10 = very blemishing) 4.0 ± 3.3 5.3 ± 3.8 0.18* Amount of scarring, n (%) Less than expected 5 (17) 3 (15) 0.48† As expected 17 (59) 10 (50) More than expected 7 (24) 7 (35) Visibility of scarring, n (%) Less than expected 7 (24) 5 (25) 0.75† As expected 14 (48) 8 (40) More than expected 8 (28) 7 (35) Change of abdominal contour, n (%) None 18 (62) 14 (70) 0.76‡ Bulging 11 (38) 6 (30) Hernia 0 (0) 0 (0) More satisfied with appearance of abdomen after surgery, n (%) No 4 (14) 4 (20) 0.51† Neither yes or no 8 (27) 6 (30) Yes 17 (59) 10 (50) Data are expressed as mean ± SD if not otherwise stated. *Mann-Whitney U test. †Ordinal test (Gamma). ‡Fisher’s exact test (Freeman-Halton extension).

Table 3. General Outcomes

DIEAP Group (N = 29) AP Group (N = 15) Neither Yes Neither Yes Question Yes or No No Yes or No No P Satisfied with body when dressed 25 (86) 3 (10) 1 (4) 11 (55) 2 (10) 7 (35) 0.009* Altered self-image 12 (41) 6 (21) 11 (38) 12 (60) 1 (5) 7 (35) 0.39* Altered body image 17 (59) 3 (10) 9 (31) 17 (85) 2 (10) 1 (5) 0.016* Sad about body image 3 (10) 1 (4) 25 (86) 3 (15) 2 (10) 15 (75) 0.36* Angry about body image 1 (3) 1 (3) 27 (93) 2 (10) 0 (0) 18 (90) 0.68* Improved Unchanged Worse Improved Unchanged Worse Social relationship 5 (17) 24 (83) 0 (0) 5 (25) 15 (75) 0 (0) 0.52* Being naked with partner 10 (35) 16 (55) 3 (10) 11 (55) 7 (35) 2 (10) 0.22* Sexual desire 4 (14) 20 (69) 5 (17) 8 (40) 12 (60) 0 (0) 0.003* Less Unchanged More Less Unchanged More Worried about health 2 (7) 22 (76) 5 (17) 5 (25) 14 (70) 1 (5) 0.031* Yes No Yes No Would have gone through the 28 (97) 1 (3) 20 (100) 0 (0) 0.41† same operation again Overall satisfied with the operation 28 (97) 1 (3) 17 (85) 3 (15) 0.15† Would recommend the operation 27 (93) 2 (7) 19 (95) 1 (5) 0.78† to other patients Satisfied with the preoperative 26 (90) 3 (10) 15 (79) 5 (21) 0.31† counseling Data are expressed as number (%). Bold numbers qualify as significant. *Ordinal test (Gamma). †Mann-Whitney U test.

The response rates of the 2 groups were different, and the respondents in a way that could influence the results). only 2 thirds of the AP group responded. There is, however, Consideration for the possibility of bias from dependent no agreed-upon standard for acceptable response rates. misclassification is also noted; the tendency of respondents Some literature and medical associations state that a re- to systematically answer high or low on questions. sponse rate of more than 50–60% is adequate.14 The lower One can argue that the significantly different mean the response rate, the higher is the likelihood of response ages between our DIEAP and AP groups might be an im- bias (respondents not representing the patient group) portant confounding factor. We chose, nonetheless, to and/or nonresponse error (nonrespondents differing from not perform statistical tests with this in mind based on the

