Single Perforator Research Articles

Influence of vertical location and spacing of perforators on perfusion in deep inferior epigastric artery perforator flap breast reconstruction: quantitative analysis using indocyanine green angiography.

This study quantitatively assessed perfusion of the deep inferior epigastric artery perforator (DIEP) flap according to vertical location and vertical spacing of perforators during DIEP flap breast reconstruction. In 67 patients who underwent unilateral DIEP flap breast reconstruction between November 2018 and August 2021, flap perfusion was intraoperatively assessed using indocyanine green angiography. Perforators located at or above the umbilicus were defined as vertical zone 1 perforators and those below the umbilicus as vertical zone 2 perforators. Perfusion assessment was conducted in two stages: at stage 1, perfusion solely by single dominant perforators was assessed. At stage 2, the perfusion increment effected by adding a single additional perforator was assessed. Perfused area proportions were compared between patients with dominant perforators in zone 1 versus zone 2. The effect of adding an additional perforator to another vertical zone ("vertical spacing") was also assessed. The perfused proportion was significantly higher among vertical zone 2 perforators compared with zone 1 perforators in the evaluation of single dominant perforators (70% vs. 56%; P<0.001). In the evaluation of incremented perfusion by single additional perforators, the perfused proportion was significantly higher in the vertical-spacing group compared to the no-vertical-spacing group (17% vs. 12%; P=0.004). Fat necrosis developed in 4.5 percent of the patients over at least 6 months of follow-up. DIEP flap perfusion can be affected by the vertical location of perforators, and flap perfusion can be augmented effectively by vertical spacing of perforators.

Abdominoplasty and Breast Augmentation with Outpatient Cosmetic Deep Inferior Epigastric Perforator Flaps.

The authors describe the use of deep inferior epigastric perforator (DIEP) flaps in outpatient cosmetic breast augmentation. The authors reviewed patients who had undergone cosmetic breast augmentation with DIEP flaps over a 12-month period. Any patient who desired breast augmentation, implant exchange, or augmentation mastopexy with concomitant abdominoplasty was considered a candidate for the procedure. All patients underwent an early recovery protocol including microfascial incisions to harvest the DIEP flaps and rib preservation in addition to early recovery after surgery protocols with intraoperative anesthetic blocks. Eleven consecutive patients underwent bilateral cosmetic breast augmentation with DIEP flaps and mastopexy. Overall, all patients reported preoperative dissatisfaction with their abdomen and breasts. Microfascial incisions for single perforator abdominal flaps ( n = 17) averaged 1.7 cm (range, 1.3 to 2.4 cm) and flaps with multiple perforators ( n = 5) averaged 2.4 cm (range, 2 to 2.5 cm). Dissection of recipient internal mammary artery vessels was performed without disruption of the rib. No fascia or muscle tissue was taken during flap dissection. All patients had strong Doppler signals before discharge within 23 hours. No partial or total flap losses, major complications, or take-backs were reported. Patients who desire abdominoplasty and augmentation are ideal candidates for this procedure. Breast augmentation with autologous tissue, particularly the DIEP flap, is an attractive option inherent to the additional abdominal tissue available to harvest. The early recovery protocol allows the surgeon to perform microsurgical breast reconstructions and augmentations in an outpatient setting, with excellent results and no total or partial flap losses, offsetting the high costs associated with the DIEP flap. Therapeutic, IV.

Efficacy of Human Epidermal Growth Factor in the Regeneration of Tympanic Membrane Perforation

Introduction: Majority of tympanic membrane perforations require myringoplasty for closure. Recently, epidermal growth factor (EGF) has been shown to promote the healing of tympanic membrane perforations. Aim: The aim of this study was to find out a simple nonsurgical outpatient procedure to close one-quadrant tympanic membrane perforations that could reduce the hospital stay, medical cost, and morbidity in these patients. Materials and Methods: An interventional prospective randomized clinical study was done on 120 patients at our tertiary hospital. The allocation ratio was 3:1. Pure-tone audiometry, otomicroscopy, and otoenodoscopic recording were performed in all eligible patients who consented to take part in the study. Ninety cases received EGF gel application, whereas 30 controls received antibiotic ofloxacin application. Trichloroacetic acid chemical cautery and fibrin glue application were done in patients of both groups. Results: The closure rate was 97.7% in the EGF group and 70% in the ofloxacin group. The time taken for closure of perforations was 10 to 14 days in the EGF group and 3–4 weeks in the ofloxacin group. Hearing gain was observed in healed perforations of both groups. Conclusion: EGF application enhances the healing effect of one-quadrant nonhealing tympanic membrane perforations. It showed encouraging results and reliable safety in the regeneration of tympanic membrane. Clinical Significance: Apart from its use in single quadrant perforation, EGF may be considered for treating residual perforations after failed tympanoplasty.

