The most common causes such as gas pains, indigestion or a pulled muscle usually aren't serious. Our team can help you navigate surgical options from facelift and browlift to necklift and eyelid rejuvenation. Giammarino AT, Sarmiento IC, Scheinerman S, Winalski J, Lazzaro RS, Brinster DR, Hemli JM. endobj 0000002214 00000 n Numerous alterations in muscle physiology were observed due to surgical dissection of perforator vessels, and rectus muscle distress without functional impairment was a common result. 0000001686 00000 n Bulge and hernia were evaluated on exam and then by imaging and/or operative exploration. Serletti JM. A classification and algorithm for treatment of functional abdominal wall morbidity after DIEP flap is provided. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 500 0 500 500 0 stream Although the DIEP flap scar is long, it typically fades over 12-18 months. abdominal tightness after diep flap 931-528-4000. The usual hospital stay for a DIEP flap procedure is 1-3 days. Background: This study analyzes abdominal weakness, hernia, and bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. i had my diep flap surgery six weeks ago, and like you, I'm struggling with recovery. Health Conditions. After surgery, many women enjoy having a flatter abdomen, similar to the effects of a tummy tuck.. WebFor the abdomen Your incision and belly button are covered in a special medical grade sealant, which will come off in the office, two-three weeks after surgery. I can imagine that it must be so frustrating to be left with a lot of discomfort after your surgery. /ItalicAngle 0 1959;22:719748. Your prescription pain medication may contain acetaminophen. Please bring this sheet to your appointment after surgery. Conclusion: Featured. Copyright 2016 by Houghton Mifflin Harcourt Publishing Company. 0000010904 00000 n Take the time to ensure proper technique. When the abdominal wall is excessively stretched, the muscles may not recover properly, causing a bulge that looks like a hernia or a permanent pregnant belly (diastasis recti). and transmitted securely. xc```c``e`e`(bdf"FaV6B&aX6GpJqj\MShlWmpQdrj&G7&/AO%aS?5T5.xe5?5 y"YNtB.A^ Xp?l? A MEDLINE and manual search of English-language articles on DIEP and free TRAM flap surgery published up to April of 2007 yielded 338 citations. Unlike some You can start massaging your DIEP flap scar after surgery, after [] << 8600 Rockville Pike /FontFile3 51 0 R Abdominal wall morbidities are categorized, and an algorithm for management is provided. J. Surg. /T 675506 Dear Simi so sorry to hear about your infection and tightness. One type of breast reconstruction is the DIEP flap. /ProcSet [ /PDF /Text /ImageC /ImageB /ImageI ] After flap reconstruction, the new breast made of living tissue becomes part of your body, while. Effects of Obesity on Postoperative Complications After Breast Reconstruction Using Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous, Deep Inferior Epigastric Perforator, and Superficial Inferior Epigastric Artery Flap: A Systematic Review and Meta-analysis. Referring to the ABDOMEN. The Mantel-Haenszel fixed-effects and DerSimonian and Laird random-effects models were used to perform the meta-analysis. Clin. 0000025015 00000 n You can start massaging your DIEP flap scar after surgery, after all sutures have been removed and all scabs have fallen off by themselves. Bookshelf trailer Before 0000003586 00000 n /S 196 Then, use two fingers to make small circles along the scar and the surrounding area. The use of lateral row perforators, keeping the umbilicus, higher BMI, and the use of biological mesh in the initial abdominal wall repair trended toward an increased incidence of bulge or hernia; however, these data were not statistically significant. Craigie J.E., Allen R.J., Dellacroce F.J., Sullivan S.K. FOIA Be aware that there may be some tightness around your abdomen as the skin, abdominal muscles and other tissues heal. The https:// ensures that you are connecting to the {$3.1l`7!fgZcTj8_Fu The space constituting the abdomen is termed the abdominal cavity. DIEP flap reconstructioncan often benefit from minor touch-up orenhancement procedures, which are usually performed in an outpatient setting a few months after the initial surgery. It is not a life-threatening problem, but an annoying one. The abdomen refers to the region between the pelvis (pelvic brim) and the thorax (thoracic diaphragm) in vertebrates, including humans. 