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PubMed2000

The use of pedicled perforator flaps for reconstruction of lumbosacral defects.

Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in the nonparaplegic patient. Traditional options for closure include local rotation or transposition flaps and musculocutaneous flaps. These flaps, however, are not an optimal option in previously irradiated or operated areas, or in cases of large defects. Application of the perforator principle to the traditional musculocutaneous flap creates perforator flaps, which are an additional tool in the treatment of these defects in the nonparaplegic patient. A large amount of healthy, well-vascularized tissue can be transferred on one perforator without sacrificing important underlying muscles. The arc of rotation is also larger than in traditional flaps. The authors present an anatomic overview of three types of pedicled perforator flaps: the superior gluteal artery perforator flap, the lumbar artery perforator flap, and the intercostal artery perforator flap. They also report 4 patients in whom a pedicled perforator flap was used to reconstruct a large lumbosacral defect.

Adult↗

PubMed2000

Effect of the delay phenomenon in the rat single-perforator-based abdominal skin flap model.

During the last decade, innovations in reconstructive surgery have presented a new type of flap called the "perforator-based flap." Perforator-based flaps became useful alternatives for solving difficult problems. In the authors' previous study, they created a single musculocutaneous perforator-based abdominal skin flap. In their current study they evaluate the effect of various surgical delay procedures on this model. They divided 32 Sprague-Dawley rats equally into four groups (one control group and three delay groups). Three different delay procedures were employed in the delay groups. In one group, only the flap boundaries were incised (delay group 1). In the other delay groups, flap boundaries were incised and the contralateral (opposite side of the pedicle, delay group 2) or ipsilateral (pedicle side, pedicle left intact; delay group 3) musculocutaneous perforators were ligated. The period of delay was 1 week in all groups. After 1 week, a single-perforator-based abdominal skin flap was elevated as in the control group. One week after the final procedure, surviving skin areas were calculated and microangiograms were acquired. The mean surviving skin area was 75% +/- 3% (standard deviation) in the control group, 97% +/- 3% in delay group 1, 81% +/- 6% in delay group 2, and 96% +/- 3% in delay group 3. Delay group 2 showed substantial necrosis 1 week after the delay procedure and was thus excluded from the study. Results were analyzed using one-way analysis of variance, and post hoc analyses were performed using Tukey's multiple comparison test. The authors observed the advantages of the delay phenomenon in the two delay groups (p < 0.05). Microangiograms were examined grossly, and a marked difference between the two delay groups and the control group was observed. Many dilated choke vessels were seen in delay groups 1 and 3. Incising the flap boundaries with or without ligating the ipsilateral perforators (keeping the pedicle intact) 1 week before harvesting single-perforator-based abdominal skin flaps in the rat results in a delay effect. Conversely, incising the flap boundaries and ligating the contralateral perforators have no delay effect in this model.

Abdomen↗

PubMed2003

Perforator flaps: evolution, classification, and applications.

In this article, the authors review the literature regarding perforator flaps. Musculocutaneous perforator flaps have evolved from musculocutaneous flaps and offer several distinct advantages. By sparing muscle tissue, thus reducing donor site morbidity and functional loss, perforator flaps are indicated for a number of clinical problems. The versatility of the perforator flap makes it ideal for the reconstruction of three-dimensional defects such as breast reconstruction or as a thin flap for resurfacing shallow wounds when bulk is considered a disadvantage. The authors review the historical development of the perforator flap and discuss the advantages and disadvantages of perforator flaps compared with free and pedicled musculocutaneous flaps. The nomenclature traditionally used for perforator flaps is confusing and lacks a standardized anatomic basis. The authors present a method to describe all perforator flaps according to their artery of origin.

Humans↗

PubMedDate not supplied

Gastrointestinal perforations associated with interleukin-2 administration.