Modeling Proppant Transport in Perforated Casing Based on Surface Testing

Summary The results of a series of proppant transport surface tests (PTSTs) were used in conjunction with Eulerian multiphase-computational fluid dynamics (EMP-CFD) modeling to develop an engineering model of proppant distribution. The PTSTs were carried out to evaluate proppant placement through perforated casing. In these tests, sand slurry was pumped at realistically high flow rates through perforated casing, and the distribution of sand and slurry from each perforation cluster was observed. The tests show that gravitational settling in horizontal casing, proppant slip past perforations, and the viscoelastic properties of slickwater fluids strongly affect the distribution of proppant from the heel to the toe of the completion. The EMP-CFD modeling was used to estimate the gravitational settling of sand in fully developed turbulent slurry flow in horizontal casing as a function of casing velocity. A survey of 36 calculations was carried out to generate tables of sand concentration in a cross section through the casing as a function of flow rate and particle size. A single-phase CFD analysis showed how sand exiting each perforation is taken from a limited ingestion area, which is proportional to the ratio of flow through the perforation to total flow in the casing. A detailed EMP-CFD analysis of flow through single perforations showed how sand slips past the perforation. The results of 28 EMP-CFD calculations provided slip factors as a function of particle size, casing flow velocity, and perforation flow velocity in straight and angled perforations. The EMP-CFD settling tables and a parameterization of the slip factors were integrated into an engineering model. The model predicts the distribution of slurry and sand through each perforation based on the proppant size, perforation phase angle, and pump rate. The engineering model was used to predict the sand distributions observed in the PTSTs. The PTSTs were conducted with a range of sand sizes and with friction-reducing (FR) polymer additives, while the EMP-CFD analysis assumed water. A weight factor is introduced in the settling model to account for the increased dispersion of sand in water with FR and to match the observed sand distributions in the PTSTs. The observed slip of 100 and 40/70 mesh sand is consistent with the EMP-CFD calculations in water. The model reflects the PTST observations that fine sand is distributed relatively uniformly throughout the length of a perforated completion, while coarser sand tends to slip past the heel perforations and concentrate at the bottom toward the toe of the completion.

Simultaneous Optimization of Well Count and Placement: Algorithm, Validation, and Field Testing

SummaryRobust identification of the optimal well count and corresponding well locations/trajectories under the influence of subsurface uncertainty is a very challenging yet crucial element of field development plans. The well-count optimization (WCO) component of the problem involves an integer-valued optimization parameter because of the discrete nature of the well count. On the other hand, the well-location, well-trajectory, and well-opening-time optimization components typically feature real-valued continuous optimization parameters. The combined optimization problem encompasses both integer- and real-valued parameters. This class of problems is referred to as the mixed-integer nonlinear optimization problem in the literature. It is one of the most challenging classes of optimization problems and requires specialized optimizers. We have developed a new optimization protocol and accompanying optimizers to enable the joint optimization of well-count, well-locations (including well-trajectory parameters), and well-opening time within the framework of an industrial-grade subsurface field development optimization (sFDO) platform which encompasses state-of-the-art well-location optimization (WLO) capabilities. We have extended effective fault-tolerant global and local optimizers to solve the mixed-integer nonlinear optimization problem associated with the presence of well count in addition to real-valued parameters and optionally including well-opening-time parameters. We have introduced a novel well-priority-order concept to enumerate the wells subject to WCO. The resulting novel capability is simply coined as the simultaneous well-count optimization (SimWCO) method.The SimWCO method is first validated on a small yet well-known benchmark model. Investigations include assessing the effects of the objective-function type, well-priority order, and robust optimization including the optimization of well-opening-time parameters. SimWCO has been field tested on two real-life field development optimization problems. SimWCO has been compared with computationally intensive concurrent WCO and cumbersome-to-apply reverse- and forward-creaming WCO techniques as part of the field testing work. Reservoir A case involves optimization of well count and locations of up to three vertical production wells. It is a robust optimization application involving multiple subsurface realizations. The optimal well count and locations are sought in a single perforation target zone in this test. Reservoir B case involves the optimization of up to six deviated production wells in addition to eleven active production wells. This case features well-by-well assignment of perforation-target zones, a new development in sFDO. Results of this work demonstrate the viability of simultaneous optimization of well count, well locations, and optionally well-opening times on realistic real-life field development optimization problems using an industry-grade distributed parallel optimization framework. We also quantitatively demonstrate that SimWCO is more than three-fold computationally more efficient compared to alternative techniques in the Reservoir B field test.

