ORIGINAL ARTICLE

EXTENDED DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR FLAP FOR HEAD AND NECK RECONSTRUCTION: A CLINICAL EXPERIENCE WITH 100 PATIENTS Jaume Masia`, MD, PhD,1 Maria Sommario, MD,1 Daniele Cervelli, MD,1 Carmen Vega, MD,1 Xavier Leo´n, MD, PhD,2 Gemma Pons, MD1 1

Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau (Universitat Autonoma de Barcelona), Sant Antoni M. Claret 167, 08025 Barcelona, Spain. E-mail: [email protected] 2 Department of ENT, Hospital de la Santa Creu i Sant Pau (Universitat Autonoma de Barcelona), Sant Antoni M. Claret 167, 08025 Barcelona, Spain

Accepted 12 August 2010 Published online 10 November 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hed.21628

Abstract: Background. The extended deep inferior epigastric perforator (DIEP) artery flap had been described in 1983. For head and neck reconstruction, we have been using a variation of this flap, namely a perforator free flap of the deep inferior epigastric system with a superolateral extension of the skin paddle. Methods. The purpose of this study was to present our 10year experience in the performance of 102 soft tissue head and neck reconstructions with the extended DIEP flap in 100 patients. Results. Depending on the reconstructive needs, we used the extended DIEP flap in 3 ways: as a cutaneous perforator flap (52.9%), as a chimeric perforator flap (6.9%), and as a myocutaneous perforator flap (40.2%). The overall flap survival rate was 97.1%. Three flaps (2.9%) totally necrosed. Partial flap loss occurred in 5.9% of the cases. Conclusion. The extended DIEP flap is reliable, has a safe vascular supply, and has a long pedicle. Its versatility makes it suitable for reconstruction of moderate to large head and neck C 2010 Wiley Periodicals, Inc. Head Neck 33: reconstruction. V 1328–1334, 2011 Keywords: extended DIEP flap; perforator flap; head and neck reconstruction; microsurgical reconstruction; head and neck cancer

Management

of patients after ablative head and neck surgery often presents challenging reconstruction of complex 3-dimensional defects. The extended deep inferior epigastric perforator (DIEP) artery flap was described by Taylor et al1 in 1983.

Correspondence to: J. Masia` This work was presented at the XLIII Congreso Nacional de la Sociedad Espan˜ola de Cirugı´a Pla´stica Reparadora y Este´tica, Zaragoza, Spain, June 18–21, 2008; 57 Congresso Nazionale della Societa` Italiana di Chirurgia Plastica Ricostruttiva ed Estetica, Napoli, Italy, September 24–27, 2008; and XXIII Congresso Nazionale della Societa` Italiana di Microchirurgia, First Atlanto–Pacific Microsurgery Conference, Modena, Italy, October 1–3, 2009. C 2010 Wiley Periodicals, Inc. V

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Regardless of the size, such defects can have a dramatic effect on cosmesis, speech, respiration, and alimentation and may significantly impact the patient’s quality of life. In this setting, the ultimate goal of the reconstructive surgeon is to achieve adequate functional and morphological rehabilitation of the treated area, matching shape, tissue type, and volume of the surgical defect as closely as possible. At the same time, any compromise of the remaining normal tissue function must be minimized. To achieve better postoperative functional and aesthetic outcomes, and to provide a reasonable quality of life, microvascular free tissue transfers are now the first choice in many cases for head and neck reconstruction. A number of free flap donor sites have been described in the literature for the head and neck; these include rectus abdominis, latissimus dorsi, serratus and gracilis for myocutaneous flaps, radial forearm, ulna, lateral arm, temporoparietal, anterolateral thigh, deep inferior epigastric perforator, superficial inferior epigastric artery, and superficial circumflex iliac artery for fasciocutaneous flaps, jejunum for visceral flap, fibula, radial forearm, scapula, and iliac crest for osteocutaneous flaps.2–6 With the development of perforator flaps, another safe and reliable surgical option has become available for reconstructive surgeons. Since Taylor and Palmer7 introduced the concept of angiosomes, we know that a single perforator vessel of adequate caliber can nourish tissues contained within its angiosome, and also within neighboring angiosomes by means of choke vessels. The pedicle of a perforator flap originates from a main vessel, runs through a muscle and/or intermuscular septum to the fascia, and ramifies at a suprafascial level in the subcutaneous fat. The main advantage in the use of these flaps is lower donor site morbidity, as the muscle through which the perforators pass is spared. Concerning the application of perforator flaps in soft-tissue head and neck reconstruction, the

