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PubMed2000

[Perforator flap-plasty and applications to hand surgery].

In contrast to the classical fasciocutaneous and musculocutaneous flaps, perforator flaps are supplied only by a single perforating branch. The aim of this paper is to present the surgical technique and to discuss the use of perforator flaps in hand surgery. Our previous studies have demonstrated the reliability of a preoperative Doppler for planning perforator flaps in reconstructive surgery of the breast: With 286 preoperatively localized perforating branches, a total of 162 were confirmed in intraoperative dissection. In 37 out of these 46 perforator flaps (80%), a preoperatively localized perforating branch could be used. Based on these results, the individual design of perforator flaps harvested on the forearm for defects on the dorsum of the hand is possible. In a preoperative Doppler exam, a perforating branch, i.e. of the posterior interosseous artery, can be localized. The intraoperative confirmation of the perforating branch allows the successful defect coverage with a distally pedicled flap without taking fascia or septum. In our experience, this possibility of planning an individually designed perforator flap is the major advantage for applications of the perforator flap technique in hand surgery. This is especially true in cases where the harvest of a fasciocutaneous flap is unreliable or impossible due to anatomic variations. On the other hand, the dissection of the pedicle is technically demanding and the individual distribution of the perforating branches requires a high degree of flexibility. However, we do consider this new technique to be a further extension in the armamentarium for soft-tissue coverage of the hand.

Adult↗
PubMed2005

Clinical applications of free soleus and peroneal perforator flaps.

Clinical applications of two free lateral leg perforator flaps are described: a free soleus perforator flap that is based on the musculocutaneous perforator vessels from one of the three main arteries in the proximal lateral lower leg, and a free peroneal perforator flap that is based on the septocutaneous or direct skin perforator vessels from the peroneal artery in the distal and middle thirds of the lateral lower leg. The authors applied free soleus perforator flaps to 18 patients and free peroneal perforator flaps to five patients with soft-tissue defects. The recipient site was the great toe in 14 patients, the hand and fingers in five patients, the leg in two patients, and the upper arm and the jaw in one patient each. The largest soleus perforator flap was 15 x 9 cm, and the largest peroneal perforator flap was 9 x 4 cm. Vascular pedicle lengths ranged from 6.5 to 10 cm in soleus perforator flaps and from 4 to 6 cm in peroneal perforator flaps. All flaps, except for the flap in one patient in the peroneal perforator flap series, survived completely. Advantages of these flaps are that there is no need to sacrifice any main artery in the lower leg, and there is minimal morbidity at the donor site. For patients with a small to medium soft-tissue defect, these free perforator flaps are useful.

Accidents, Occupational↗
PubMed2006

Glove perforation during oral surgical procedures.

OBJECTIVE: The aim of this study was to determine the incidence of glove perforation among undergraduates and residents performing maxillofacial surgery and identify procedures associated with the perforations. STUDY DESIGN: For this purpose, 200 pairs of surgical gloves were used. For inspecting the perforations, the gloves were filled with water, at least 500 ml. RESULTS: Sixteen gloves (8%) were perforated, 8 (4%) by residents and 8 (4%) by undergraduate students. Only the residents noticed that 2 gloves (1%) were perforated and identified the object causing the perforation. The left hand was the more affected with 9 perforations (4.5%). The finger pulp was the region most affected with 12 perforations (6%). The perforated forefinger appeared in 8 gloves (4%), representing the highest incidence of perforations. CONCLUSION: We concluded there was no difference in surgical glove perforation between undergraduate students and residents, the incidence of perforations was greater in the left hand (nondominant hand) and the fingers in which most perforations occurred were the forefinger and the thumb.

Finger Injuries↗
PubMed2002

Free perforation in Crohn's disease: review of the Japanese literature.