Congenital diaphragmatic hernia with fetal hydrops causing postoperative intestinal perforation: An unusual manifestation seen in a neonate

Congenital diaphragmatic hernia (CDH) is a common cause of neonatal mortality. If CDH is associated with non-immune fetal hydrops (FH), the mortality rate is even higher. However, the pathogenesis and management of FH associated with CDH are still under discussion. We present here a case of left-sided CDH accompanied by prolonged FH, where unexpected ileal perforation developed after CDH repair. The female patient was diagnosed with left-sided CDH with right-sided pleural effusion (PE) at 26 weeks' gestation. At 35 weeks' gestation, FH progressed with bilateral PE and the patient was delivered by cesarean section with a body weight of 2068 g and Apgar 3/7. Subcutaneous edema progressed, but PE attenuated with improvement of pulmonary hypertension, and CDH repair was performed on Day 4. Postoperatively, the patient's pulmonary hypertension worsened, and intestinal perforation was observed on Day 11. In the emergency laparotomy, there was a single small bowel perforation of 5 mm in diameter in the terminal ileum. A 5 cm of the ileum was resected and the bowel was anastomosed in a single stage. The patient was weaned from the ventilator on Day 28. Although bilateral periventricular leukomalacia was confirmed, the patient was discharged without significant neurological symptoms on Day 76.

The Superthin Profunda artery perforator flap for Extremity Reconstruction: Clinical Implications

The profunda artery perforator flap has numerous advantages. For coverage of extremity wounds, however, traditional subfascial harvest results in a thick flap, which routinely requires secondary thinning. The author describes his approach and experience with thin and superthin profunda artery perforator flaps for extremity reconstruction. With preoperative perforator localization via computed tomography angiogram, color Doppler, and handheld Doppler, the author used a single dominant perforator for extremity reconstruction in 10 consecutive patients. The mean age of patients who had a thin or superthin profunda artery perforator flap for extremity reconstruction was 41.2 ± 21.3 years. Flaps were used to cover wounds in the upper ( n = 3) and lower ( n = 7) extremities. Mean flap thickness was 0.7 ± 0.2 cm. Mean flap artery diameter was 16 ± 3 mm; mean flap vein diameter was 21 ± 6 mm. Mean pedicle length was 6.8 ± 1.2 cm. The difference between the actual measured intraoperative proximal-distal distance and the preoperative computed tomography angiogram measurement for each patient was calculated, with a mean difference of 1.2 ± 0.6 cm. Advantages of the profunda artery perforator flap include a concealed donor site, large perforator caliber, long pedicle length, and a straightforward perforator dissection. Intraoperative measurement of the proximal-distal distance of the dominant perforator fell within 2 cm of the preoperative computed tomography angiogram measurement in all cases. The thin and superthin profunda artery perforator flaps provide new reconstructive options, particularly suited for use in the extremities. Therapeutic, IV.