0 0 0 0 760 0 0 0 250 0 0 250 564 250 250 0 500 250 250 250 250 250 0 0 250 Abdomen: Infection 10%, seroma 5%, wound dehiscence 21%, necrosis 4%, abdominal hernia 6%, other 12%. doi: 10.1097/GOX.0000000000003970. /Filter /FlateDecode While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. Swelling Because of the overall healing response of multiple surgical sites, swelling is normal and expected of the breasts and the abdomen after surgery. WebThe length of surgery varies from 6-10 hours. Working the whole abdomen during your massage can release tension in unexpected areas and help prevent or manage adhesions in other parts of the abdomen that are not directly beneath the visible scar. Abdominal wall morbidities are categorized, and an algorithm for management is provided. >> MeSH The tummy scar is still raised & bumpy in the middle but flattened and soft at the edges. 0000028861 00000 n 333 278 333 469 500 333 444 500 444 500 444 333 500 500 278 278 500 278 778 If you feel that it would be helpful to chat to one of the nurses on the helpline then do get back to us or give us a ring. Abdominal wall morbidity is classified as: type 1 abdominal weakness; type 2 smaller, unilateral abdominal bulge; and type 3 true abdominal hernia or large bilateral bulge. -, Knox A.D.C., Ho A.L., Leung L., Tashakkor A.Y., Lennox P.A., Van Laeken N., Macadam S.A. Risk factors were analyzed. PMC Plast. Abdominal wall morbidity is classified as: type 1 abdominal weakness; type 2 smaller, unilateral abdominal bulge; and type 3 true abdominal hernia or large bilateral bulge. 2002 Aug;110(2):466-75; discussion 476-7. doi: 10.1097/00006534-200208000-00015. We will instruct you to shower once you have drains removed from your breasts in the office. DIEP patients had one-half the risk of abdominal bulge or hernia (relative risk, 0.49; 95 percent CI, 0.28 to 0.86). Patients in the umbilicus sacrificing cohort had an increased incidence of weakness (p < 0.05). 0000020286 00000 n The use of lateral row perforators, keeping the umbilicus, higher BMI, and the use of biological mesh in the initial abdominal wall repair trended toward an increased incidence of bulge or hernia; however, these data were not statistically significant. ly adv. The type of DIEP flap post surgical garments you will wear may very depending on your plastic surgeon. 46 0 obj 0000026585 00000 n 0000028974 00000 n Just remember it is early days for you. /TrimBox [ 9 9 603 801 ] For the drains to be working appropriately, the bulbs need to be collapsed to create a light suction. The use of lateral row perforators, keeping the umbilicus, higher BMI, and the use of biological mesh in the initial abdominal wall repair trended toward an increased incidence of bulge or hernia; however, these data were not statistically significant. Do not lift your arms above your head. >> Your tummy is likely going to always feel a bit tight after DIEP flap surgery. The area was stretched and sewn down. Unless you gain a tremendous amount of weight, the underlying tissue has been altered and will always have a new, tighter feel. I personally like the fact I can no longer grab a handful of tummy skin. Oncol. Begin by running your fingertips back and forth over the length of the scar, applying light pressure in the beginning and working up to deeper, firmer pressure. /Rotate 0 Your breast scars will largely depend on thetype of mastectomyyou end up having. I also found walking helpful try not to sit for long periods I am quite active and found the more active you are it helps with the scarring to keep it supple. This is normal and not a cause for concern. I had a mastectomy three weeks ago with immediate reconstruction! If youve already had a mastectomy, the DIEP can be at a later date (delayed reconstruction). Methods: A retrospective review of 644 patients who underwent abdominal based flap breast reconstruction between 2009 and 2018 and met selection criteria was performed. /Type /Catalog Sorry I do not have time to rewrite response. Six studies reporting both DIEP and free TRAM flap outcomes were used to estimate pooled relative risks of complications and confidence intervals. Please notify us immediately if: 600 Northern Blvd, Suite 310 Greak Neck, NY 11021, 130 E 77th Street, 10th Floor New York, NY 10075, All Rights Reserved. Abdominal wounds, nerve sacrificing procedures and obesity correlated with an increased incidence of weakness; these data were not statistically significant. /Font << /F1 49 0 R /F2 52 0 R /F3 55 0 R /F4 58 0 R /F5 61 0 R /F6 65 0 R ( a ) Pt