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Selecting a Connective Tissue Graft
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Septal Perforation Repair
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Connective tissue autografts are used commonly to interpose between the repaired septal flaps. Commonly used materials are temporalis fascia and pericranium, both of which require a separate donor site (Fig. 5A and B). Pericranium, fascia, and temporalis are extremely thin grafts with very low metabolic requirements that act as templates for overlying mucosal tissue migration and vascularization. Additionally, the graft maintains a barrier between the corresponding repaired flaps during the healing process and decreases any risk of incisional breakdown and reperforation. If temporalis fascia is harvested, and if the surgeon is righthanded, the right temporal scalp is generally the donor site. A horizontal incision is made with care to bevel the incision site so as to remain parallel to the hair follicles, and therefore protect them. The scalp is retracted and dissection is carried down to the deep temporalis fascia with wide undermining. The dimensions of the harvested graft must be significantly larger than the perforation, because the graft must have a large enough diameter so its edges go far beyond the perimeter of the original perforation. The surgeon should take into account the possibility of enlargement of the perforation through manipulation and dissection of the flaps. A large circular piece of temporalis fascia is harvested and hemostasis is maintained with a cautery. The wide undermining and the size of the graft, which is usually about 5 centimeters in diameter, warrants simple passive drainage with the incision closed in layers. A pressure dressing of the mastoid-type variety is used.
Because there is some donor site morbidity to obtaining temporalis fascia or pericranium, and because these grafts are exceedingly thin and difficult to manage when they are wet, acellular dermal grafts (AlloDerm, Life-Cell Corporation, Branchburg, New Jersey)14 can be used as the connective tissue interpositional graft, with similar success rates to those of temporalis fascia or pericranium.12 Acellular dermal grafts are thicker, and easier to place and suture, and may give more substance to the repaired septum (Fig. 6). Readers are directed to the paper by Kridel, Foda, and Lunde12 for a more in-depth discussion for the use of acellular human dermal allografts.
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Figure 5. A, The temporalis fascia as it is being harvested. B, A 4 cm x 4 cm piece of temporalis fascia spread out to dry prior to insertion between the mucoperichondral flaps. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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Surgical Procedure
The patient is placed on perioperative antibiotics, which should be taken before and after surgery for up to 1 week. General oral tracheal anesthesia is preferred, because the operation is lengthy and requires meticulous and tedious dissections and may require two different operative sites, the nose and the temporal scalp, if so harvested. An oral pharyngeal throat pack is placed prior to localization to prevent any blood from entering down into the esophagus and stomach, thereby helping prevent any postoperative nausea. Infiltrative anesthesia with 1% lidocaine (Xylocaine) with 1:100,000 epinephrine is used more for hemostasis. Endoscopic photographic documentation of the perforation usually is carried out, and diagnostic endoscopy performed to fully examine the nose.
A low transcolumellar incision with an inverted V configuration is outlined on the columella. It is important to make the incision for open rhinoplasty low so as to make it less visible postoperatively, because this procedure does tend to rotate the tip of the nose cephalad. Any straight columellar incision may lead to postoperative retraction and an unsightly appearing scar. The nose is opened, however, not at the columella first, but laterally at the caudal marginal edge of the lower lateral cartilages. It is important never to make rim incisions in the approach to the lower lateral cartilages, because rim incisions are extremely visible, difficult to repair, and enter into the soft tissue triangle at the dome, causing facet irregularities later on. The lower lateral cartilages are palpated with the back of the knife handle and the caudal edge is identified. Intranasally at the caudal edge of the lower lateral cartilage is where the initial marginal incision is created. The surgeon's nondominant hand is used to hold a double hook along the ala, and one of the fingers on the nondominant hand is used to push down the lateral cartilage to improve visualization. Once the caudal edge of the lower lateral cartilage is palpated and a small incision has been made along a short length of it, an assistant uses a single hook to place under the vestibular skin beneath the cartilage for retraction and exposure.
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Figure 6. AlloDerm (Life-Cell Corporation, Branchburg, New Jersey) is inserted between the mucoperichondral flaps as an interposition acellular dermal graft. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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The incision should proceed toward the dome using tenotomy scissors, cutting 1 millimeter at a time so as not to cut through the dome cartilage as it makes its curve inferiorly. The incision then should proceed in a more vertical direction down along the lateral columella just at the cartilage edge, with care to turn the scissors so that the incision is again more lateral along the columella and does not ever become visible along the anterior edge. Once these incisions are completed along both lateral cartilages, both domes, and along both medial crura down to the area of planned transcolumellar incision, a Joseph scissors is placed through these lateral columellar incisions anterior to the medial crura, but deep to the still-intact columellar flap (Fig. 7). A Joseph double hook is used to elevate the columella at the nasal apices to put traction on the columella. The previously outlined transcolumellar incision is then incised, using a #15 blade. Care is taken to remain perpendicular to skin and the medial crura with this important incision. The one or two small columellar blood vessels usually must be cauterized.