COMPARISON OF OUTCOMES OF ILEOSTOMY,PRIMARY REPAIR AND RESECTION ANASTOMOSIS FOR ILEAL PERFORATION IN TERTIARY CARE HOSPITAL

ntroduction: Ileal perforation peritonitis is a commonly encountered surgical emergency in the Indian subcontinent and in tropical countries. Despite the availability of modern diagnostic facilities and advances in treatment regimes, this disease has an abrupt onset and a rapid downhill course with a high mortality if not treated [1,2]. Better antibiotics, aggressive surgery and the elimination of conservative treatment, better preoperative and postoperative management have all signicantly contributed to the improvement in patient outcome. The present studyMethods: includes 50 patients of ileal perforation with emphasis on typhoid, nonspecic and traumatic perforations, their preoperative and postoperative management and the factors inuencing outcome. This was an observational study of patients presented with ileal perforation managed with operative management like primary closure , resection- anastomosis and ileostomy Fever and abdominal pain were the most common. Result: clinical presentations. Ileostomy was performed in the majority of the cases after proper preoperative resuscitation , general condition of patient and intra-operative ndings. Nonspecic was the leading cause followed by typhoid. Abdominal pain, fever and vomiting were theDiscussion: most common symptoms of peritonitis. Most of the patients with ileal perforation have single perforation of size ranging 0.5-1 cm. Ileostomy as a treatment modality performed in 28 patients out of 50 Ileostomy may be given priority over other surgical options especially in those. Conclusion: moribund patients who present late in the course of their illness, have more than one perforation with massive fecal contamination of the abdominal cavity. Primary closure of perforation is a preferred technique in clinically stable patients with a single perforation with minimal soiling of the abdominal cavity. After adequate preoperative resuscitation , loop ileostomy holds the best result in terms of complications like postoperative leak, intra abdominal abscess, fecal stula, peritonitis, septicemia, paralytic ileus.

Arthroscopic Repair of Hip Labrum Using a Technique of Single Perforation and Double Loop

Arthroscopic Repair of Hip Labrum Using a Technique of Single Perforation and Double Loop

Geometrically nonlinear large-deflection analysis of heated functionally graded composite panels with single and multiple perforations

In this article, the nonlinear flexural analysis of perforated functionally graded composite panel is performed under heat conduction and uniform/sinusoidal pressure. Here, functionally graded composite panel is modeled with single (1 × 1) and multiple (2 × 2, 3 × 3) perforations having identical surface area. A geometrically nonlinear mathematical model is adopted using the Green-Lagrange strain field via the higher-order shear-deformation mid-plane kinematics. The overall temperature-dependent elastic and thermal properties of the functionally graded (metal/ceramic) material are computed using the power-law function via Voigt’s homogenization scheme. The equilibrium equations are derived through the minimum total potential energy principle via isoparametric finite element approximations and solved further by adopting Picard successive technique. The convergence and validation of the model are carried out by performing mesh refinement and comparison tests, respectively. In adding, new numerical results for single/multiple perforated FGM panels are illustrated at various sets of parametric combinations, and compared in detail.

Perforator Characteristics and Impact on Postoperative Outcomes in DIEP Flap Breast Reconstruction: A Systematic Review and Meta-Analysis.

High-quality evidence on perforator selection in deep inferior epigastric perforator (DIEP) flap harvesting is lacking, making preoperative planning and choice of perforators "surgeon-specific." This lack of consensus is a subject of continuous debate among microsurgeons. We aimed to systematically review perforator characteristics and their impact on DIEP flap breast reconstruction outcomes. We conducted a systematic review and meta-analysis across six databases: ClinicalTrials.gov, Cochrane Library, Medline, Ovid Embase, PubMed, and Web of Science for all studies on DIEP flap breast reconstruction focused on perforator characteristics-caliber, number, and location. The primary goal was to analyze the impact of perforator characteristics on partial and/or total flap failure and fat necrosis. Data was analyzed using RevMan V5.3. Initial search gave us 2,768 articles of which 17 were included in our review. Pooled analysis did not show any statistically significant correlations between partial and/or total flap failure and perforator number, or perforator location. Sensitivity analysis accounting for heterogeneity across studies showed that, the risk for fat necrosis was significantly higher if single perforators (relative risk [RR] = 2.0, 95% confidence interval [CI] = 1.5-2.6, I 2 = 39%) and medial row perforators (RR = 2.7, 95% CI = 1.8-3.9, I 2 = 0%) were used. Our findings suggest that a single dominant perforator and medial row perforators may be associated with higher risk of fat necrosis after DIEP flap breast reconstruction. Adopting a standardized perforator selection algorithm may facilitate operative decision making, shorten the learning curve for novice surgeons, and optimize postoperative outcomes by minimizing the burden of major complications. This in turn would help improve patient satisfaction and quality of life.