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FIGURE 1. (A) Preoperative design of the skin flap. (B) Flap and pedicle dissection through the paramedian skin incision. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

We retrospectively reviewed 102 cases of soft tissue head and neck reconstruction with the extended DIEP flap, carried out in 100 patients. All operations were performed at our institution by the same surgical team from June 1999 to June 2009. There were 73

male patients and 27 female patients, with a mean age of 58 years old. Follow-up ranged from 2 months to 10 years. All patients were preoperatively submitted to perforator mapping. Until October 2003, this was performed by means of a Doppler ultrasound scan. As of this date, we performed the mapping with the aid of multidetector-row CT, a technique with high sensitivity and specificity that proved to be very useful in evaluating perforating vessels, and, therefore, in planning abdominal perforator flaps.15–18 To describe our operative technique, we first draw the axis of the flap from the umbilicus to the inferior tip of the scapula, parallel to the ribs, at a 45 degree angle to the anterior axillary line. The skin paddle is then traced by placing the main perforator, preoperatively located, centrally at its base. The flap extends from the midline upward and laterally and can reach the anterior axillary line, if required. Its width is determined by the laxity of local soft tissues, using the ‘‘pinch test’’ (Figure 1). Dissection begins at the distal end of the flap and proceeds along a suprafascial plane toward the lateral border of the rectus muscle. When the anterior rectus sheath is reached, careful dissection is performed over this fascia until the best perforator is encountered. The perforator is then carefully evaluated at the suprafascial level and subsequently dissected. On continuation, the flap is harvested along the upper, medial, and inferior borders of the skin paddle, skirting the umbilicus, and the adipocutaneous flap is isolated. At these levels, the rectus sheath is opened around the main perforator, so as to spare the fascia as much as possible and to facilitate donor site repair.

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anterolateral thigh (ALT) perforator flap, described and widely applied by Wei et al8 and Koshima et al,9 has become the work-horse in this setting over the last 10 years. In 1999, we started to incorporate perforator flaps into our routine head and neck reconstruction surgery. For small defects located in the neck and buccal floor, we preferably use the internal mammary artery perforator flap, transferred with the propeller method.10 In case of wider defects, we usually use free perforator flaps, such as the superficial circumflex iliac artery perforator flap, the ALT perforator flap, and the extended DIEP flap, these last 2 being our first choices. The extended deep inferior epigastric artery flap was first described by Taylor et al1 in 1983. This versatile flap of the upper-lateral portion of the abdomen is supplied by a reliable cluster of periumbilical perforators of the deep inferior epigastric artery and connected by means of choke vessels with the anterior branches of the lateral intercostal vessels.11–14 In this article, we describe our 10 years’ experience using the perforator variation of the extended deep inferior epigastric artery flap in soft tissue head and neck reconstruction. We report the reliability and versatility of this flap, showing its high effectiveness in meeting our surgical needs in this setting. MATERIALS AND METHODS

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To facilitate the intramuscular dissection, we perform a cutaneous incision opening the subcutaneous fat and fascia over the rectus abdominis muscle. If a muscle-sparing procedure is chosen, the rectus muscle is split and freed from the perforator and the deep inferior epigastric pedicle, taking care not to damage the segmental motor nerves which allow its function. Depending on reconstructive needs, another option is to dissect a muscular branch of the deep inferior epigastric vessels and the cutaneous perforator, to incorporate a separate muscular component in the flap. Both these components are supplied by a common vascular source, providing a ‘‘chimeric’’ perforator flap. We can also leave a small portion of muscle and fascia around the selected perforator to give major projection to the flap, as a musculocutaneous flap. After completing the pedicle dissection, we wait for 10 minutes to ascertain skin paddle perfusion. The flap is then transposed to the recipient site and anastomosed. With this technique, we preserve the integrity of muscle, muscular fascia, and innervation, thereby facilitating direct defect closing. RESULTS