BACKGROUND: Reports of free perforation in Crohn's disease have been increasing in Japan. In this study, we investigated the characteristics of free perforation in Japanese patients with Crohn's disease. METHODS: We reviewed the data for 104 patients with free perforation in Crohn's disease reported in the Japanese literature, in addition to 22 patients from our hospital. RESULTS: There were 89 men and 37 women in this series, with ages ranging from 16 to 92 years. Free perforation was the presenting sign of the disease in 72 patients. The perforation sites were the jejunum in 7, the ileum in 102, and the colon in 17. Multiple perforations occurred in 13 patients. Steroid therapy was administered in 25 patients, but the relation between steroid therapy and free perforation had not been well established. The incidence of free perforation in Crohn's disease in Japan was between 2.9% and 10.5%. This incidence was higher than that in Western countries. Ninety-eight patients were treated with resection and drainage, and 22 patients with resection and diversion (details were not known in 6 patients). There were no patients with simple closure of the perforation site. Anastomotic rupture occurred in 13 patients. Five patients died after the operation. Four of these five patients had multiple perforations. CONCLUSIONS: The incidence of free perforation in Japan is higher than that in Western countries and patients with multiple perforations have a poor prognosis.

Adolescent↗
PubMed1996

Esophageal perforation: emphasis on management.

BACKGROUND: Perforation of the esophagus is a deadly injury that requires expert management for survival. METHODS: We performed a retrospective clinical review of 66 patients treated at Emory University affiliated hospitals for esophageal perforation between 1973 and 1993. RESULTS: Iatrogenic perforations accounted for 48 injuries (73%), barogenic perforations occurred in 12 patients (17%), trauma was causative in 3 (5%), and 3 patients had esophageal infection and other causes. Lower-third injuries occurred in 43 cases (65%), middle third in 14 (21%), and upper third in 9 (14%). Early contained perforations were managed successfully by limiting oral intake and giving parenteral antibiotics in 12 patients. Cervical perforations were drained without attempt at closure of the leak. Perforations with mediastinal or pleural contamination recognized early were managed by primary closure and drainage in 28 patients. Reinforcement of the primary closure using stomach fundus, pleural, diaphragmatic, or pericardial flap was performed in 16 patients. Those perforations that escaped early recognition required thoughtful management, using generous debridement and drainage and sometimes esophageal resection. The esophageal T tube provided control of leaks in 3 of these patients and was a useful adjunct. Using these management principles, we achieved a 76% survival rate for all patients. Six patients with perforations complicating endoesophageal management of esophageal varices were a high-risk subset with an 83% mortality rate. CONCLUSIONS: Esophageal perforation remains an important thoracic emergency. Aggressive operative therapy remains the mainstay for treatment; however, conservative management may be preferred for contained perforations and the esophageal T tube may be used for late perforations.

Aged↗
PubMed2004

Personal management of 57 consecutive patients with esophageal perforation.

BACKGROUND: Esophageal perforation is a surgical emergency associated with high morbidity and mortality. There is no consensus regarding the appropriate management of this life-threatening condition. METHODS: A retrospective review was made of 57 patients with esophageal perforations treated at the Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between September 1986 and December 2001. RESULTS: Forty-four (77%) perforations were due to iatrogenic causes, spontaneous perforations occurred in 6 patients (11%). Foreign body ingestion caused perforation in 4 (7%), followed by blunt trauma in 2 (4%) and caustic injury in 1 patient. A total of 6 (11%) patients had cervical injury, 49 (86%) patients had thoracic, and 1 patient had abdominal esophageal injury. Thirty-three (58%) patients underwent emergency esophagectomy, 4 (7%) patients underwent primary repair, and 4 patients (7%) underwent drainage alone, whereas 16 (28%) patients were managed by nonoperative treatment. Using these treatment principles, we achieved 86% survival rate for all patients. Eight (14%) patients died. Spontaneous perforation had the highest mortality (67%). CONCLUSIONS: Esophageal perforation needs aggressive treatment. The treatment depends mainly on two factors: perforation in a healthy esophagus, and perforation with a preexisting underlying intrinsic esophageal disease causing distal obstruction. Esophageal perforation associated with stenotic lesions (benign or malignant) needs esophageal extirpation. Perforation in a healthy esophagus should be treated by primary closure if encountered early. Nonoperative conservative treatment is appropriate when esophageal perforation is encountered late.

Adolescent↗
PubMed1998

Gastrointestinal perforation after pediatric orthotopic liver transplantation.