n# 11, preoperative transverse CT scan at sub-umbilical level;, ( a ) Pt n#12, preoperative transverse CT scan at sub-umbilical level; (, ( a ) Pt n#8, preoperative transverse CT scan at sub-umbilical level; (, ( a ) Pt n#7, preoperative transverse CT scan at sub-umbilical level; (, ( a ) Pt n#3, preoperative transverse CT scan at sub-umbilical level; (, MeSH Designed & Developed by Studio III, Dr. Neil Tanna named fifth year in a row to Newsday Top Doctors List, Dr. Tanna and surgeons successfully address patients specific request, Effects of Radiation on Breast Reconstruction. I could almost pinpoint the date. 2021 Dec 7;9(12):e3970. /OpenAction [ 47 0 R /Fit ] [Myosonographic evaluation of rectus abdominis muscle function after DIEP flap breast reconstruction]. During that time frame they wear a compression garment over the abdomen, avoid lifting object That's a very good question. The abdomen is the part of the body between the thorax and pelvis, in humans and in other vertebrates. Ann Plast Surg. /Descent -213 >> There is no need for a direct comparison between For example, Percocet (oxycodone/acetaminophen) contains 325mg of Tylenol. doi: 10.1002/jso.25325. Please enable it to take advantage of the complete set of features! Both the breast and abdomen will have drains. If you missed the first part of my Cosmetic and Restorative Tattoo Series, take a look at the video included for instructions you can watch about how best to utilize the above techniques. Non-surgical facial rejuvenation options include Botox, fillers, laser peels, and chemical peels. Abdominal scars have the benefit of underlying soft tissue, which tends to make them less noticeable and firm, as I mentioned in my general scar massage post. The reconstructed breast is permanent. After breast reconstruction, youll have little to no sensation in the breast. Disclaimer, National Library of Medicine abdominal tightness after diep flap 931-528-4000. It is important to get a clear answer on the total cost of the procedure. After a successful surgery, patients will be given supportive garments to wear on their breasts and around their stomachs. Tissue can be taken from your abdomen for breast reconstruction just once. And it seems to be having aneffect on my back and making that ache. Patients can get occasional pains in their abdomen for some time after a DIEP, just as one would after a tummy tuck, because there is deep scarring on the inside. Ann Plast Surg. WebConclusions: A classification and algorithm for treatment of functional abdominal wall morbidity after DIEP flap is provided. You have a sudden increase in swelling of the abdomen. You may be prescribed another pain medicationToradol/ketorolac. Robotic-assisted closed-chest management of a fungal-infected prosthetic aortic graft: a case report. The nurse in the hospital will review the drain care with you and your family prior to discharge home. You have redness develop around the incisions. You should find time to massage your scar two to three times a day for ten minutes at a time. Sometimes its necessary to remove a small piece of cartilage from the chest to access the vessel. Auto-suggest helps you quickly narrow down your search results by suggesting possible matches as you type. /Type /Page See this image and copyright information in PMC. Yes you can wear a bikini once swelling settles down and wounds are healed , which can be 3-6 months from surgery. Kurlander DE, Le-Petross HT, Shuck JW, Butler CE, Selber JC. But it seems to be getting 'tighter' (16 months post-op) - to the point where I'm aware of it all the time now, not only when I move around or turn over in bed. Do not massage the incisions until we instruct you in the office (six weeks after surgery). Simi sorry you are going through a rubbish time it is frustrating when infections happen as it delays recovery. DIEP refers to no muscle being taken up with flap (the abdominal tissue that is transferred to the chest). Epub 2017 Dec 8. In addition to nose-reshaping, our surgeons perform procedures that can alleviate breathing difficulties associated with deviated septum and internal nasal blockages. For men facing mastectomy, we offer a variety of procedures including natural tissue flaps, fat grafting, and nipple reconstruction. /Info 42 0 R Oncoplastic procedures like oncoplastic closure, reduction and lift, and local tissue flaps for volume loss preserve breast shape after a lumpectomy. I am hoping that this message will help bump it up for you. 2022 Apr 