We used the extended DIEP flap as a cutaneous perforator flap in 54 cases (52.9%), as a ‘‘chimeric’’ perforator flap in 7 cases (6.9%), and as a myocutaneous perforator flap in 41 cases (40.2%). Skin paddle size ranged from 11 to 20 cm in length (mean, 15 cm) and from 7 to 12 cm in width (mean, 9 cm). The overall flap survival rate was 97.1% (99 of 102). There were 3 flap losses (2.9%) due to postoperative complications, represented by hematoma due to a cervical vessel bleeding during the first 24 hours of the postoperative period in radiated patients. These were repaired with an extended DIEP flap of the contralateral side in 2 cases and with an ALT flap in the third. Necrosis occurred in 6 cases; it involved only a small area, about 1 to 2 cm, and it affected the distal edge of the flap. The patients with necrosis were smokers. All had a very wide skin paddle, of almost 20 cm, going beyond the costal margin. There was no association with increased abdominal wall fat. All necroses were successfully treated by suture or medication (Figures 2–4). DISCUSSION

The use of Taylor’s flap as a free flap for reconstruction of the head and neck has been described in very few articles to date. Taylor et al11 applied this flap to repair complex head and neck defects, Gottlieb et al19 used it for wound closure and nasal reconstruction after a total rhinectomy and ethmoidectomy, and Lee and Dumanian25 provided a case in which the flap was used for a face reconstruction. In all 3 cases, the

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FIGURE 2. (A) Preoperative design of the skin flap for the tongue reconstruction. (B) Cutaneous perforator flap with pedicle. (C) Result of tongue reconstruction after 6 months. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

flap was used as a non-perforator, muscle, myocutaneous, or myosubcutaneous flap. Koshima and Soeda28 were the first to provide the report of a DIEP flap, describing an inferior epigastric artery skin flap without rectus abdominis muscle

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FIGURE 3. (A) A 68-year-old man with full-thickness left cheek mucosa squamous cell carcinoma. (B) Preoperative design of the chimeric perforator flap. (C) Residual defect after wide resection of tumor and left hemimandibulectomy. (D) Chimeric perforator flap and pedicle dissection. (E) Chimeric perforator flap with 2 skin paddles based on 2 distinct cutaneous perforators of the deep inferior epigastric artery. One skin paddle is for cheek mucosa reconstruction and the other for cheek skin reconstruction. An abdominis rectus muscle portion is taken with the skin paddle for skin cheek reconstruction. (F) The chimeric perforator flap is positioned on the defect. The mandible was not reconstructed because in view of the patient’s poor prognosis the multidisciplinary head and neck committee decided to perform a soft tissue reconstruction only. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

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FIGURE 6. Myocutaneous perforator flap. DIEA, deep inferior epigastric artery. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

FIGURE 4. Result after 6 months. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

pedicled on perforators of the deep inferior epigastric system. They later described the periumbilical perforator variation of this flap.29 In our experience in free-flap reconstruction of the head and neck, we prefer to use a perforator variation of Taylor’s flap, that is, an extended DIEP flap. We use this flap in 3 different ways. The first is as a cutaneous perforator flap without the corresponding muscular portion. The second is as a ‘‘chimeric’’ perforator flap where the cutaneous and muscular components can be separately placed because each is supplied by a distinct branch of the common source, that is, the pedicle. The third is as a myocutaneous perforator flap. In this case, the 2 components are not separated because

FIGURE 5. Cutaneous perforator flap. DIEA, deep inferior epigastric artery. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

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the perforator is not dissected in its initial intramuscular portion (Figures 5–7). The DIEP flap with the transverse skin paddle (a design that is often used in breast reconstruction) has also been described by several authors for head and neck reconstruction. In this setting, however, we consider it could be advantageous to opt for other skin paddle designs as less tissue is generally required than in breast reconstruction. We also prefer to harvest the DIEP flap on periumbilical perforators, but we use the superolateral extension of the skin paddle, as described by Taylor. With this modification, the distal part of the flap is placed on the upper-lateral portion of the abdomen toward the anterior chest wall. Skin and subcutaneous tissues are often hairless, pliable, and relatively thinner in this area than in the periumbilical region. This feature can be particularly useful, especially in cases of detailed reconstructions, such as for molding the tip of a reconstructed tongue after a partial or total glossectomy, and for buccal floor reconstruction. The vascular anatomy of the extended DIEP flap has been well studied.1,11–14 The inferior epigastric vessels give rise to large (greater than 0.5 mm diameter) periumbilical perforators which communicate with the anterior branches of the lateral intercostal vessels by means of choke vessels. This constant vascular network means the flap is always well vascularized, even in smokers and older patients with vascular disorders. This property allows us to extend the skin paddle to the anterior