High-dose interleukin-2 (IL-2) results in objective clinical regression in up to 17% of patients with metastatic melanoma and renal cell carcinoma, with about half of these patients experiencing a complete regression of all lesions. Gastrointestinal (GI) perforation is a rare but potentially serious complication of IL-2 administration. A retrospective review of all patients treated with IL-2 in the Surgery Branch of the National Cancer Institute (NCI) between Nov. 1, 1984, and May 1, 2002, was performed. In addition, a review of the published English literature on GI perforation in conjunction with IL-2 therapy was performed. Among the 1,797 patients treated at the NCI, there were eight (0.44%) cases of GI perforation. Seven of the eight patients were treated with high-dose (720,000 IU/kg every 8 hours) intravenous IL-2 (7/1,680, 0.42%) and one was treated with subcutaneous IL-2 (1/117, 0.85%). These patients developed various signs and symptoms of GI perforation. Six patients developed abdominal pain, yet only two of the eight patients had a fever. All six patients who underwent radiographic evaluation prior to diagnosis had free intraperitoneal air seen on the study. The location of the perforation included the stomach, small bowel, appendix, and colon. All underwent surgical treatment successfully, and four patients received further IL-2 therapy after recovering from the perforation. With the patients presented in this article, there have now been 20 cases reported in the English literature. Two of the patients at the NCI had a ruptured appendix, which has not been previously reported in the literature. The key to early diagnosis of GI perforation during IL-2 therapy is radiographic evaluation. Patients with GI perforation can be safely retreated with IL-2 if they are given adequate time to recover from their surgical intervention and if careful assessment is performed to rule out residual infection.

Adult↗

PubMedDate not supplied

Glove perforation in pediatric orthopedic practice.

A prospective study was conducted to assess the glove perforation rate during 100 consecutive pediatric orthopedic operations. Eight hundred fifty-four gloves were tested for perforations. The overall glove perforation rate was 8.43%. Assistant surgeons had a rate of 45.8%, surgeons 33.4%, and scrub nurses 20.8%. More perforations were noticed on the left glove; the thumb and index finger were the most common sites of perforation. The duration of surgery was significantly related to the perforation rate. Two patients had postoperative wound infections and the gloves of surgeons and assistant surgeons were found to be perforated. Every attempt needs to be made to reduce the risk of glove perforation.

Equipment Failure↗

PubMed1994

Evaluation of fasciocutaneous perforators using color duplex imaging.

Technological improvements in conventional ultrasound, including color duplex imaging, have greatly facilitated the evaluation of vascular-related problems for virtually every specialty. Higher-frequency transducers now permit the scanning of superficial depths beneath the skin surface with high sensitivity for an analysis specific to the microcirculation. This attribute has already been recognized as a valuable tool for the preoperative mapping of musculocutaneous perforators. A logical extension of this capability would be for the localization and calibration of deep fascial perforators, which may have even greater clinical significance because anomalies at this level are more the rule rather than the the exception. Over the preceding 10-month period, all eight elective fasciocutaneous flaps performed in eight patients had initial scans using color duplex imaging to identify and calibrate all relevant cutaneous perforators. All fasciocutaneous flap subtypes were included. If feasible at the time of flap elevation, all identified perforators were dissected and measured. All were found at the exact site as marked preoperatively, and their diameter closely approximated that predicted. The occasional unanticipated presence in vivo of minor perforators suggests that color duplex imaging may not be reliable for fascial perforators less than 0.5 mm in diameter. Since perforator caliber qualitatively is a major determinant of flow, color duplex imaging can then objectively establish a hierarchy of the importance of perforators in a given region. From such data, the definition of new and more reliable fasciocutaneous flap donor territories should be forthcoming.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed2004

A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity.

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.

Adolescent↗

PubMed2004

The medial sural artery perforators: anatomic basis for a surgical plan.

We performed an anatomic study on 20 fresh lower limbs. Resin was injected in the popliteal artery. Medial sural artery perforator flaps were sculptured according to anatomic markings. On average, length of flaps was 12.9 cm, width was 7.9 cm; all 38 perforators were musculocutaneous: 1 perforator was always found (on average, 1.9 per flap). All perforators gathered between 7 and 18 cm from the popliteal crease; 34.2% of perforators arose on the midline of the medial head of gastrocnemius muscle; before entering the fascia, the perforator artery diameter was on average 0.5 mm. Two configurations of the intramuscular course of perforators were found. Sixty-six percent of perforators originated from the lateral branch of the medial sural artery, 34% from the medial one. These results improve the anatomic knowledge of the medial posterior calf region and allow us to describe a convenient plan to make flap sculpturing easier.

Arteries↗

PubMed1989

A clinical and roentgenological study of 55 cases of root perforation.