PURPOSE: The aim of this review was to determine the incidence of gastrointestinal perforation after pediatric liver transplantation and to identify risk factors and clinical indicators that may lead to an earlier diagnosis. METHODS: A retrospective chart review of all children who presented with gastrointestinal perforation after liver transplantation at our institution between January 1, 1987 and August 1, 1996 was performed. RESULTS: One hundred fifty-seven orthotopic liver transplants were performed in 128 children. Fifty-eight reexplorations, excluding those for retransplantation, were performed in 38 children. Ten perforations occurred in six children (incidence, 6.4%). Two children required multiple reexplorations because of several episodes of perforation. The sites of perforation were duodenum (n=1), jejunum (n=8), and ileum (n=1). A single-layer closure was used to repair five perforations, two-layer closures in four, and resection with primary anastomosis in another. The type of repair did not affect the occurrence of subsequent perforations. All the children were less than 18 months old. Four children had undergone prior laparotomy. All children had choledochoenteric anastomoses, but only one had a perforation associated with it. One child sustained bowel injury during the dissection for the liver transplant, but none of the perforations occurred at this site. Bowel function had returned before perforation in five children. Five children were receiving systemic antibiotics at the time of their perforation, and none had been dosed with pulse steroids for rejection. All of the children had significant changes in their temperature. Acute leukopenia developed in one child. A leukocytosis developed in the rest of the children. Abdominal radiographs demonstrated pneumoperitoneum in only one child. All children had positive culture findings from their abdominal drains. Cytomegalovirus developed in one child. Although the diagnosis of gastrointestinal perforation after pediatric liver transplant remains difficult, positive drain culture findings and significant alterations in temperature and leukocyte counts suggest its presence. Pneumoperitoneum is rarely present. CONCLUSION: A high index of suspicion and timely laparotomy, especially in children less than 2 years of age, may be the only way to rapidly diagnose and treat this potentially devastating complication of liver transplant.

Humans↗
PubMed2006

Colonic perforation at CT colonography: assessment of risk in a multicenter large cohort.

PURPOSE: To assess retrospectively the incidence, clinical features, and treatment of colonic perforation at computed tomographic (CT) colonography in a large multicenter cohort. MATERIALS AND METHODS: The study was performed in accordance with the institutional ethics committees' requirements of a retrospective review in each of the participating centers, and no informed consent was required. A review of all patients who underwent CT colonography between January 2001 and December 2004 in 11 medical centers representing more than 95% of studies performed in a single country was performed to determine the rate of colorectal perforation. Data about patient demographics and patient- and procedure-related risk were recorded. Information about the location of the perforation, its likely mechanism, and treatment was collected. Analysis included calculation of rates of colonic perforation and surgical treatment and of 95% confidence intervals. RESULTS: A total of 11 870 CT colonographic studies were performed in 6837 (57.6%) men and 5033 (42.4%) women (mean age, 59.9 years; range, 38-90 years) with seven cases of colorectal perforation, yielding a risk rate of 0.059% (one of 1696 studies; 95% confidence interval: one of 974, 971 of 6537). The mean age of the patients with perforation was 77.8 years. Six (84%) of seven cases of perforation occurred in symptomatic patients at high risk for colorectal neoplasia, and one (16%) occurred in an asymptomatic average-risk patient. All studies were performed after insufflation of room air. Six (84%) cases of perforation occurred in patients in whom a rectal tube was inserted, and in five of them, a balloon was inflated. Five (71%) cases of perforation occurred in the sigmoid colon; and two (29%), in the rectum. Four (57%) patients (one in 2968 patients; 95% confidence interval: 1.5 in 10 000, 14.7 in 10 000) required surgical treatment. Possible factors that contributed to perforation were left inguinal hernia containing colon (n = 4), severe diverticulosis (n = 3), and obstructive carcinoma (n = 1). CONCLUSION: Perforation of the colon and rectum is a rare complication of CT colonography. Older age and underlying concomitant colonic disease were present in patients with perforation.

Adult↗
PubMed2004

Endoscopic perforation rates at a Canadian university teaching hospital.