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Figure 7. After bilateral marginal incisions have been developed along the caudal edge of the lower lateral cartilages and extended along the medial crura, an inverted "V" columellar incision is made. A double hook at the nostril apices helps to stabilize the columella and Joseph scissors, in front of the medial crura and behind the columella skin, act as a protective barrier to avoid cutting the medial crura. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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The nasal skin then is elevated sharply off the underlying medial crura and dome cartilages, and dissection continues back in an avascular plane directly on and over the upper lateral cartilages and dorsum. Cautery can be used for any bleeding. The dome cartilages then are separated and the medial crura are retracted laterally to gain access to the caudal end of the septum. Elevation of each mucoperichondral flap is carried out as one would for a septoplasty, staying directly on the cartilage and carrying out the elevation posteriorly toward the perforation. Superior mucoperichondral pockets are developed along with the flap elevation just beneath the junction of the upper lateral cartilages and the septum. The upper lateral cartilages then are cut sharply away from the septum, using a knife blade that leaves the mucoperichondral flap still attached to the now laterally retracted upper lateral cartilage (Fig. 8). At this point, one can see the definite advantage of using the open approach, because of superb visualization of the septum superiorly. The open approach also affords the surgeon the ability to go back behind the perforation with ease. One needs to note that the upper lateral cartilage release is accomplished through an incision that is usually straight and parallel to the septum, but closer to the rhinion the incision fades approximately 15° off the midline. Elevation also is carried out along the inferior portion of the perforation and extended onto the nasal floor and under the inferior turbinate. When connecting the mucoperiosteal floor flaps with the mucoperichondral flap over the septum, there frequently are fibrous bands at the premaxilla that need to be incised. The surgeon also should be aware that there are sometimes penetrating vessels here at the junction of the floor of the nose and the maxillary crest, which must be cauterized well.
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Figure 7. After bilateral marginal incisions have been developed along the caudal edge of the lower lateral cartilages and extended along the medial crura, an inverted "V" columellar incision is made. A double hook at the nostril apices helps to stabilize the columella and Joseph scissors, in front of the medial crura and behind the columella skin, act as a protective barrier to avoid cutting the medial crura. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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The perforation now is opened into from the front, using a broad exposure technique and careful dissection. Avoiding enlargement of the perforation is important with this maneuver. Dissection must proceed posteriorly for at least a centimeter back behind the perforation. A very comforting step when dissecting between the septal flaps, especially if they are adherent and there is no septal cartilage around them, is to finally reach normal septal bone or cartilage posteriorly. Dissection then is done exactly the same on the other side of the septum until the surgeon has three different structures with perforations, the totally free mucoperichondral flaps on each side and the intervening septum with its cartilaginous defect (Fig. 9).
At times, a septoplasty may be necessary if deviation of the residual septum is noted or a septal spur exists posteriorly. It is incumbent upon the surgeon to attempt this correction during perforation closure, because after septal perforation repair entering the septum again for any reason, other than reperforation, is discouraged. If any cartilage needs to be removed for the septoplasty, it is best to do so conservatively and avoid compromising the structural support that the nonperforated portion of the septum provides.
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Figure 9. Both upper laterals with mucoperichondral flaps are laterally retracted, revealing the bare cartilage of the septum, which in this case has a caudal deflection to the right. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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Once adequate mucosa has been freed for planned advancement flaps, an anterior to posterior incision is made underneath the inferior turbinate at the lateral nasal wall. Care is taken not to perforate through the very thin lateral bony wall and enter into the maxillary sinus. The flaps should be checked to ensure thorough elevation off the nasal floor and off the nasal wall (Fig. 10). At times the size of the inferior turbinate makes visualization difficult and an infracture or limited partial resection will be necessary. If partial resection is performed, the surgeon should avoid inferior turbinate mucosal incisions that may, when combined with nasal floor flap mobilization incisions, lead to postoperative scar band formation and closure of the inferior meatus. The surgeon then should check to see that the advancement flap is mobilized totally off the septal cartilage, off the nasal floor, and from beneath the inferior turbinate. Gentle manipulation of the edge of the perforation and advancement superiorly along the septum will demonstrate the degree of extra laxity that flap creation has obtained. The flap attached anteriorly and posteriorly is then a bipedicle flap that has a blood supply from both of these directions (Fig. 11). Because the inferior turbinate position is posterior relative to the anterior caudal septum where most perforations occur, however, floor flaps may seem limited for very anterior perforations. The anterior extent of the nasal floor incision, however, can extend up onto the bony vestibule. In some cases, that incision alone is not adequate for mobilization and a unipedicled flap is needed. The incision along the nasal floor then can be angled medially and joined with the perforation at its most anterior aspect (Fig. 12). A bipedicled flap is preferable because of increased vascular supply.