The treatment outcome of 55 root perforations in man were related to pretreatment conditions and various treatment procedures used, with a mean recall period of 3 years 5 months. In this study maxillary teeth were perforated three times more often (74.5 per cent) than mandibular teeth (25.5 per cent); 47 per cent of the perforations were due to endodontic and 53 per cent due to prosthodontic treatment. The buccal and mesial root surfaces as well as the midroot areas were most often perforated. In 25 per cent, radiographic changes were directly related to the perforated areas. Twenty-eight perforations were repaired by orthograde fillings with gutta-percha and Kloro-percha N-phi; eight received a combined orthograde and surgical repair, and in only three cases a surgical approach was used. Four cases received no treatment but were recalled, and twelve perforations showed a size and location hopeless for repair; the teeth were therefore extracted. Five failures of the primary orthograde treatment group later underwent surgical treatment and were followed up for 3 years 3 months. The overall success rate in the primary treatment group of teeth was 56 per cent while 36 per cent became failures. Five failures were retreated, and four of these became successful. A combined orthograde and surgical repair of the perforations provided the most favourable outcome with 92 per cent successful. The study stresses the importance of preventing this type of treatment complication.

Humans↗

PubMed2005

Perforation repair with mineral trioxide aggregate: a modified matrix concept.

AIM: To present a modified matrix concept for repair of root perforations using mineral trioxide aggregate (MTA). SUMMARY: Root perforations may occur during preparation of endodontic access cavities or during post-space preparation. The perforation creates the potential for an inflammatory reaction in the periodontal ligament. A concept for the repair of root perforations is presented using a matrix of resorbable collagen. This matrix reconstructs the outer shape of the root and facilitates the adaptation of MTA. The indications for the use of MTA are discussed. Two clinical cases of 5-year successful root perforation repair using the technique are presented. KEY LEARNING POINTS: Long-term perforations with periodontal inflammation can be successfully treated with MTA. Matrices for MTA placement can be developed with commercially available collagen. Infection control within the root canal and at the perforation site is required for satisfactory perforation repair and healing.

Aluminum Compounds↗

PubMed2005

Outcomes after cardiac perforation during radiofrequency ablation of the atrium.

BACKGROUND: Perforation during catheter procedures in either the atrium or ventricle is relatively uncommon, but potentially fatal if tamponade ensues. This study analyzes the occurrence and outcomes of cardiac perforation during catheter-based radiofrequency ablation procedures in the left atrium. METHODS: All patients with a periprocedure perforation who have undergone radiofrequency ablation for atrial fibrillation (AF) or tachycardia were included. RESULTS: Of 632 procedures performed from January 1999 to October 2004, 15 (2.4%) were complicated by perforation requiring pericardiocentesis. The perforation site was left atrium in 9 (60.0%), right atrium in 1 (6.7%), and right ventricle in 5 (33.3%). Intracardiac echocardiography was used in 13 (86.7%) and revealed an effusion before overt instability in 11 (73.3%). Thirteen (86.7%) patients developed a blood pressure <60 mmHg. The pressure stabilized in all patients after pericardiocentesis (hypotension to intervention: 10.1 +/- 5.1 minutes). The total blood volume removed was 848 +/- 880 mL (left atrium/right atrium: 1,074 +/- 1,002 vs right ventricle: 396 +/- 266, P = 0.168). Two patients required surgery to close left atrium dome perforations. The ablation was completed in 7 (46.7%) patients. Ten (66.7%) later developed early reoccurrence of AF. All patients were neurologically intact at hospital discharge. During a 1.5 +/- 1.1 year follow-up, AF was eliminated (n = 4) or controlled (n = 1) in 5 (71.4%) patients with complete procedures, and 2 (20.0%) patients underwent successful repeat ablation. CONCLUSION: The incidence of perforation during ablation of the left atrium is low. Most perforations occur in the left atrium; however, few require surgical closure. Although less than with uncomplicated procedures, the majority of patients with complete ablations achieve long-term elimination of AF.

Adult↗

PubMed1993

Mechanisms underlying induction of long-term potentiation in rat medial and lateral perforant paths in vitro.