BACKGROUND: Despite advances in training, operative techniques and endoscopic technology, upper and lower endoscopic procedures continue to have potential for intestinal perforation. Perforation rates provided to patients at the time of consent have frequently been derived from historical cohorts and survey datasets. OBJECTIVE: This study examined the perforation rates of upper and lower endoscopic procedures at a major Canadian tertiary care centre. METHODS: Inpatient and outpatient gastroscopies and colonoscopies performed during a three year period were evaluated. Endoscopies with perforations occurring within 14 days of procedure were retrospectively isolated using the International Classification of Diseases - 9th Revision code descriptions, then retrieved and hand searched to confirm a procedure-related perforation. Data were extracted to identify risk factors and patient outcomes. RESULTS: A total of 21,217 endoscopies (13,792 gastroscopies and 7425 colonoscopies) were reviewed. Of these, 359 were identified, isolated and hand searched for confirmation of a perforation event. Eighteen were found to have an endoscopy-associated perforation. Ten perforations occurred with colonoscopy (0.13%) (incidence, 1.3/1000 procedures), resulting in one death (0.013%) (incidence, 0.13/1000 procedures). Eight perforations occurred with gastroscopy (0.06%) (incidence, 0.6/1000 procedures), resulting in zero mortality. Of colonoscopy procedures the rate of perforation with diagnostic colonoscopy was 0.13% (incidence, 1.3/1000 procedures) and with therapeutic colonoscopy was 0.14% (incidence, 1.4/1000 procedures). Of gastroscopy procedures the rate with therapeutic gastroscopy was 0.15% (incidence, 1.5/1000 procedures). No perforations occurred with diagnostic gastroscopy. CONCLUSION: Gastroscopy and colonoscopy procedures, especially those with therapeutic maneuvers, continue to carry morbidity and mortality risks associated with perforation.

Adult↗
PubMed2000

Tympanic membrane Patcher: a new device to close tympanic membrane perforations in an office setting.

OBJECTIVE: To assess a new device intended to cover tympanic membrane (TM) perforations in an office setting. STUDY DESIGN: Not all patients with TM perforations require or choose tympanoplasty surgery. Alternatives to surgery (e.g., paper and plastic onlay) have limitations that prompted a need for an alternative method. A new, simple device, designed to be inserted into the perforation, is made out of a very soft silicone in the shape of a sealed tympanostomy tube. The TM Patcher is self-stabilizing without adhesives. SETTING: An outpatient office. PATIENTS: Twenty-nine patients with 30 consecutive dry TM perforations, who volunteered to participate in the study. Patients with known cholesteatomas or persistent drainage were excluded. INTERVENTIONS: In the office, patients had the Patcher inserted into their dry TM perforation. No anesthetics were needed. MAIN OUTCOME MEASURES: Hearing was tested before and after patching by conventional audiometry. The ears were assessed for Patcher position, perforation status, and infection. RESULTS: Patients with normal ossicular chains had immediate improvement of hearing. No patient experienced hearing loss. Twenty-six of 30 patients (87%) were free of infection. Two patients (7%) with persistent drainage were taken to surgery and were found to have mastoid disease (cholesteatoma or granulation tissue). Three patients (10%) had rare otorrhea after patching and were treated by drops or temporary removal of the Patcher. Two of these three ears subsequently became dry and then healed. Small perforations often healed or became smaller (46% of 3-mm perforations) despite failure of tympanoplasty or conventional office patching with a flat piece of paper or plastic. Perforations >5 mm did not heal; however, these patients simply continued wearing their Patcher and benefited by protection of their middle ear, typically with improved hearing and resolution of tinnitus. Occasional spontaneous lateralization was allowed to occur in the small perforations, which often later healed. In larger perforations, the Patcher was simply repositioned. CONCLUSIONS: The Patcher is a safe and effective alternative for office patching of dry perforations when surgery is contraindicated or is refused by the patient. New materials should increase healing rates when applied to a Phase II Patcher.

Adolescent↗
PubMed2001

Acute colonic perforation associated with colorectal cancer.