13;32(2):10521. doi: 10.4081/ejtm.2022.10521. /LastChar 223 endobj Methods: A retrospective review of 644 patients who underwent abdominal based flap breast reconstruction between 2009 and 2018 and met selection criteria was performed. * To protect your identity do not use your full name. I had a left breast mastectomy and reconstruction, using tummy tissue, in October 2020. In the DIEP procedure, a flap of tissue containing fat and skin is removed from the lower abdomen and used to form a new breast. We offer brachioplasty, or arm lift, and thigh lift to transform your extremities. Plast. stream 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. But it is a page taken directly out of the Breast Reconstruction Planner from my An algorithm of treatment is presented, which includes physical therapy and surgical repair recommendations. Or maybe because the tightness in the abdomen is stressing other muscles? Learn how it works, its risks, and more. 2003;30:359369. 0000060530 00000 n I've been lucky enough not to get any infections but the tightness around my whole tummy area is really uncomfortable. Knox ADC, Ho AL, Leung L, Tashakkor AY, Lennox PA, Van Laeken N, Macadam SA. Patients in the umbilicus sacrificing cohort had an increased incidence of weakness (p < 0.05). I generally tell patients to plan on being not themselves for about 6 weeks. Youll also have less sensation in the area around the abdominal incision after the DIEP procedure. However, you may call the office at any time with additional questions or concerns. Accessibility Independent of the surgeon's fee, the price of OR time and anesthesia can Can I wear a bikini 1 year after tummy tuck? Biomed Res Int. !^=, Webappearance of an abdominal bulge following DIEP ap breast reconstruction is illustrated in Figure 1, and the appearance of the abdomen following repair of the bulge is illustrated in Figure 2. An algorithm of treatment is presented, which includes physical therapy and surgical repair recommendations. You have just undergone a breast reconstruction with the DIEP flap. 0000026267 00000 n It's a very emotional journey isn't it ? At that point, it is often best to work around the scar, massaging the surrounding area. A systematic approach to post mastectomy pain. eCollection 2021 Jul. Robotic DIEP Patient Selection: Analysis of CT Angiography. The DIEP flap is the most common tissue flap procedure performed at the Friedman Center due to its natural-looking results. Using microsurgery, the plastic surgeon connects the tiny blood vessels in the chest to the vessels in the flap. / Haddock, Nicholas T.; Culver, Abby J.; Teotia, Sumeet S. T1 - Abdominal weakness, bulge, or hernia after DIEP flaps, T2 - An algorithm of management, prevention, and surgical repair with classification, N1 - Funding Information: doi: 10.1016/j.breast.2017.12.003. << In most cases, the DIEP surgery can be done on the same day as the mastectomy (immediate reconstruction). WebThe DIEP flap is the most common tissue flap procedure performed at the Friedman Center due to its natural-looking results. Abdominal wall morbidity is classified as: type 1 abdominal weakness; type 2 smaller, unilateral abdominal bulge; and type 3 true abdominal hernia or large bilateral bulge. Your breast will likely have bruising and possibly some blistering on the skin, which is expected after a mastectomy. If you are comfortable, you can begin to pinch the area around the scar as tolerated. pW/ KWJ The benefits are therefore clear although it requires a longer operation than just having breast implants to make the new breast. Surg. At this time the treatment is wound care. doi: 10.1097/00006534-198167020-00007. /E 61970 Post-meeting report of the 2022 On-site Padua Days on Muscle and Mobility Medicine, March 30 - April 3, 2022, Padua, Italy. << HHS Vulnerability Disclosure, Help Sending a big virtual hug to you . 