4 Ingvaldsen et al. • Abdominoplasty Outcomes in DIEAP Flap Reconstruction thought that most female patients in their early 40s or 50s roma/hematoma rate among AP patients). With larger have a rather similar life situation (eg, partner, children, patient groups, we could have performed adjusted analy- work). Expectations related to body contour, weight, and sis based on complication type and number of revisions. fitness level might also be comparable. Despite having aforementioned methodological limi- Although not reported in baseline characteristics due tations, the data presented in the study make clinical to lack of data, the patient groups probably do differ in sense, and are agreeable with several related publications: terms of psychiatric comorbidity: Cosmetic surgery pa- First, based on the abdominal outcomes (Table 2), tients (including our AP group) are more prone to psy- the DIEAP group reported more reduced abdominal wall chiatric comorbidities (eg, body dysmorphic disorder) muscle function and more abdominal wall pain. Although as several studies have shown this when compared with not significantly different from the AP group, these varia- a normative sample.15,16 With regard to cosmetic surgery tions were expected as the intramuscular perforator dis- and patient-reported outcomes, von Soest et al.17 reported section causes a greater rate of iatrogenic muscle and that preoperative psychological problems predict less sat- nerve damage. isfaction with surgical results. Their study indicated that Second, the overall satisfaction levels were comparable patients with none or few psychological problems have a with similar publications: In a survey-based study, Niddam greater improvement and overall satisfaction with surgery. et al.1 specifically assessed patient satisfaction regarding Furthermore, AP patients are more strongly associated the abdominoplasty outcomes after DIEAP flap surgery. with patient dissatisfaction.18,19 They may consequently They reported that 52 % of their DIEAP flap breast recon- have a tendency of reporting less improvement with sur- structed patients were satisfied with the aesthetic result gery (although achieving aesthetically acceptable or supe- of the abdomen. This percentage is similar to our find- rior results). Such considerations could explain why the ing, where 59% in the DIEAP group were more satisfied AP group reported a lower level of satisfaction with the with the postoperative abdomen. Among a group of AP appearance of the abdomen and were significantly less sat- patients, Papadopulos et al.25 reported matching percent- isfied with their bodies when dressed compared with the ages to ours in terms of overall satisfaction (84% versus DIEAP group postoperatively. 85%), and numbers of patients who would have done One should, however, not underestimate the psychoso- the same operation again (93% versus 100%) and recom- cial impact of breast cancer treatment (such as mastecto- mended it to a friend (89% versus 95%). my and alopecia), and the consequent risk of developing Third, the significant improvements in general outcomes trauma- and stressor-related psychiatric disorders. This (eg, body image and sexual desire) have been similarly re- aspect has been thoroughly studied in the literature.20–22 corded for both DIEAP flap and AP patients: In a prospective Additionally, Becherer et al.21 have documented that the study, Gopie et al.26 reported a significant increase of both prevalence of psychiatric disorders actually increases after body image and sexual desire after completing DIEAP flap the breast reconstruction has been completed. Our results surgery. de Brito et al.27 demonstrated that the AP procedure showing that DIEAP flap patients were significantly more improves sexual desire. These 2 outcomes have, in fact, been worried about their health compared with AP patients shown to have a strong association as improvements in body postoperatively might support these data. image specifically increase sexual desire.28 Such statistical The contrasting patient group backgrounds may result correlations and common features do to some degree vali- in different expectations regarding the AP outcomes. The date the methodology and data of the study. DIEAP patients go through major cancer treatment before Interestingly, none of the outcomes rendered in opting for a breast reconstruction modality. The results of Table 2 are significantly different between the 2 groups the abdominoplasty are probably (for most patients) less (apart from a trend of DIEAP flap patients being more of a concern than the cancer treatment and breast recon- satisfied with the appearance of the abdomen). In terms struction outcomes. The AP patients, however, seek cos- of umbilical appearance, abdominal wall muscle function, metic surgery mainly to achieve a higher level of body and abdominal wall pain, scarring, and contour, the patient self-image and do not share the same concerns. Evidently, groups were equally satisfied. These results were some- their expectations of the aesthetic abdominal outcomes what unexpected, considering the differences in the op- are somewhat dissimilar. This may also influence the level erative technique between the 2 procedures. of satisfaction/dissatisfaction. Pusic et al.23 have, in fact, Since introducing DIEAP flap surgery in 2000 at our documented the critical role of patient expectations. They surgical department, we have experienced that the aesthet- reported that unfulfilled expectations are more strongly as- ic abdominal outcomes are to some extent different from sociated with dissatisfaction than actual technical success of the AP procedures. The DIEAP flap patients more com- the procedure. In other words, high abdominoplasty out- monly experience high-positioned scars (not concealed come expectations increase the risk of dissatisfaction. by underwear), slight umbilical displacement, and dog ear Differences in complication and/or revision rates formation. Some of the patients also get a varying degree could have been a natural reason for the various satisfac- of lumbar and/or epigastric fullness due to the lack of li- tion levels presented in the study. Although our complica- posuction before harvesting the flap. This can be corrected tion data were too small for statistical analysis (Table 1), with secondary procedures; however, patients themselves a larger meta-analysis by Salgarello et al.24 found that the do not seem to bother with these outcomes. The better part complication rates at the donor-site after DIEAP flap and of DIEAP flap patients seen at postoperative controls are, AP procedures are comparable (apart from a higher se- as presented in our study, very satisfied with the abdomen.