Our purpose was to evaluate long-term outcome in patients presenting with acute colonic perforation in the setting of colorectal cancer. We conducted a retrospective review of 48 consecutive patients presenting with acute colonic perforation associated with colorectal cancer at a single institution. Patients presented either with free air or acute peritonitis. No patients with colonic obstruction were included. Forty-eight patients presented with colon perforation. Thirty-six had perforation at the tumor, 11 proximal to the tumor, and one distal to the primary tumor. Patients who perforated proximal to the tumor were older (74.5 +/- 2 vs 64.7 +/- 3; P < 0.04) and had a longer length of stay (46.8 +/- 17 vs 11.6 +/- 1 P < 0.001). Fourteen patients had stage II disease, 19 stage III, and 15 stage IV. Thirty-day mortality was 14 per cent (n = 7) with nine in-hospital deaths. Of 30-day survivors 29 (60%) had curative resection (21 with local perforation and nine with proximal perforation). Of these 14 received adjuvant chemotherapy. Eleven patients (33%) had either unresectable or metastatic disease on exploration. Mean follow-up was 21.5 months. Ten patients developed metastatic disease after potentially curative resections. Of these nine patients had perforations of the primary tumor. Three patients developed local recurrence and all had local tumor perforations. One-year survival was 55 per cent (n = 16). Five-year disease-free survival was 14 per cent (n = 4). There were no long-term survivors after perforation proximal to the tumor, although disease stage was comparable in both groups. We conclude that perforation proximal to a cancer is associated with a higher perioperative mortality and worse long-term outcome when compared with acute perforations at the site of the tumor. Long-term survival requires both aggressive management of the concomitant sepsis and definitive oncologic surgery.

Acute Disease↗
PubMed1998

Growth factors in tympanic membrane perforations.

OBJECTIVE: Little is known about the arrested healing of chronic central tympanic membrane perforations and the mechanism involved in this process. Some authors have traced the failure to a growth factor deficiency at the perforation margin. In addition, recently, several growth factors have been tried out to improve tympanic membrane (TM) closure in animals. The authors sought to determine the expression of some well-known growth factor peptides in normal human TM and in TMs with a chronic central perforation. MATERIALS AND METHODS: Total TM specimens were obtained from patients with a normal TM (N = 10) soon after death and from patients with a chronic perforation (N = 20) undergoing myringoplasty with use of an allograft TM. Formaldehyde solution-fixed TMs were analyzed after immunohistochemical staining using highly purified monoclonal antibodies to determine whether epidermal growth factor receptor (EGF-r), transforming growth factor-alpha (TGF-alpha), basic fibroblast growth factor (b-FGF), or transforming growth factor-beta 1 (TGF-beta 1) was expressed in the TMs. RESULTS: The distribution pattern for EGF-r, TGF-alpha, and b-FGF was similar in perforated and nonperforated TMs. In contrast to this, TGF-beta 1 staining was markedly different in perforated and nonperforated TMs. No or minimal TGF-beta 1 was observed in normal TMs, whereas TGF-beta 1 staining was prominent in perforated membranes, mostly at the perforation border. CONCLUSIONS: The authors experimental findings imply that EGF-r, b-FGF, and TGF-alpha expression are not significantly different in TMs with and without a central chronic perforation. However, for TGF-beta 1, the authors found an increased staining pattern in perforated TMs when compared with that of normal TMs, and staining at the fibrotic and scarred perforation margin was pronounced. Based on these findings, the authors speculate on the possible role of TGF-beta 1 in the development of the fibrotic scar at the perforation margin explaining the deficient healing pattern of tympanic membranes in chronic otitis media. Possible clinical implications for the future, including growth factor therapy, are discussed.

Antibodies, Monoclonal↗
PubMed1998

Esophageal perforations encountered during the dilation of caustic esophageal strictures.

BACKGROUND: The most common cause of esophageal stricture in children is the accidental ingestion of strong alkalies and the life-threatening complication of dilations for treating caustic esophageal strictures is esophageal perforation. METHODS: During a 25-year period between 1971 and 1996, 195 patients with caustic esophageal strictures underwent repeated dilations program and 34 had 36 complicating perforations (17.4%) at the Hacettepe Children's Hospital Department of Pediatric Surgery. A retrospective clinical study was performed to evaluate the risks, results and outcome of esophageal perforations encountered among strictured esophaguses. Thirty-four patients, of whom 19 were male (56%) and 15 female (44%) with 25 (74%) being younger than 5 years of age, were evaluated retrospectively. RESULTS: There was no relation between the type of therapy against stricture formation and perforation of the esophagus. Seventy-five percent of perforations occurred during antegrade dilations with stiff woven dilator and most perforations (69.4%) occurred in the first, second or third dilations. Esophageal perforation was suspected during dilation procedure in 7 perforations while the remaining 29 were diagnosed following a suggestive clinical course. The diagnosis of perforation was confirmed by chest X-ray, esophagography, and esophagoscopy in 30, 5, and 1 perforations respectively. The treatments included antibiotics, digoxin and drainage through gastrostomy among 13 patients, and additionally chest tube drainage among 12 patients, and additionally feeding jejunostomy among 7 patients while three patients underwent only feeding jejunostomy in addition to antibiotics, digoxin and drainage through gastrostomy. Six patients (18%) died, 6 patients (18%) required esophageal replacement for previous cervical esophagostomy or persisting stricture that impairs swallowing. Esophageal strictures in 22 patients (64%) have been treated by dilations. Redilation therapy started within 3 months following perforation and 68% of patients required 2 to 3 years of chronic dilations to be accepted as normal swallowers. CONCLUSIONS: The esophageal perforations encountered during dilating caustic esophageal strictures present a spectrum from a minimal peri-esophageal leakage to massive rupture with pneumothorax causing mediastinal shift and sudden death. The diagnostic and therapeutic approaches should be individualised according to the place of the patient in this spectrum.