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Figure 10. The effect of making a floor/inferior turbinate flap with advancement of the mucosal floor flap toward the septum to close the perforation. (From Kridel R: The open approach for repair of septal perforations. Aesthetic Plastic Surgery: Rhinoplasty, 1993; with permission.) |
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Figure 11. A bipedicled floor flap has been advanced toward the wall of the septum, and the perforation has been closed. Note the effect the tension of closure has in rotating the tip cephalad. A bipedicled flap has excellent blood supply. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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Figure 12. When the bipedicled floor flap cannot be adequately mobilized, especially if the perforation is quite anterior, a unipedicled flap may be necessary. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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For larger perforations, the inferior advancement floor flaps alone are not adequate for closure, and a superiorly based bipedicle flap may be necessary also. This flap can be developed in one of two ways. The mucoperichondral flap can be dissected off of the now lateralized upper lateral cartilage to provide a few more millimeters of laxity. This technique denudes the upper lateral cartilage on its undersurface, but an actual incision in the mucosa is not made, thereby preserving even more blood supply. The surgeon can release the mucosa from the upper lateral cartilage without fear of viability to the dorsal septum and its cartilage. Occasionally even this method does not provide enough mucosa, and a through-and-through superior incision in the mucoperichondral flap at the junction of the upper lateral cartilages and septum is necessary. The incision may be extended posteriorly if needed. The surgeon needs to be aware that the blood supply from the ethmoid vessels comes into the mucosa in this area, and often there is brisk bleeding that must be cauterized carefully. If a bipedicled superior flap is created through this superior mucosal incision, it can be performed only on one side for fear that the dorsal cartilaginous septum would be exposed bilaterally. Loss of cartilaginous viability in the cartilaginous dorsal area may result in dorsal saddling or a high perforation. Whichever technique is used, a few millimeters of mucosa generally are mobilized (Fig. 13). Furthermore, if the patient has a large dorsal hump and wishes refinement of this simultaneously, more mucosa can be provided by taking down the bony and cartilaginous dorsum after separation of the upper lateral cartilages, which then would allow the upper lateral cartilages to be resewn in closure at a lower level later providing more lax tissue. The readers are encouraged to read the article by this author,8 entitled “Combined Septal Perforation Repair With Revision Rhinoplasty,” if one plans to combine septal perforation repair with rhinoplasty, as this can indeed be a very challenging combination of procedures.
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Figure 13. If the inferior floor flaps do not provide enough mucosa for closure, a superior bipedicled flap may also be necessary, but it should only be developed on one side so as not to leave bare septal cartilage exposed up high on both sides. If one side of the perforation is totally closed, the other side usually heals if protected and kept moist with silicone sheeting. Note the eflect the tension of closure has in rotating the tip cephalad. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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Once enough mucosal laxity has been provided by these advancement flaps, the perforation in each mucoperichondral flap is closed using interrupted sutures of either 4-0 or 5-0 chromic or plain gut sutures (Fig. 14A and B). Any granulation tissue or scarring that is present at the periphery of the perforation should be removed prior to suturing to provide fresh edges that would be more likely to heal. At this point, the temporalis fascia graft, pericranium, or human acellular dermal graft is used. The interposition graft then is placed between the mucoperichondral flaps and brought back posteriorly at least 1 centimeter beyond the closed perforation. The graft may extend to within a millimeter or two from the caudal edge of the septum to 1 centimeter posterior to the perforation, depending upon the quantity of grafting material available. The graft then should be stabilized to prevent postoperative movement by using a few individual sutures to sew it directly to the septal cartilage remnant. After fixation, the graft should be inspected to be certain that the center of the closed perforation is well-covered by the graft.