Prognostic Factors and Primary Healing on Root Perforation Repaired with MTA: A 14-year Longitudinal Study

IntroductionFew data are available on the long-term efficacy of mineral trioxide aggregate (MTA) in treating root canal perforations. This prospective cohort study builds on a previously reported trial to determine the outcome for teeth with root perforations treated with orthograde MTA after longer follow-up and identify potential prognostic factors. MethodsA prospective cohort study was performed, enrolling (1999–2009) patients with a single dental perforation treated with MTA. Preoperative, intraoperative, and postoperative information was evaluated, and the outcomes were dichotomized as healed or nonhealing. Patients were followed up yearly until 2018 for a maximum of 17 years after treatment, with controls carried out until 14 years. Clinical and radiographic outcomes were evaluated using standardized follow-up protocols. ResultsOf the 124 entrolled patients (median age = 36.5 years, 53.2% male), 115 were healed at the first (n = 110, 89%) or second (n = 5, 4%) annual posttreatment checkup, while 9 subjects (7%, 4 females, 18–65 years old) did not heal. Characteristics significantly associated with nonhealing were gender, positive probing, size, and perforation site. Perforations recurred in 48 teeth during the follow-up with the estimated probability of reversal at 5, 10, and 14 years of 6% (95% confidence interval [CI], 2%–10%), 30% (95% CI, 20%–38%), and 62% (95% CI, 46%–73%), respectively. Positive probing had a higher reversal risk (hazard ratio = 3.3, P ≤ .001), and perforations >3 mm were more likely to have a reversal (hazard ratio = 4.1, P < .001). ConclusionsThe risk of reversal for healed MTA-treated root canal perforations, initially relatively low, vastly increases over time.

Evaluation of perforator flap for soft tissue reconstruction of distal leg and foot

Background and objectives: Reconstruction of soft tissue defect of the distal leg and foot regarded as a major task in plastic reconstructive surgery, durable coverage of such defect is usually needed. Using of local flap based on single perforator raising interest for reconstructive surgeon to reconstruct leg. The aim of study is to evaluate the versatility of perforator flap for reconstruction of the soft tissue defect in distal leg and foot according to: donor sit morbidity, flap viability and extent of coverage. Method: This is prospective study conducted in KRG (Kurdistan region government) of Iraq, twelve patient involved in this study, seven of them are males (n=7) and the other were females (n=5), mean age 31 years (8-62), with soft tissue defect mean (5.8-14.5cm), defect where located in distal leg in eleven patients and two located in foot, all defects was due to road traffic accident treated with perforator flap (one patient both legs operated). Results: in this study twelve patient involved and thirteen procedure done for them, in eight out of thirteen procedures the flap survived totally without complication 61.5%, in one patient flap is totally lost 7.7%, while in other develop complication in form of partial necrosis in three cases 23.1% and flap congestion in one case. Conclusion: The perforator flap is reliable flap for soft tissue reconstruction of distal leg and foot and can replace free flap in our practice in selected cases.