5 PRS Global Open • 2018

Fig. 1. Pre- and postoperative picture of DIEAP flap breastreconstructed patient. A, Preoperative pic- ture. B, Postoperative picture showing a symmetric and slim abdomen with midline-positioned umbi- licus. The scar is located above the underwear and without any dog ears. Photograph: Kari Samuelsen.

Like depicted in Figure 1, a tailored DIEAP flap donor-site 2. Pereira N, Sciaraffia C, Danilla S, et al. Effects of abdominoplasty closure (as described in Methods) does result in abdominal on intra-abdominal pressure and pulmonary function. Aesthet aesthetic outcomes resembling an AP. Surg J. 2016;36:697–702. In our opinion, the insignificant data comparing the 3. Talisman R, Kaplan B, Haik J, et al. Measuring alterations in intra-abdominal pressure during abdominoplasty as a predic- abdominoplasty outcomes of DIEAP flap and AP surgery tive value for possible postoperative complications. Aesthetic Plast might be the most interesting results of the study. The data Surg. 2002;26:189–192. do not support the idea of progressively modifying the 4. Miszkiewicz K, Perreault I, Landes G, et al. Venous thromboem- DIEAP flap abdominoplasty as suggested in referred lit- bolism in plastic surgery: incidence, current practice and recom- erature. By achieving equally good satisfaction levels as an mendations. J Plast Reconstr Aesthet Surg. 2009;62:580–588. AP, the DIEAP flap procedure succeeds in both replacing 5. Modarressi A, Schettini AV, Rüegg EM, et al. Venous thromboem- malignant breast tissue and mimicking a tummy tuck. The bolism events after breast reconstructions with DIEP free flaps in results justify the description of a DIEAP flap breast recon- 192 consecutive case. Ann Chir Plast Esthet. 2018;63:11–19. struction being a “two-in-one procedure”. 6. Pannucci CJ, Chang EY, Wilkins EG. Venous thromboembolic disease in autogenous breast reconstruction. Ann Plast Surg. 2009;63:34–38. CONCLUSIONS 7. Clayman MA, Clayman ES, Seagle BM, et al. The pathophysiol- DIEAP flap patients were equally as satisfied with the ogy of venous thromboembolism: implications with compression abdomen as patients undergoing AP procedures. Al- garments. Ann Plast Surg. 2009;62:468–472. though the DIEAP group had surgery to 2 regions (ab- 8. Eom JS, Kim DY, Kim EK, et al. The low DIEP flap: an en- hancement to the abdominal donor site. Plast Reconstr Surg. domen and breast), the AP group experienced a greater 2016;137:7e–13e. alteration of body image. The AP procedure had signifi- 9. Munhoz AM, Sturtz G, Montag E, et al. Clinical outcome of cantly greater positive effect on sexual desire. Overall sat- abdominal wall after DIEP flap harvesting and immediate ap- isfaction was good in both groups. plication of abdominoplasty techniques. Plast Reconstr Surg. 2005;116:1881–1893. Christoffer Aam Ingvaldsen, MD 10. Blondeel PN, Landuyt KHV, Monstrey SJ. Surgical-technical as- Department of Plastic and Reconstructive Surgery pects of the free diep flap for breast reconstruction. Operat Tech Rikshospitalet, Oslo University Hospital, Norway Plast Reconstr Surg. 1999;6:27–37. E-mail: [email protected] 11. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87:1009– ACKNOWLEDGMENTS 1018. Are Hugo Pripp (Oslo Centre of Biostatistics and Epidemiol- 12. Henderson PW, Dent BL, Disa JJ. Technical tip: Mark Scarpa’s ogy, Research Support Services, Oslo University Hospital) is ac- Fascia to facilitate proper abdominal closure during autologous breast reconstruction. Plast Reconstr Surg Glob Open. 2017;5:e1303. knowledged for his advices on statistical analysis. Kari Samuelsen 13. Bohman VR, Gilstrap Iii LC, Ramin SM, et al. Subcutaneous tis- (Medical Photography, Rikshospitalet, Oslo University Hospital) sue: to suture or not to suture at cesarean section. Infect Dis Obstet is acknowledged for her pre- and postoperative pictures. Gynecol. 1994;1:259–264. 14. Draugalis JR, Coons SJ, Plaza CM. Best practices for survey re- REFERENCES search reports: a synopsis for authors and reviewers. Am J Pharm 1. Niddam J, Bosc R, Lange F, et al. DIEP flap for breast reconstruc- Educ. 2008;72:11. tion: retrospective evaluation of patient satisfaction on abdomi- 15. Glaser DA, Kaminer MS. Body dysmorphic disorder and the lipo- nal results. J Plast Reconstr Aesthet Surg. 2014;67:789–796. suction patient. Dermatol Surg. 2005;31:559–560; discussion 61.