1. The mechanisms underlying the induction of long-term potentiation (LTP) in the medial and lateral perforant paths were studied by recording excitatory postsynaptic potentials (EPSPs) from rat dentate granule cells in vitro using extracellular and whole-cell recording techniques. 2. Paired stimuli (interstimulus interval, 50-1,000 ms) resulted in facilitation of the lateral and depression of the medial perforant path-evoked EPSPs, respectively. This physiological difference was used to isolate responses evoked by stimulation of a single path. 3. Tetanic stimulation induced LTP in both pathways, although the magnitude of LTP in the lateral perforant path was significantly less than that in the medial perforant path. Both forms of LTP were blocked by the N-methyl-D-aspartate (NMDA) receptor antagonist D-2-amino-5-phosphonovaleric acid (D-APV). 4. Buffering intracellular calcium by loading granule cells with the calcium chelator bis (O-aminophenoxy) ethane-N,N,N',N'-tetraacetic acid prevented LTP in both pathways. 5. Pairing of low-frequency (0.25 Hz) afferent stimulation with postsynaptic depolarization induced LTP in the medial but not the lateral perforant path. However, pairing of higher-frequency stimulation (1-4 Hz) with postsynaptic depolarization did potentiate the lateral perforant path-evoked EPSP in some cells. 6. Both the medial and lateral perforant path-evoked EPSPs had two components; a fast component blocked by the non-NMDA receptor antagonist 6-cyano-7-nitroquinoxaline-2,3-dione and a slower, voltage-dependent component blocked by D-APV. 7. The results indicate that the induction of LTP in both the medial and lateral perforant paths requires activation of postsynaptic NMDA receptors and a rise in intracellular calcium.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed2005

The nasal airflow in noses with septal perforation: a model study.

BACKGROUND: Septal perforation is a common clinical problem in rhinology. Affected patients suffer from a dry nose, crusts as well as recurrent epistaxis and sometimes an inspiratory whistle. The aim of this study was to investigate the underlying flow dynamic mechanisms. METHODS: The physical flow effects of such pathologies were examined in functional nose models (box models) and anatomically exact models of the nose. Therefore, septal perforations of different sizes and localisations were studied in straight and deviated nasal septa. RESULTS AND CONCLUSIONS: It could be seen that the localisation of the perforation has no impact on the flow pattern. In large septal perforations, the air jet collides with the posterior edge of the perforation and disintegrates turbulently. Since airflow is physiologically turbulent in the posterior part of the nose, posterior perforations do not cause clinical complaints. The inspiratory whistling sound during respiration is based on the principle of a lip whistle. Large perforations do not cause a whistling sound. The necessary high flow velocity needed in large perforations is usually not achievable.

Humans↗

PubMed1993

Surgical glove perforations in otolaryngology: prevention with cut-resistant gloves.

This study examines the role of cut-resistant, "orthopedic-type" gloves in prevention of exposure of surgical personnel to infectious body fluids through surgical glove perforation. The incidence of glove perforations in 12 consecutive cases of intermaxillary fixation (IMF) was studied. Surgeons were double-gloved with standard latex gloves and wore cut-resistant gloves between the outer and inner gloves. As controls, six cadaver heads were wired into IMF with surgeons double-gloving without the cut-resistant glove. The rates of latex glove perforation were then compared between the two groups. Fifty-three percent (32 of 60) of outer latex gloves, but no inner latex gloves (0 of 50) were perforated when surgeons wore cut-resistant gloves. In the control group, 45% of outer gloves (9 of 20) and 15% of inner gloves (3 of 20) were perforated. The difference of inner glove perforations--hence cutaneous exposure--between these two groups was statistically significant (p < 0.01). The use of cut-resistant gloves in addition to double-gloving with latex surgical gloves is recommended for facial plastic and reconstructive procedures with metal implants and major head and neck surgery, because these operations have a high rate of glove perforation. Because some loss of dexterity is noted when cut-resistant gloves are worn, the risk of glove perforation must be weighted against the need for optimal dexterity.

Equipment Design↗

PubMed1994

Tympanic membrane perforation in survivors of a SCUD missile explosion.