2007;120:14431449. UR - http://www.scopus.com/inward/record.url?scp=85099713252&partnerID=8YFLogxK, UR - http://www.scopus.com/inward/citedby.url?scp=85099713252&partnerID=8YFLogxK, JO - Journal of Plastic, Reconstructive and Aesthetic Surgery, JF - Journal of Plastic, Reconstructive and Aesthetic Surgery, Powered by Pure, Scopus & Elsevier Fingerprint Engine 2023 Elsevier B.V, We use cookies to help provide and enhance our service and tailor content. The recovery was good. It usually gets better over time and you should consult your surgeon for advice. Federal government websites often end in .gov or .mil. For this reason, the muscle is permanently weakened in the abdomen and may be painful. I did sonography during the summer and the doctor said he can't see anything wrong on the image. Effects of Radiation on Your Reconstruction. Walking is encouraged, but strenuous exercise is not allowed until six weeks after surgery. >> << << eCollection 2022. Pooled flap-related complication rates were higher in DIEP patients, whereas donor-site morbidity was higher in free TRAM patients. Statistical analysis was performed using the SAS System and the Fisher exact test. About Breast Reconstruction Natural Tissue (Flap) Reconstruction Abdominal Tissue Site DIEP Flap Procedure. /O 47 Reconstr. Of a surgical operation performed through an incision in the wall of the abdomen, which could be performed via a different route, e.g. Do not take a bath or submerge yourself in water. Results: Of the 644 patients, 23 (3.6%) had a clinically significant bulge or hernia on exam postoperatively. 0000025849 00000 n Just wondering whether anyone out there has had problems in the reconstructed breast after DIEP flap op with hardness. Abdominal wall morbidities are categorized, and an algorithm for management is provided. Abdominal pain is pain that occurs between the chest and pelvic regions. Answer: Pain with sit ups after DIEP flap The DIEP flap removes rectus abdominus muscle to reconstruct the breast. 0000002012 00000 n Each of my patients is put into a physical therapy program for DIEP flap patients.This program is used starting 1 to 2 weeks after surgery. The site is secure. This analysis suggests that the DIEP flap reduces abdominal morbidity but increases flap-related complications compared with the free TRAM flap in breast reconstruction. /BaseFont /NGLDJC+TimesNewRomanPS The area was stretched and sewn down. I would be happy to receive news and updates from Cancer Chat, NICE suspected cancer referral guidelines, Cancer Research UK for Children & Young People, DIEP FLAP surgery - abdominal tugging 16 months post-op. Kssmann C, Peek A, Luxenhofer F, Scheufler O, Exner K. Handchir Mikrochir Plast Chir. 0000061227 00000 n Each of my patients is put into a physical therapy program for DIEP flap patients.This program is used During the procedure, a flapa piece of tissue containing skin, fat and blood vesselsis removed from the lower abdomen, below the belly button, and transplanted to the chest. For less severe pain, you may take over the counter Tylenol (acetaminophen), instead of the prescribed pain medication. Abdominal weakness, bulge, or hernia after DIEP flaps: An algorithm of management, prevention, and surgical repair with classification. Sleep on your back for the first two weeks after surgery. During recovery, physical activity must be limited. Keywords: I had a DIEP surgery in January 2013. Please do not drive while taking narcotic pain medication. Breast. 2022 Feb 15;9:729181. doi: 10.3389/fsurg.2022.729181. -, Mathes S.J., Nahai F. Classification of the vascular anatomy of muscles: Experimental and clinical correlation. It is important to check this skin paddle daily. It would be helpful to get a physio's opinion about where the pain is coming from and whether it is indeed still scar tissue. Should I expect the same from my abdominal area?) Liposuction, abdominoplasty, or tummy tuck, and butt augmentation can all reshape the body to improve your appearance. Abdominal tightness may be related to the wound closure. Take this pain medication as prescribed as needed for moderate to severe pain. 0000055838 00000 n Plast Reconstr Surg. and Teotia, {Sumeet S.}". government site. AB - Background: This study analyzes abdominal weakness, hernia, and bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. The skin should remain the same color. WebOne type of breast reconstruction is the DIEP flap. DIEP flap breast reconstruction takes place along on the lower abdomen and typically leaves a scar. Based on the output, the drains will be removed one to 3 weeks after surgery. Each donor tissue site has its own set of contraindications. Sitting in a comfortable chair is better than sitting in bed. Because DIEP flap surgery preserves the abdominal muscles, patients have better outcomes than with TRAM flap procedures: youll retain more core strength, feel less pain, have lower risk of abdominal hernias, and recover more quickly. /Linearized 1 2021 Jul 28;9(7):e3704. 