FIGURE 7. Chimeric perforator flap. DIEA, deep inferior epigastric artery. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

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FIGURE 8. (A and B) Preoperative study of supraumbilical perforators with multidetector CT of the patient in Figure 2. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

axillary line to restore large defects if required. Choosing a cranial paraumbilical perforator, the extended DIEP flap has one of the longest pedicles in the human body. We know from the literature that the DIEP flap pedicle has an average length of 10.3 cm and a mean caliber of 3.6 mm.30 The use of high periumbilical perforators implies that the mean pedicle length of the extended DIEP is greater. In our experience, the average length is 16.8 cm. We compared the length of the extended DIEP flap pedicle with that of the ALT flap pedicle. As described by Shieh et al,31 the average length of vascular pedicle of the ALT flap is 12.01  1.50 cm. The pedicle of the extended DIEP flap is, therefore, longer. This feature is particularly helpful for reconstruction in patients with radiated necks. In this setting, there is a recipient vessel deficit so contralateral vessels should be used if those of the omolateral side are not suitable. This flap provides good quality vessels for anastomoses far from the treated area. The recipient arteries generally used are: superior thyroid artery, facial artery, and lingual artery. The recipient veins are either a vein of the thyroid-lingual-facial trunk or the external jugular vein. Nowadays, with preoperative perforator planning using a multidetector CT scan, we can determine where the most reliable perforator is and therefore, can optimize our flap design directly (Figure 8). Due to its versatility, the extended DIEP flap can be used for the reconstruction of a great variety of head and neck defects, particularly medium-sized and large defects. It can provide bulky tissue if a portion of the rectus muscle is raised with the flap and it can

allow simple flap molding and insetting if the cutaneous and muscular components are separated. Extended DIEP flap dissection is relatively fast and straightforward. It can be done with the patient in a supine position, allowing 2 surgical teams to operate comfortably at the same time. Finally, the donor site can be closed as a linear scar with direct repair of the rectus sheath. We think that this flap is excellent because it has a lot of advantages compared to other flaps commonly used for head and neck reconstruction. First the radial flap, like the extended DIEP flap, can provide a large skin paddle but an important artery (the radial artery) is sacrificed. Besides, a graft may be needed to cover the defect in the forearm as this area is more commonly exposed than the abdomen. Furthermore, the extended DIEP flap offers either a thin or thick flap depending on reconstructive needs, whereas the radial technique provides only a thin flap. Second, the extended DIEP flap is not better than the ALT flap but it is a very good alternative because it has a longer pedicle. Also, an abdominal scar is generally more widely accepted than a thigh scar, above all in women. The extended DIEP flap is preferable to the transverse rectus abdominus myocutaneous flap because in the myocutaneous variation it involves a smaller quantity of muscle and, therefore, less morbidity. The muscle is only needed to give more projection to the flap, such as in buccal floor reconstruction. Third, the extended DIEP flap is preferable to the superficial circumflex iliac artery perforator flap because its vascular anatomy is constant and it provides a long pedicle.

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The disadvantages of the DIEP flap should also be taken into account. First, an abdominal scar is less aesthetic than a transverse lower abdominal approach. Moreover, the periumbilical portion of the flap may be excessively bulky in an obese patient. Occasionally, however, this can be advantageous such as when a high projection flap is needed, for example, after a total glossectomy. Another drawback is that dissection of the perforator can be somewhat tedious, especially with the cutaneous and ‘‘chimeric’’ variations of the flap. Furthermore, there is a potential risk of abdominal wall weakness and herniation if a portion of the muscle is harvested with the flap. We did not encounter this complication in our series, but it has been reported in the literature.32 CONCLUSION

With all its variations, the flap described here provides a reliable and safe vascular supply and the versatility of its design makes it suitable for any type of head and neck defect. As the goal of the reconstructive surgeon is to achieve a postoperative result that will ensure a maximum quality of life, the extended DIEP flap should be considered a valuable resource in the armamentarium of ablative head and neck surgery. REFERENCES 1. Taylor GI, Corlett R, Boyd JB. The extended deep inferior epigastric flap: a clinical technique. Plast Reconstr Surg 1983;72:751–765. 2. Suh JD, Sercarz JA, Abemayor E, et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg 2004;130:962–966. 3. Rosenthal E, Carroll W, Dobbs M, Magnuson SJ, Wax M, Peters G. Simplifying head and neck microvascular reconstruction. Head Neck 2004;26:930–936. 4. Haughey BH, Wilson E, Kluwe L, et al. Free flap reconstruction of the head and neck: analysis of 241 cases. Otolaryngol Head Neck Surg 2001;125:10–17. 5. Nakatsuka T, Harii K, Asato H, et al. Analysis review of 2372 free flap transfers for head and neck reconstruction following cancer resection. J Reconstr Microsurg 2003; 19:363–368; discussion 369. 6. Disa JJ, Pusic AL, Hidalgo DH, Cordeiro PG. Simplifying microvascular head and neck reconstruction: a rational approach to donor site selection. Ann Plast Surg 2001;47:385–389. 7. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987;40:113–141. 8. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:2219– 2226; discussion 2227–2230. 9. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92:421–428; discussion 419–430.

