Ǧ ȋȌ ǤǤ 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 Ǥ ǡ ȋȌ ǡǤ Ǥ ȂǡǦ ͶͲͲ Ǥ Ǥ ǯ ǯ Ǧ ǡǡ Ǥ ǡǡǡǤ ǡǤǡ Ǥ Ǥ ǡ ǡǡǡ ǡ Ǥ ǡ Ǥ Ǥ ʹͲͳʹǡ Ǧ Ǥ Ǥ Ǥ Ǥ Ǥ Þ ʹͲͳ͵ Ǥ Ǥǡ ǡ Ǥǡ Ǥ ǡ ǣDz dzȋȌǡǤ ǡ ǡ Ǥ Ǥ Ǥ ǦǤ ǡǡ Ǥ ǦǤ Ǥ Acknowledgements ǡǡ ʹͲͳ͵Ǧ ʹͲʹͲǤ ǡ Ǥ ʹͲͳͺǡ Ǥ Ǥ ǡ ǡǡ Ǥ I wish to express my heartfelt gratitude to: Professor Kim Alexander Tønsethǡ ǡ ǡǦ ǣ ǡ ǡǤǡ Ǥǡ Ǥ ʹʹǦǦǡ ǡǡǡ Ǥ Ǥǡ ǤǤ Dr. med. Tyge Tind Tindholdtǡ Ǧǣ Ǥ Ǥ ʹͲͳ͵ǡ Ǥǡ ǡ ǡǤ ǡ ǡǡ Ǥ Ǥ Ǥ Dr. med. Hans Erik Høgevoldǡ ǣ Ǥ Ǥ Ǥ Dr. med. Thomas Bergǡ Ǧǣ Ǥ Ǥ Ǥ Department of Radiology, Rikshospitalet, Oslo University Hospitalǣ Ǥ Dr. Gerhard Bosse Dr. Georg Mynarek Ǥ Professor Are Hugo Prippǡ ǣ Ǥ ǡǤ Master Øystein Horgmoǡ ǡ ǡǣ ǡ ǡ Ǥ Ǥ Ǧ Ǥ Dr. med. William Winterǡ ǣǡ ǡ Ǧ Ǥ ǡǡ Ǥ ǡ Ǥ All patients Ǥ Ǥ Irene, Pål, Annelin, Aleksander, and Torunǣ ǡ Ǥ Ǥ Ǥ Mariaǡ ǣǡǡ Ǥ Ǣ ȂǤ ǡ ʹͲʹͲ ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ Table of contents §¤ 1. Background 1 Why write this thesis? 1 Breast cancer in Norway 1 Breast reconstruction 1 ͳǦʹ ʹǦͷ ͷǦͺ ͺ ͺǦͳͲ ͳͲǦͳͳ Abdominal wall anatomy 11 ͳͳ ͳͳǦͳʹ ͳ͵ǦͳͶ ͳͶǦͳͷ Abdominoplasty 15 ͳͷ ͳͷǦͳ͸ 2. Aims 17-18 3. Material and methods 19 ȋ Ǧ Ȍͳͻ ȋ Ǧ Ȍ ͳͻ ȋ Ǧ Ȍ ͳͻ ȋ Ǧ ȌͳͻǦʹͲ ȋ Ǧ Ȍ ʹͲ ȋ ȌʹͲǦʹͳ ȋ Ȍ ʹͳ ȋ Ȍȋ Ȍ ʹͳǦʹʹ ȋ Ȍ ʹʹǦʹ͵ ȋ Ȍʹ͵ǦʹͶ ȋ Ȍ ʹͶǦʹͷ ȋȌȋ Ȍ ʹͷǦʹ͸ ȋ Ȍ ʹ͸ ȋ Ȍʹ͸ 4.Results 27-31 5. Discussion of main findings 32-51 6. Methodological considerations 52-70 Ǧ ͹ͲǦ͹ͳ Ǧ 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 Clinical photographs Thesis at a glance PAPER I PAPER II PAPER III Aim Ǧ Ǧ ȋȌ Ǥ ȋȌ ǡ ȋȌǡ Ǥ ȀȀ Ǥ Patients & ǡ Methods ʹͲ ͳͶ Ǥ Ǧ Ǥ Ǧ ͵Ͷ ͵Ͳ Ǧ Ǥ Ǥ Ǥ ǡ ȋ Ǥ ǦǢ Ȍ ȋͳǦͶǢ ǡ ȌǤ ǡ ǡǤ Results ǡ ͵Ͷ ȋȌ ͳǤ ȋȌ ǡ ͳǦ͵ Ǥ Ǥ Ǥ Ǧ ǡ ǡ ǡ Ǥ ǡǡ ǡ ǡ Ǥ Ǥ ǡ Ǥ Ǥ Ǥ Ǥ Ǥ Ǥ Ǥ Ǧǡ ǡ ǡ Ǥ Conclusion ǡ ǡ Ǥ ǡ Ǥ ǡ Ǥ Ǧ Ǥ Ǥ Ǥ 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 ¤Ǥ ȋȌǤ Ǥ §ȋȌ¤ Ǥ Ǥ Ǽ ǽǦȋ Ȍ§ ¤ÞǤ Ǧ ¤ǡǤ¤ ǡ¤Ǥ ¤¤ǤͷͲ ¤Ǥ ¤¤ ǤǼǽǡ¤ ȋȌÞǤ Ȃ¤¤§Ǥ ¤ ÞǤ ¤ǡ ǡǤ Ǥ ¤Ǥ ¤ǡÞ Þ Ǧǡ¤ ¤Ǥ¤¤ Ǥ Mål Ǧ Ǥ ¤Þ ȋȌǡȋǦȌ ȋÞȌǤ Metoder 1) Sirkulasjonsstudie (artikkel 1):ȋ Ȍ¤Þ ǦÞǡǤ¤ ¤ÞÞ Ǥ 2) CT-studie (artikkel 2): Ǧ Ǧ Þ¤¤ Ȃǡǡ¤§Ȁǡ ǤǤ 3) Spørreskjemastudie (artikkel 3): ÞÞÞ ¤ Ǧ ¤ ǦÞÞ Ǥ Resultater 1) Sirkulasjonsstudie (artikkel 1): ǦǡÞ ÞǤ ǡ Þ¤ ÞǤ 2) CT-studie (artikkel 2): ¤ ǣͳȌ ÞʹȌ ǡÞǤ ¤¤Ǥ 3) Spørreskjemastudie (artikkel 3): ǦÞ Ǥ Ǧ ÞǤ Konklusjon ǦÞ Ǥ Ǥ Þ ǦǤ List of papers ǡ ǣ Paper I ǡÞǡ ǡǤMicrocirculatory Evaluation of the Abdominal Skin in Breast Reconstruction with Deep Inferior Epigastric Artery Perforator Flap. ǤʹͲͳ͸ ͳͲǢͶȋʹȌǣ͸ͳ͸ Paper II ǡ ǡ ǡǡǡÞǤDonor-site Morbidity After DIEAP Flap Breast Reconstruction – A 2-Year Postoperative Computed Tomography Comparison. ǤʹͲͳ͹ ʹͷǢͷȋ͹ȌǣͳͶͲͷ Paper III ǡǡÞǤDIEAP Flap Patients Equally as Satisfied with the Abdomen as Abdominoplasty Patients. Ǥ ʹͲͳͺǢ͸ǣͳͺ͹͸ Abbreviations Abbreviation Full word/phrase AP Abdominoplasty CT Computed tomography CTA Computed tomography angiography DIEAP Deep inferior epigastric artery perforator DIEAP flap Deep inferior epigastric artery perforator flap Ǧ IMA Internal mammary artery IMV Internal mammary vessel ǡ Ƭ LDPI Laser Doppler perfusion imaging/imager Ǧ ǦȋȌ Ǧ PROM Patient-reported outcome measure ȋ Ȍ PU Perfusion unit(s) SIEA flap Superficial inferior epigastric artery flap SIEV Superficial inferior epigastric vein TRAM flap Transverse rectus abdominis myocutaneous flap bold.