1. Careers. DIEP and pedicled TRAM flaps: A comparison of outcomes. You might experience some loss of sensation, which is often temporary at the donor tissue site. Plast Reconstr Surg Glob Open. 2. : performed by entry through the abdominal wall. /CapHeight 662 eCollection 2022. By continuing you agree to the use of cookies. Plast. They would usually advise you to continue exercise as normal as long as you feel comfortable. 51 0 obj I was told it can all take up to a year or so to settle. Methods: Comparison of Outcomes following Autologous Breast Reconstruction Using the DIEP and Pedicled TRAM Flaps: A 12-Year Clinical Retrospective Study and Literature Review. 47 0 obj Plast Reconstr Surg. Epub 2015 Nov 25. I am thankful this forum is available to communicate with people going through the same thing xx. /Resources 48 0 R Results: Of the 644 patients, 23 (3.6%) had a clinically significant bulge or hernia on exam postoperatively. We're here for you. WebDIEP flap is considered as the gold-standard for autologous breast reconstruction, whereas PAP flap is an alternative for patients with low BMI and previous abdominal surgery history. WebThe abdominal DIEP flap is now considered the gold standard for perforator flap reconstruction, but also the thigh-based PAP flap has proven to be a safe alternative [9,11,22,23]. The DIEP flap removes rectus abdominus muscle to reconstruct the breast. For this reason, the muscle is permanently weakened in the abdomen and may be painful. Return to your plastic surgeon, explain the problem. Tightening the fascia or mesh support may be helpful. eCollection 2021 Dec. Plast Reconstr Surg Glob Open. endobj Seven percent of patients who answered the BREAST-Q{\texttrademark} reported abdominal weakness. % Bulge and hernia were evaluated on exam and then by imaging and/or operative exploration. I've kept asking aboutthe abdominal tightness/tugging, around the permanent stitches the surgeon added to the muscle fascia (below, and to the right of, the scar), and have been told that because I was slim, fit, and had never had children, thatit could take 18 months to 2 years to ease off. You will get better ! /XObject 69 0 R Bulge and hernia were evaluated on exam and then by imaging and/or operative exploration. Some surgeons quote their fee, and you are responsible for the anesthesia and facility costs, which fluctuate based on how long the procedure takes. You may choose to have breast reconstruction after a mastectomy (breast removal) or lumpectomy (partial (I know my breasts don't have too much feeling and know this will not change significantly over time. This study compared the risk of fat necrosis, partial flap loss, total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis myocutaneous (TRAM) flap surgery for breast reconstruction. Results: Expect soreness, swelling, and bruising at all surgery sites, including the abdomen. The .gov means its official. A year. An official website of the United States government. You may take sponge baths following discharge. I'm afraid patience is not one of my virtues! ;Vq 0 ; 0000011292 00000 n Abdominal wall morbidity is classified as: type 1 abdominal weakness; type 2 smaller, unilateral abdominal bulge; and type 3 true abdominal hernia or large bilateral bulge. %l@V!f!-L$r5%u{v[2+JJZ I7w8K+6'dUzf"'TEkEm:%POnUWE5\P{FN4tn6/rjjZL0())|!. A tummy tuck (abdominoplasty) is one of the more painful and longer recoveries when it comes to cosmetic surgery. 2016 Jul;138(1):16-28. doi: 10.1097/PRS.0000000000001747. >> But need to nurture and take care of yourself emotionally and physically as your body heals.Good luck. 0000010368 00000 n Plast Reconstr Surg. /QInserted true HHS Vulnerability Disclosure, Help note = "Funding Information: Not required Publisher Copyright: {\textcopyright} 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons". Abdominal pain can be crampy, achy, dull, intermittent, or sharp. The incidence of abdominal weakness was evaluated by BREAST-Q data. An algorithm of treatment is presented, which includes physical therapy and surgical repair recommendations. sharing sensitive information, make sure youre on a federal I am struggling to get a good nights sleep as longing to sleep on my side ! You will have special adhesive glue or tape over the incisions. Your tummy is likely going to always feel a bit tight after DIEP flap surgery. This type of abdominal scar is a great candidate for scar massage, which can help to keep the scar from becoming firm and assist in overall abdominal healing.
abdominal tightness after diep flap
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