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10. Masia J, Moscatiello F, Pons G, Fernandez M, Lopez S, Serret P. Our experience in lower limb reconstruction with perforator flaps. Ann Plast Surg 2007;58: 507–512. 11. Taylor GI, Corlett RJ, Boyd JB. The versatile deep inferior epigastric (inferior rectus abdominis) flap. Br J Plast Surg 1984;37:330–350. 12. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73:1–16. 13. Palmer JH, Taylor GI. The vascular territories of the anterior chest wall. Br J Plast Surg 1986;39:287–299. 14. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flap based on the deep superior epigastric system. Plast Reconstr Surg 1988; 82:815–832. 15. Masia J, Clavero JA, Larran˜aga J, Alomar X, Pons G, Serret P. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006;59:594–599. 16. Masia J, Larran˜aga J, Clavero JA, Vives L, Pons G, Pons JM. The value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap: our experience in 162 cases. Ann Plast Surg 2008;60:29–36. 17. Masia J, Clavero JA, Larran˜aga J, Vives L, Pons G. Preoperative planning of the abdominal perforator flap with the multidetector row computed tomography: 3 years of experience. Plast Reconstr Surg 2008;122:80e–81e. 18. Clavero JA, Masia J, Larran˜aga J, et al. MDCT in the preoperative planning of abdominal perforator surgery for postmastectomy breast reconstruction. AJR Am J Roentgenol 2008;191:670–676. 19. Gottlieb ME, Chandrasekhar B, Terz JJ, Sherman R. Clinical applications of the extended deep inferior epigastric flap. Plast Reconstr Surg 1986;78:782–792. 20. Tonkin MA, Lai MF, Kennedy PJ. The extended deep inferior epigastric flap: a case report. Br J Plast Surg 1987;40:518–520. 21. Seitchik SH, Granick MS, Solomon MP, Berman AT. Posttraumatic upper extremity wound coverage utilizing the extended deep inferior epigastric flap. Ann Plast Surg 1992;28: 465–471. 22. Wellisz T, Sherman R, Nichter L, Romano JJ, Lorant J, Chandrasekhar B. The extended deep inferior epigastric pedicle flap for lower extremity reconstruction. Ann Plast Surg 1993;30:405–410. 23. Va´sconez HC, Sengezer M, McGrath PC. Flap coverage of a large defect after excision of a massive dermatofibrosarcoma protuberans. Plast Reconstr Surg 1995;95:136–141. 24. Classen D. The extended deep inferior epigastric flap: a case series. Ann Plast Surg 1999;42:137–141. 25. Lee MJ, Dumanian GA. The oblique rectus abdominis musculocutaneous flap: revisited clinical applications. Plast Reconstr Surg 2004;114:367–373. 26. Sharma RK, Mehrotra S, Dhaliwal RS. ‘Extended deep inferior epigastric artery flaps’ for reconstruction after excision of chondrosarcoma sternum. Br J Plast Surg 2005;58:1004–1006. 27. Cedidi CC, Felmerer G, Berger A. Management of defects in the groin, thigh, and pelvic region with modified contralateral TRAM/VRAM flaps. Eur J Med Res 2005;10:515–520. 28. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42:645–648. 29. Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda N. Free thin paraumbilical perforator-based flaps. Ann Plast Surg 1992;29:12–17. 30. Heitmann C, Felmerer G, Durmus C, Matejic B, Ingianni G. Anatomical features of perforator blood vessels in the deep inferior epigastric perforator flap. Br J Plast Surg 2000;53:205–208. 31. Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 2000;105:2349–2357; discussion 2358–2360. 32. Blondeel PN, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997;50:322–330.

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