Burns, Chemical↗
PubMed1998

Septal perforation repair with acellular human dermal allograft.

BACKGROUND: Connective tissue autografts are commonly used as interpositional grafts between septal flaps in the repair of septal perforations. The most common graft materials used include temporalis fascia and pericranium, both of which are accompanied by donor site morbidity, do not provide septal bulk, and are exceedingly thin and difficult to manage. OBJECTIVE: To study the use of an acellular human dermal allograft (AlloDerm, LifeCell Corp, The Woodlands, Tex) as a connective tissue interpositional graft in septal perforation repair. SETTING: Private facial plastic surgery and reconstructive practice of 1 of the authors (R.W.H.K.), Houston, Tex, and the private and university practice of another author (H.F.), Alexandria, Egypt. PATIENTS: Twelve consecutive patients with septal perforation who received the acellular dermal allograft constituted this evaluation. The causes of the septal perforations were previous nasal surgery, previous nasal cautery, or cocaine use by the patient. DESIGN: Interposition grafting between mucoperichondrial flaps for septal perforation repair was accomplished with decellularized human dermal grafts. Follow-up periods ranged from 3 to 14 months. MAIN OUTCOME MEASURES: The repair was considered successful when, on postoperative examination at 3 months, the right and left mucoperichondrial flaps were entirely healed. From the experience of 1 author (R.W.H.K.) with the repair of more than 75 septal perforations, no perforation that was healed at 3 months broke down at a later date, unless trauma or cocaine use occurred after the operation. An outcome was considered acceptable but nondesirable if a perforation was still present after the operation but the number and severity of the patient's symptoms were reduced and the perforation was considerably smaller than before the operation. RESULTS: Eleven of the 12 patients had successful outcomes with complete closure of their perforations. The 1 remaining patient had an acceptable result but incomplete closure; his initial perforation of 3 cm was reduced to 5 mm, making him asymptomatic after surgery. CONCLUSION: Acellular human dermal grafts can be used as connective tissue interpositional grafts in the repair of septal perforations with success rates similar to the use of temporalis fascia, mastoid periosteum, or pericranium. One distinct advantage is the absence of donor-site morbidity. In addition, this graft material is thicker and easier to place and suture and may give more substance to the repaired septum.

Adult↗
PubMed1990

Synaptic remodelling of perforated synapses during development and maturation in a visual projection area in birds.

Perforated synapses are characterized by the appearance of one or more discontinuities in the postsynaptic density (PSD). These synapses are thought to represent intermediate stages in synaptic remodelling and turnover. To determine the dynamic level of these processes, the development of perforated synapses at different ages was examined in the neuropil of the ectostriatum, a visual projection area in birds. The overall number of perforated synapses per unit volume increases during development. Single and multiple perforated synapses, however, show a different developmental trend. Between 20 and 100 days, when the number of multiple perforated synapses decreases by 46%, single perforated synapses increase by 83% in number per unit volume. No significant changes in single or multiple perforated synapses can be observed at younger ages (i.e., 5 or 10 days). Various parameters increase between 10 and 20 days, followed by a reduction at 100 days: The relative frequency of perforations per synaptic contact, the length of the postsynaptic density including the size of the perforation, the length of the synaptic contact zone in perforated synapses excluding the size of the perforation, and the size of the perforation follow the same trend.

Animals↗
PubMed2005

Perforator flaps in head and neck surgery.