V04-10 GENDER-AFFIRMING PHALLOPLASTY WITH ANTEROLATERAL THIGH FLAP

You have accessJournal of UrologyCME1 May 2022V04-10 GENDER-AFFIRMING PHALLOPLASTY WITH ANTEROLATERAL THIGH FLAP Ömer Acar, Alexi Millman, Luca Morgantini, Loren Schechter, and Ervin Kocjancic Ömer AcarÖmer Acar More articles by this author , Alexi MillmanAlexi Millman More articles by this author , Luca MorgantiniLuca Morgantini More articles by this author , Loren SchechterLoren Schechter More articles by this author , and Ervin KocjancicErvin Kocjancic More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002560.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: One of the options that can be employed within the context of gender-affirming masculinizing genital reconstruction is the anterior lateral thigh (ALT) flap. Our objective is to demonstrate our technique with ALT flap phalloplasty. METHODS: This is a 25-year-old trans male who desired to void in a standing position. Given the subcutaneous thickness of less than 1 cm in his thigh and concerns related to donor-site scarring, the shared decision was to proceed with phalloplasty with an ALT flap constructed in a “tube within a tube” technique. RESULTS: Acoustic Doppler followed by fluoro angiography to confirm perforator location helped outline the ALT flap. A suprapubic tube (SPT) was inserted under direct cystoscopic guidance. Anterior vaginal wall flap was mobilized and tubularized around the catheter. Clitoris was de-epithelialized. A semilunar suprapubic skin incision was made. Clitoris was sutured to the pubic periosteum. The remaining vaginal mucosa was ablated with electrocautery. Colpocleisis was completed using concentric stitches. The patient was then taken out of lithotomy position and the ALT flap was elevated. Dissection was performed to the intermuscular septum between the rectus femoris and the vastus lateralis. Descending branch of the lateral femoral circumflex artery was identified. The lateral femoral cutaneous nerve was dissected proximally. The flap was elevated on a single perforator and repeat fluorescence angiography confirmed intact perfusion. The urethra was reconstructed over an 18 Fr. council tip catheter and closed in a layered fashion. Methylene blue confirmed urethral integrity. Shaft skin was wrapped around the phallic portion of the urethra and closed in a layered fashion. The left ilioinguinal nerve was clipped for later coaptation with the lateral femoral cutaneous nerve. The flap was passed beneath the rectus femoris, sartorius, and then subcutaneously into the recipient site over the pubic symphysis. The anastomosis between the phallic urethra and elongated native urethra was performed over an 18 Fr. council tip catheter using interrupted stitches. Scrotoplasty was performed using labia majora flaps. The flap was then inset in a layered fashion. The donor site was closed by reapproximation and advancing the skin edges. A split-thickness skin graft was harvested from the thigh and applied over the donor site. The donor site was dressed with wound VAC. The procedure lasted 12 hours with an estimated blood loss of 550 ml. The patient was discharged on day 18. The urethral catheter was removed after a 30 days retrograde urethrogram (RUG). SPT was removed a month later. The patient initially voided without issues but then started to notice urine leakage through a phallic skin defect. RUG demonstrated distal phallic urethral stricture and a small urethrocutaneous fistula just proximal to it. The stricture was dilated with sounds. The patient was instructed to do intermittent self-calibration. Voiding improved, stricture did not recur and fistula healed spontaneously. No other urinary complications were encountered. CONCLUSIONS: ALT flap is a valid option for gender-affirming phalloplasty. It can be considered in patients with favorable body habitus who are concerned with donor-site scarring. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e369 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ömer Acar More articles by this author Alexi Millman More articles by this author Luca Morgantini More articles by this author Loren Schechter More articles by this author Ervin Kocjancic More articles by this author Expand All Advertisement PDF downloadLoading ...

Characterizing Outcomes of Medial and Lateral Perforators in Deep Inferior Epigastric Perforator Flaps.

Perforators are typically found in rows in the deep inferior epigastric perforator (DIEP) flap. As methods to assess flap perfusion continue to improve, surgeons may be more likely to select perforators traditionally avoided. The purpose of this article is to describe clinical outcomes based on row and number of perforators to reevaluate flap and abdominal donor site morbidity. A retrospective analysis was performed on patients who underwent breast reconstruction with DIEP flaps by four microsurgeons from 2013 to 2020. The row and number of perforators were determined from operative reports. Chi-square and t-test or nonparametric Fisher's exact test and Wilcoxon two-sample test were used for discrete and continuous variable, respectively, as applicable. Logistic regression was used for multivariable analyses. Of 628 flaps, 305 were medial row (58.7%), 159 were lateral row (30.6%), and 55 had both rows (10.6%). Partial flap loss was higher in both rows (p = 0.003). Fat necrosis was higher with medial (p = 0.03) and both rows (p = 0.01) when compared with lateral using multivariable analysis. Hernia or bulge was higher in lateral row flaps (lateral: 8/157, 5.1%; medial, 5/299, 1.7%; both, 0/55; p = 0.05); however, mesh was more commonly used in both row flaps (p = 0.05). There was no difference in fat necrosis or abdominal morbidity between single and multiple perforators. There was no difference in fat necrosis based on the number or row of perforators. The lateral row provides adequate perfusion but may be associated with an elevated risk of hernia or bulge. Patients may benefit from mesh, especially when both rows are dissected.

Transcatheter closure of fenestrated atrial septal aneurysm in children: Feasibility and long-term results.