On February 25, 1990, an Iraqi SCUD missile exploded inside a building housing United States military personnel in Dhahran, Kingdom of Saudi Arabia. One hundred seventy-two individuals who were near the impact site at the time of the blast were interviewed and examined to determine blast injury to the ear. Tympanic membrane (TM) perforation was used as the clinical marker for aural blast injury. Thirty-four personnel had unilateral TM perforation and 28 had bilateral TM perforation. Eighty-six sustained sufficient injury to be hospitalized. Fifty-nine of hospitalized personnel (70%) had TM perforation. Of a total of 90 TM perforations, 39% were estimated to be 25% or less of the tympanic membrane surface area, 36% were 26% to 50%, 16% were 51% to 75%, and 10% were greater than 75%. Morphology of the perforations and estimated proximity to the blast were documented. Personnel distant from the blast, in open doorways or wearing headphones, had relative protection from TM perforation. Historic nuclear blast data were used to estimate the SCUD blast waveform based on measurements of the SCUD impact crater. A mathematical model based on the estimated waveform was validated against the actual field data by comparing the proximity and incidence of TM perforations in the SCUD missile explosion.

Adolescent↗

PubMed2006

Spontaneous biliary tract perforations: an unusual cause of peritonitis in pregnancy. Report of two cases and review of literature.

Spontaneous perforations of the biliary tract are rare in adults and even more so during pregnancy. Perforation of the gall bladder is a potentially fatal complication of cholecystitis. The infrequency of perforation in the setting of calculous disease of the gall bladder is probably due to the thickened wall of the organ that has long been the seat of chronic inflammation. Common bile duct perforations have been reported in adults most commonly in association with choledocholithiasis. The diagnosis of biliary tract perforations is often delayed due to their non specific symptoms, which results in high morbidity. Early diagnosis and aggressive therapy are mandatory to alleviate this condition. Delayed diagnoses and treatment may have more serious consequences for pregnant women than for other patients. Very few cases of biliary tract perforations have been reported in pregnant women. We report two such cases in pregnancy: first of a gall bladder perforation associated with cholelithiasis and the second of a common bile duct perforation in pregnancy in which no apparent cause was found.

Journal Article↗

PubMed1993

The surgical anatomy of the perforating branches of the basilar artery.

The perforating branches of the basilar artery were examined in 14 brain stems injected with india ink or methylmethacrylate. Three groups of the perforators were distinguished: the caudal, the middle, and the rostral. The caudal perforators varied in number from two to five and in diameter from 80 to 600 microns. In addition to their terminal branches, which entered the foramen cecum, the perforators occasionally branched off the pontomedullary artery, the pyramidal vessels, and the hypoglossal branches. The middle perforators arose either separately from the basilar artery or along with the basilar artery collateral branches. They ranged in number from five to nine and in diameter from 210 to 940 microns. The perforators gave rise to the pontomedullary artery (8.3%), the long pontine arteries (25.0%), and the anterolateral vessels (100%). The rostral perforators originated from the terminal part of the basilar artery (91.6%), as well as from the superior cerebellar artery (91.6%) and the posterolateral artery (16.6%). They varied in number from one to five and in diameter from 190 to 800 microns. The anastomoses among various perforating vessels were noted in 41.6 to 66.6% of the cases. The authors discussed the possible clinical significance of the anatomical data observed in this study.

Basilar Artery↗

PubMed2005

Effects of race, insurance status, and hospital volume on perforated appendicitis in children.

OBJECTIVE: Previous research suggests that perforated appendicitis is more common in Medicaid patients, but the roles of minority race and hospital volume remain largely unstudied. We sought to investigate the association of perforated appendicitis in children with minority race, insurance status, and hospital volume. METHODS: We conducted a retrospective, population-based cohort study of 33184 children who had an International Classification of Diseases, Ninth Revision diagnosis code for acute appendicitis in The Kids' Inpatient Database, a pediatric database from 22 states in 1997. A multivariate logistic regression model was developed to determine patient and hospital characteristics predictive of perforated appendicitis. RESULTS: Of 33184 children with acute appendicitis, 10777 (32.5%) were perforated. In multivariate analysis, black (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.10-1.39) and Hispanic (OR: 1.19; 95% CI: 1.10-1.29) children were more likely to have perforated appendicitis than white children. Perforation was also more likely in Medicaid patients (OR: 1.30; 95% CI 1.22-1.39) compared with privately insured children. Annual hospital volume of cases of appendicitis was not significantly associated with perforation in multivariate analysis. CONCLUSIONS: Perforated appendicitis disproportionately affected both children of minority race and children insured by Medicaid. No effect of hospital volume was observed. To reduce this racial disparity, efforts should focus on the causes of delayed diagnosis and the treatment of appendicitis in children of minority race.

Acute Disease↗