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Figure 14. A, The separated mucoperichondral flaps with the perforation in each flap is readily seen. B, The perforation is sutured closed on one side. The dark marks identify the interrupted sutures. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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The upper lateral cartilages then must be resutured to the septum. If the perforation was large and required superior advancement flaps, it maybe difficult to reattach the upper lateral cartilages to the septum at their original height and at the same time avoid tension on the newly closed perforation site. The surgeon may be forced to resecure the upper lateral cartilages to the septum at a lower level, with the potential cosmetic outcome being a pinched appearance to the nasal dorsum. The pinched appearance results from the upper laterals being lower than the central septal dorsum. Recognition of this potential problem would necessitate cartilaginous onlay grafts over the reset upper lateral cartilages to provide better dorsal symmetry. If a reduction rhinoplasty was carried out at the same time, this problem would be less of an issue.
The intranasal septal flaps then must be mattressed together reapproximating both flaps and sandwiching the interposition graft. Mattressing the septum aids in the healing of the perforation and speeds the revascularization of the graft. It furthermore helps to prevent the occurrence of a postoperative hematoma. The mattress stitch is usually a 4-0 chromic suture, and a continuous suture technique is used (Fig. 15). The needle must be extremely sharp so that it passes freely through not only the flaps, but also the graft, and causes little displacement of the interposition graft. If an acellular human dermal graft is used, the graft is relatively thick and can make passage of the needle more difficult. Mattress sutures must be used above and below the repaired perforation so that the sutures are placed in a perpendicular plane to that of the perforation repair. This suture technique strengthens and reinforces closure.
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Figure 15. The interposition graft is centered under the closed perforation. Mattress sutures go through both mucosal flaps and the graft in order to prevent migration of the graft, to hold the graft in apposition to the flaps as an aid in healing, and to prevent postoperative bleeding or hematoma formation. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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As noted previously, resupport of the nasal tip support mechanisms is crucial. The medial crura must be resewn together with or without a columellar strut. The nose also should be evaluated at this time to see if there has been any unwanted rotation of the tip because of tension of the closure and continuity of the septal flaps with the mucosa of the medial crura. If unwanted rotation and shortening of the nose has occurred, the surgeon may use a caudal septal replacement graft14 to lengthen the nose or place a large cartilaginous batten in front of the medial crura to camouflage such rotation. A tip graft also can be added that does not extend above the dorsum, and so acts to provide extra length to the tip without increased rotation or projection. The dome cartilages then must be sewn together with permanent sutures reconstructing the dome complex and preventing postoperative bossae. Routine open external rhinoplasty closure then is performed after returning the nasal skin back to its normal anatomic position. Because of the inverted V in the transcolumellar incision, alignment of this flap is quite easy. Tension is first taken off the skin incision by using a subcutaneous 6-0 Polydioxanone (Ethicon, Inc., Somerville, New Jersey) (PDS) suture placed deeply at the apex of the inverted V. Closure of the external skin of the columella is carried out using interrupted 6-0 Prolene (Ethicon, Inc., Somerville, New Jersey) sutures at each corner and turn of the transcolumellar incision. The rest of the skin is closed meticulously using an interlocking 6-0 fast-absorbing plain gut suture. The marginal incision is closed on each side using a 5-0 plain suture.
The repaired septal flaps now must be protected during their healing phase. Soft pliable 0.02 inch thick polymeric silicone sheeting (Silastic [Dow Corning, Midland, Michigan]) is placed on both sides of the septal flaps, covering almost all of the septum on each side, and is secured into place by approximately three 5-0 nonabsorbable sutures (Fig. 16). These sutures should not be overly tight, so as not to constrict the blood supply to the septum. Because the polymeric silicone sheets are transparent, the repair site can be visualized postoperatively with monitoring of the progress of the healing mucosa. Monitoring of the protected repaired site is especially helpful if the surgeon is unable to close the perforation fully. The surgeon can monitor the mucosal migration over time and keep the Silastic sheets in place. The sheeting protects the graft site from airflow drying and allows safe postoperative suctioning. Keeping the area moist and preventing it from drying out accelerates the healing process. The use of hard thick septal splints, such as the Doyle splint (Xomed, Jacksonville, Florida), is not advocated because they are too firm and are not easy to see through. Usually, three mattress sutures are necessary to hold the sheeting in place. If one suture comes out, the others still allow fixation without rotation.