6 Ingvaldsen et al. • Abdominoplasty Outcomes in DIEAP Flap Reconstruction

16. Sarwer DB, Wadden TA, Pertschuk MJ, et al. Body image dissat- 23. Pusic AL, Klassen AF, Snell L, et al. Measuring and managing isfaction and body dysmorphic disorder in 100 cosmetic surgery patient expectations for breast reconstruction: impact on quality patients. Plast Reconstr Surg. 1998;101:1644–1649. of life and patient satisfaction. Expert Rev Pharmacoecon Outcomes 17. von Soest T, Kvalem IL, Roald HE, et al. The effects of cosmetic Res. 2012;12:149–158. surgery on body image, self-esteem, and psychological problems. 24. Salgarello M, Tambasco D, Farallo E. DIEP flap donor site versus J Plast Reconstr Aesthet Surg. 2009;62:1238–1244. elective abdominoplasty short-term complication rates: a meta- 18. Bragg TW, Jose RM, Srivastava S. Patient satisfaction following analysis. Aesthetic Plast Surg. 2012;36:363–369. abdominoplasty: an NHS experience. J Plast Reconstr Aesthet Surg. 25. Papadopulos NA, Staffler V, Mirceva V, et al. Does abdomino- 2007;60:75–78. plasty have a positive influence on quality of life, self-esteem, and 19. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with emotional stability? Plast Reconstr Surg. 2012;129:957e–962e. emphasis on complications. Plast Reconstr Surg. 1977;59:513–517. 26. Gopie JP, ter Kuile MM, Timman R, et al. Impact of delayed im- 20. Derogatis LR, Morrow GR, Fetting J, et al. The prevalence of psychi- plant and DIEP flap breast reconstruction on body image and atric disorders among cancer patients. JAMA. 1983;249:751–757. sexual satisfaction: a prospective follow-up study. Psychooncology. 21. Becherer BE, Kamali P, Paul MA, et al. Prevalence of psychiatric 2014;23:100–107. comorbidities among women undergoing free tissue autologous 27. de Brito MJ, Nahas FX, Bussolaro RA, et al. Effects of abdomino- breast reconstruction. J Surg Oncol. 2017;116:803–810. plasty on female sexuality: a pilot study. J Sex Med. 2012;9:918– 22. Pierrisnard C, Baciuchka M, Mancini J, et al. Body image and psy- 926. chological distress in women with breast cancer: a French online 28. Rankin M, Borah G, Alvarez S. Resumption of sexual activity af- survey on patients’ perceptions and expectations. Breast Cancer. ter plastic surgery: current practice and recommendations. Plast 2018;25:303–308. Reconstr Surg. 2007;120:1557–1563.