To date, extensive experience in transcatheter closure of fenestrated atrial septal aneurysm (ASA) in the pediatric population is limited. To report on procedural feasibility, efficacy, and long-term outcome, we enrolled all children submitted to an attempt of transcatheter closure of fenestrated ASA at two, large volume, pediatric cardiology units (Naples and Massa, Italy) between April 2000 to May 2020. This retrospective study included 139 patients (median age 9 years [range 2-18]and weight 36 kg [range 10-102]); 19 (13.7%) children were ≤20 kg (range 10-20) and 14 (10.1%) were ≤5 years old. Single perforation was observed in 28 patients (20.1%), while 111 patients (79.9%) had multifenestrated ASA. The median size of the main defect was 15 mm (range 6-34) and 25 patients (18%) had a defect ≥20 mm. The procedural success rate was 99% (95% confidence interval [CI]: 94.9-99.8) using a single device in 75 (69%), two devices in 31 (28%), and three devices in 3 (3%) cases. Early minor adverse events (AEs) occurred in four patients (2.8%). Late minor AEswere recorded in one patient (0.7%) over a median follow-up of 5 years ([range 0-18 years; total 890.2 person-years, and with 30 patients (22%) followed ≥10 years). Neither mortality nor major AEs were recorded. Freedom from AEs was 99.1% at 10-15 years (95% CI: 93.5-99.8%), without any difference according to atrial septum anatomy or patient age and weight. Transcatheter closure of fenestrated ASA is technically feasible and effective in children with excellent long-term outcomes.

Intraoperative salvaging of failure to harvest the bi-paddle anterolateral thigh flap: a case series.

BackgroundThe size and versatility of anterolateral thigh (ALT) flap enables a bi-paddle flap to cover complex and extensive defects optimally. However, it is characterized by variations in the sources of blood vessels and in the number of perforators, which increases the chances of failure of harvesting a bi-paddle flap. We present our method to overcome such failure. This is the first study exploring the optimal salvaging algorithm to overcome harvesting failure with the bi-paddle ALT flap.MethodsFrom January 2014 to December 2020, in 9 patients to be treated with bi-paddle ALT flap for soft-tissue defects (range, 48–288 cm2), there was failure of flap harvest because of perforator variations. We redesigned and converted the flaps to other forms for harvest intraoperatively, based on the characteristics of the defect, and the number and sources of perforators.ResultsSalvage of flap harvest was successfully performed in all 9 cases. In 4 cases the flap with a single perforator was converted to widened-single-perforator flaps; in 2 cases, a single perforator was converted to a de-epithelialized flap; in 2 cases of 2 perforators from different main branches, conversion was to sequential chimeric flaps; in the remaining case of 2 perforators from the descending branch and transverse branch, conversion was to a combined transverse-and-descending branches flap. Venous compromise occurred in only 1 case, and the patient survived after revised surgery. Local infection in the receiving area occurred in 3 cases, and was cured by wound dressing. All flaps survived (follow-up 5–24 months).ConclusionsDespite preoperative preparation, anatomic variations resulted in failure of bi-paddle ALT flap harvesting. As shown by our results, it is feasible to redesign and convert the bi-paddle flap to other forms based on the defect characteristics, and the number and sources of perforators.