The nose then is packed very lightly with Gelfoam (Pharmacia and Upjohn Company, Kalamazoo, Michigan) strips underneath the inferior turbinates, followed by a small Telfa (Kendall Company, Mansfield, Massachusetts) pack impregnated with antibiotic cream. If too much packing is placed, vascular compromise of the repair site could ensue as nasal swelling develops. The Gelfoam is additionally helpful because it absorbs any bleeding as the result of the development of the bipedicled flaps. The nose then is externally taped and splinted, whether or not any dorsal modifications, osteotomies, or grafts have been used. Elevation of the open rhinoplasty flap creates a potential space for blood accumulation and fibrosis postoperatively, and a standard external splint must be placed for prevention. The oral pharyngeal throat pack is removed and the pharynx is suctioned thoroughly out and inspected to be sure that no Gelfoam has pushed down into the pharynx that might be aspirated. A drip pad is placed, and the patient is then extubated by anesthesia.
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Figure 16. A, Clear 0.02-inch-thick silicone soft sheeting that is shaped to cover the perforation repair on each side of the septum. B, Silicone sheeting is sewn into place with three through-and-through mattress sutures of 5-0 Prolene (Ethicon, Inc., Somerville, New Jersey), being careful not to constrict the flaps and compromise the blood supply. One can easily monitor the healing of the septal perforation repair through these transparent sheets. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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Postoperative Care
All patients are told that there probably will be some bloody discharge postoperatively, because of the raw areas underneath the inferior turbinates. The patient is provided with a large number of 4 x 4 gauze drip pads and tape. This nasal discharge often subsides after the first 24 hours, but it usually is necessary for the patient to wear a drip pad during that time and for a few days more.
On the first postoperative day, the Telfa packs are removed and the Gelfoam usually is left in place. Sometimes, if closure of the perforation required superior advancement flaps, it is necessary to have placed Gelfoam superiorly. Gelfoam underneath the inferior turbinate and higher in the nasal vault may be left in place. No attempt is made to remove all of the Gelfoam on the first operative day. The patient is instructed to use saline nose drops three to four times per day, with at least 10 drops in each nostril. This moisture helps to keep the Gelfoam moist and allows easier suctioning over the next 7 to 10 days. Using cotton-tip applicators, the patient is encouraged to place antibacterial ointment in the nose to prevent postoperative crusting. The external nasal splint usually is removed at about 5 to 7 days, and the nose then usually is retaped for another 5 days. The nonabsorbable columellar sutures are removed at about the fifth day, and the plain gut sutures usually have dissolved by themselves by that time; if not, they also are removed.
Careful examination of the site of the previous perforation is carried out through the clear Silastic sheeting at each visit. In most cases, the sheeting is left in place for 3 weeks, but it may be necessary to prolong that time if the perforation does not appear to be fully healed. If the Silastic sheeting has been removed and there is still a small area that is unhealed, then the patient is instructed to keep this area moist, using antibacterial ointment three to four times per day in addition to a saline mist.
The patient is instructed not to use any vasoconstrictive sprays, to refrain from smoking, and to avoid noxious fumes during the postoperative phase. Blowing the nose also is to be avoided for the first month postoperatively. For patients who are in dry climates, a cool mist vaporizer and other humidification is extremely helpful. After the Silastic sheeting is removed, the patients are encouraged to avoid smoking, exposure to noxious chemicals, and certainly never to use cocaine, if that was the cause, for the rest of their life.
If the patient had a temporalis fascia graft harvested, the drain is removed on the first day, the pressure dressing is maintained for 2 or 3 more days, and the sutures are removed in about 7 to 10 days.
If any crusting is noted over the site of the perforation, it must not be removed because this may be a healing area. Rather, ointment should continue to be applied until healing takes place, which may take several additional weeks.
Outcomes
As noted before, the successful outcome of this operation is dependent upon numerous factors, including the cause of the perforation, the size and location of the perforation, the skill of the surgeon, and the cooperativeness of the patient postoperatively. If one has been unsuccessful in totally closing the perforation, usually it is made smaller with this surgery. In the event that complete closure is not likely, all perforations should be closed from an anterior to posterior direction, moving the perforation more posteriorly and thereby decreasing patient symptoms. A repeat operation, if necessary, can be attempted in about 6 months.
After the perforation is thoroughly healed, the patient can feel the same satisfaction as the physician in the successful closure. Photographic documentation once again can assist the patient in understanding this difficult and complex problem and seeing its successful outcome. It is amazing to see how well the septum heals with no, or almost no, evidence of previous perforation present.
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