A 'perforator flap' is a flap of skin or subcutaneous tissue that is based on the dissection of a 'perforating vessel'. Over the past few years a large number of 'perforator flaps' have been devised and described. By reducing any muscle harvest and trauma to a minimum, perforator flaps aim to minimize donor site morbidity whilst providing the reconstructive surgeon with more versatility than other flap types. The principal perforator flaps are discussed, particularly those employed in head and neck reconstruction including 'free style perforator flaps'. Methods of locating perforating vessels for the use of perforator flaps are described. The technique of perforator flap harvest is illustrated as exemplified in the anterolateral thigh perforator flap. Advantages in the use of this flap for head and neck reconstruction are discussed and are compared with that of non-perforator flaps, particularly the Radial Forearm Flap. The role of the primary thinning of perforator flaps is discussed. The versatility of the anterolateral flap is discussed, which may well supersede the Radial Forearm Flap as the principal soft tissue flap used in head and neck surgery.

Connective Tissue↗
PubMed1998

Ex vivo comparison of four lithotripters commonly used in the ureter: what does it take to perforate?

We hoped to determine the number of pulses and energy needed to create acute ureteral perforations with four different lithotripters in a reproducible ex vivo model. A simple model was constructed to control variables in the testing such as wall thickness, intraluminal pressure, distance between the probe tip and ureter, and power delivered to tissue. Segments of domestic pig ureter were prepared and fixed in position in a normal saline (NS) bath at room temperature. We then attempted perforation with the holmium:YAG (HoL) laser, coumarin pulsed-dye laser (CdL), electrohydraulic lithotripter (EHL), and pneumatic impactor (PI) by placing the instrument probes at right angles to the ureteral wall. The ureter was filled with a methylene blue-stained solution of NS at 90 cm H2O pressure via a urodynamics catheter, and perforation was recorded on initial extravasation of dye. The endpoints measured were time to perforation and total energy required. At 0.5 mm of separation between the wall and probe, the HoL perforated the ureter in an average of 2 seconds and 0.01 kJ delivered at 5 W (10 Hz and 0.5 J/pulse). The EHL perforated at an average of 24.44 +/- 8.77 seconds and a total energy of 0.01 +/- 0 kJ. The CdL was able to perforate but at much longer intervals (257.51 +/- 99.08 seconds) and higher energy levels (12.88 +/- 4.95 kJ) on average than either the EHL or HoL. Lastly, the PI was unable to perforate the ureter in more than 6 continuous minutes of application. In addition, we found that at 2-mm separation between the HoL probe tip and the ureteral wall, acute perforation was not possible even at very high power settings. We conclude that although each endoscopic lithotripter has advantages as well as disadvantages, in this ex vivo model, it was clear that the HoL and EHL can easily perforate the ureter and must be used with vigilance. It was found that at 2 mm of separation between the probe and target, the HoL, was unable to perforate acutely. The CdL and PI were associated with a much higher safety index, and the PI was unable to produce ureteral perforation.

Acute Disease↗
PubMed2002

The vascular anatomy of the lower anterior abdominal wall: a microdissection study on the deep inferior epigastric vessels and the perforator branches.

The deep inferior epigastric artery provides the main blood supply to the lower abdominal wall. Microdissection of the artery, its main branches, and the perforator vessels was undertaken in 20 cadavers. The artery was found to be associated with two veins in most of the cases (90 percent). The lateral division of the deep inferior epigastric artery and the perforator vessels it gives are more dominant (80 percent of cases) than the medial perforators (20 percent of cases). The lateral perforators were greater in number (80) and more consistent than those that arose from the medial division (28). The musculocutaneous perforators are the most important perforators supplying the anterior abdominal wall. An average of 5.4 large perforators (>0.5 mm in diameter) were dissected in each case. These perforators are mostly contained in the area lying laterally and below the umbilicus, with an average distance of 4 cm from the umbilicus. The musculocutaneous perforators may have a direct or indirect course. Larger perforators (>0.5 mm in diameter) were found to have a direct course through the subcutaneous fat to the skin. Smaller perforators do not reach the skin but terminate at the level of the deep fat layer by branching after piercing the rectus sheath. The direct perforator vessels with their associated veins (microdissection) keep a consistent diameter before dividing at the subdermal level and end by contributing to the subdermal plexus.

Abdominal Muscles↗