7

Appendix

CT-protokoll Studie: Bukveggsendringer etter rekonstruksjon av bryst med DIEAP- lapp (buklapp) Radiologisk avd. og Plastikkirurgisk avd. v/Rikshospitalet CT-beskrivelse: ƒ„†‘‡ȋˆ”ƒš‹’Š‘‹†–‹Ž•›ˆ›•‡Ȍ—–‡‘–”ƒ•–‹Ž‹‰‰‡†‡•–‹ŽŽ‹‰Ǥ ‡•–”ƒ‡„——•Ž‡”Ǥƒ˜•–”¤Ž‡†‘•‡Ǥ Parametere: ގ‰‡†‡¤Ž‹‰‡”‰ŒÞ”‡•—–‹ˆ”ƒˆ‹”‡‹ŽŽ—•–”‡”–‡‹˜¤Ǥ ͳȌ ‹ƒ•–ƒ•‡‡ŽŽ‘”‡–—•„—‡‡ ʹȌ ‡–—•–›‡Ž•‡ȋ•–Þ”•–‡Ȍ‘‰”‡–—•„”‡††‡ ͵Ȍ ‡––›‡Ž•‡ȋ•–Þ”•–‡Ȍ ͶȌ ”‘Ȁ„—Ž‰‹‰ȀŠ‡ƒ–‘Ȁ•‡”‘ǣ†‡”•Þ‡ˆ”ƒš‹’Š‘‹†–‹Ž•›ˆ›•‡Ǥ˜ƒ–‹ˆ‹•‡”‡ ‘‰„‡•”‹˜‡Ǥ

            

  Kontaktinfoǣ ͳȌƒ†Ǥƒ˜†Ǥǣ Ǥ‘••‡ȋ‰„‘••‡̷‘—•ǦŠˆǤ‘ȌȀǤ‘‰‡•ƒŽÞ‡ȋ–ƒƒŽ‘‡̷‘—•ǦŠˆǤ‘Ȍ ʹȌŽƒ•–‹‹”ƒ˜†ǤǣǤ ‰˜ƒŽ†•‡ȋ Š‹‰˜̷‘—•ǦŠˆǤ‘ȌȀǤސ•‡–Šȋ–‘•‡–Š̷‘—•ǦŠˆǤ‘Ȍ

Clinical photographs

This patient has completed a DIEAP flap breast reconstruction after mastectomy. ”‹––‡ ‘•‡–Šƒ•„‡‡‘„–ƒ‹‡†ˆ”‘–Š‡’ƒ–‹‡––‘’—„Ž‹•Š–Š‡•‡’Š‘–‘‰”ƒ’Š•‹–Š‹• †‘ –‘”ƒŽ–Š‡•‹•Ǥ

Photographer: ƒ”‹ƒ—‡Ž•‡ǡ‹•Š‘•’‹–ƒŽ‡–ǡ•Ž‘‹˜‡”•‹–› ‘•’‹–ƒŽ   Preoperative (after mastectomy)

Postoperative (ten months after DIEAP flap breast reconstruction)

Postoperative after nipple-areola complex reconstruction (seven years after the DIEAP flap breast reconstruction)