Gender-Affirming Phalloplasty with Anterolateral Thigh Flap

ABSTRACT Introduction Anterior lateral thigh (ALT) flap is one of the options that can be employed within the context of gender-affirming masculinizing genital reconstruction. Objective Herein, we demonstrate our technique with ALT flap phalloplasty. Methods This is a 25-year-old trans male who desired voiding in standing position. Given the quality of his thigh skin (subcutaneous thickness &amp;lt;1cm) and concerns related to donor-site scarring, the shared decision was to proceed with phalloplasty with ALT flap constructed in a “tube within a tube” technique. Results The ALT flap was designed and outlined using acoustic Doppler followed by fluorescence angiography to confirm perforator location. A suprapubic tube (SPT) was inserted under direct cystoscopic guidance. Anterior vaginal wall flap (6cm x 3cm) was liberated. Vaginal flap was tubularized around the urethral catheter. Clitoris was de-epithelialized. A semilunar suprapubic skin incision was made. Clitoris was sutured to the pubic periosteum. Remaining vaginal mucosa was ablated with electrocautery. Colpocleisis was completed using concentric stitches. Then, he was taken out of lithotomy and the ALT flap was elevated. Subfascial dissection was performed to the intermuscular septum between the rectus femoris and the vastus lateralis. Descending branch of the lateral femoral circumflex artery was identified. Lateral femoral cutaneous nerve was dissected proximally. Flap was elevated on a single perforator and repeat fluorescence angiography confirmed intact perfusion. Urethra was reconstructed over an 18 Fr. council tip catheter and closed in a layered fashion. Urethral integrity was tested with methylene blue. Shaft skin was wrapped around the phallic portion of the urethra and closed in a layered fashion. The left ilioinguinal nerve was clipped for later coaptation with lateral femoral cutaneous nerve. The flap was passed beneath the rectus femoris, sartorius and then subcutaneously into the recipient site over the pubic symphysis. The anastomosis between the phallic urethra and elongated native urethra was performed over an 18 Fr. council tip catheter using interrupted stitches. Scrotoplasty was performed using labia majora flaps. Flap was then inset in a layered fashion. Donor site was closed by reapproximation and advancing the skin edges. A split thickness skin graft was harvested from the thigh and applied over the donor site. Donor site was dressed with wound VAC. The procedure lasted 12 hours with an estimated blood loss of 550ml. Patient was discharged to a skilled nursing facility on day 18. Urethral Foley catheter was removed in a month after documenting patency on retrograde urethrogram (RUG). SPT was removed a month later. He initially voided well but then started to notice weakening in stream and urine leak through phallic skin defect. RUG demonstrated distal phallic urethral stricture and a small urethrocutaneous fistula just proximal to it. Stricture was dilated with sounds. Patient was instructed to do intermittent self-calibration. Voiding improved, stricture did not recur and fistula healed spontaneously. No other urinary complications were encountered. Conclusions ALT flap remains a valid option for gender-affirming phalloplasty. It can be considered in patients with favorable body habitus who are concerned with donor-site scarring. Disclosure No

A comprehensive study of the liquid transfer from the front to the back of a vertical perforated sheet

AbstractPerforations contribute to liquid redistribution in corrugated sheet packings. We focus on a simplified but relevant experimental configuration where a vertical perforated flat sheet is supplied with liquid on its front side. We examine how the perforations irrigate the back of the plate. We successively consider a single perforation, a spanwise row of perforations, and a staggered array of perforations. We quantify the liquid transfer through a single row of perforations and find that the transferred flow rate per unit perforation diameter varies linearly with the supply flow rate per unit width. We also analyze the spreading of the rivulets leaking from the perforations, their merging into a continuous wavy film, and the leveling of this film as it falls down the plate. The spreading and the merging exhibit a power‐law behavior in agreement with theoretical models. The leveling exhibits exponential decay behavior.

A Single Superior Gluteal Artery Perforator Flap in Reconstruction of Large Midline Sacral Defects: A Method for Practical Harvest and Safe Closure.

Large midline sacral defects are reconstructive challenges. Superior gluteal artery perforator (SGAP) flap provides enough tissue and versatility to cover large defects; however, a single flap may be insufficient. We present a technique to cover large defects using single SGAP flaps. Large sacral defects (>100 cm2) reconstructed with single SGAP flaps were included. Angle of transposition (45°-60°) was determined based on the tissue laxity and mobility of gluteal area. Perforator identification, intramuscular dissection, or skeletonization was not performed. Outcomes were measured as achieving durable reconstruction, flap viability, and complications. There were 17 patients (12 male, 5 females; aged 25-72 years) with different etiologies. The mean flap surface area (136.1 ± 45.6 cm2, between 9 × 8 and 26 × 10 cm) was smaller than the mean defect surface area (211.1 ± 87.2 cm2, between 10 × 10 and 28 × 14 cm) (P < 0.001). All flaps survived with no partial or complete flap loss. Minor dehiscence in 4 patients (2 at donor site and 2 at recipient site) healed with dressing changes or using negative-pressure vacuum therapy. All patients had durable outcomes without any recurrence. Single unilateral SGAP flaps can be used to completely cover midline large sacral defects. It is important to design the flaps to have a joint side with the defect in the proximal part and use the intrinsic mobility of gluteal soft tissues for the closure. Flaps can be (1) planned to be smaller than the defects, (2) harvested with no intramuscular perforator dissection or pedicle skeletonization, and (3) transposed with an angle less than 60°.