Resorbable mesh in the treatment of orbital floor fractures.

A variety of materials have been used to reconstruct defects of the orbital floor. Autogenous materials such as bone and cartilage have the obvious drawback of the necessary donor site, whereas alloplastic implants carry the potential risk of infection, particularly when in communication with the maxillary sinus. Consequently, there has been interest in the use of resorbable alloplastic material that acts as a barrier until completely degraded. In this series, a total of 12 patients with orbital defects larger than 1 cm2 were treated by the placement of a resorbable mesh plate of polyglycolic and polylactic acid (Lactosorb). Of the total of 12 patients treated, 3 were lost to follow-up. Of the remaining 9 patients, the mean follow-up was 6 months, with the longest follow-up being 15 months and the shortest 1 month. Two patients developed enophthalmos. In each case, this measured 2 mm using Hertel exophthalmometry, and was present in the early postoperative period (less than 1 month). The cause of the enophthalmos in both patients was found to be a technical error in placement of the mesh. One patient developed an inflammatory reaction along the infraorbital rim requiring implant removal. This occurred at 7 months. From the above series, it is concluded that resorbable mesh is an acceptable material for reconstruction of the orbital floor in selected patients. It is believed that larger floor defects are better suited for nonresorbable alloplastic reconstruction, and that placement of the mesh over the infraorbital rim is unnecessary and places the patient at risk for a local inflammatory reaction.

Brachial plexus birth injuries and current management.

OBPP is a condition that, for the majority of patients, resolves spontaneously with appropriate nonoperative treatment. However, those patients who do not improve spontaneously now have a better chance for recovery owing to recent advances in microsurgery and nerve-transfer techniques. The most important aspect of therapy is timely recognition and referral.

Subsequent proximal aortic operations in 123 patients with previous infrarenal abdominal aortic aneurysm surgery.

PURPOSE: Previous studies have reported that 3% to 8% of patients who have had resection of an infrarenal abdominal aortic aneurysm will subsequently have development of a new aortic aneurysm proximal to the repair. The actual incidence, pathogenesis, and natural history of these aneurysms are unclear. The purpose of this study is to better characterize subsequent proximal aortic aneurysms and to evaluate the outcome of their operative repair. METHOD: We retrospectively reviewed our recent experience with surgery for new proximal aortic aneurysms in 123 patients who had had a prior abdominal aortic aneurysmectomy. Seventy-two patients (58.5%) were admitted with chest or abdominal pain, six (4.9%) were admitted with ruptured aneurysms, and 41 (33.3%) were symptom free. Most subsequent aneurysms involved the thoracoabdominal aorta (n = 94; 76.4%); others involved the juxtarenal abdominal aorta, descending thoracic aorta, or transverse aortic arch. The new aneurysm was in continuity with the existing prosthetic graft in 101 cases (82.1%). Resection and graft replacement of the aneurysmal segment was performed on an emergency basis in patients with evidence of impending rupture and electively when aneurysmal diameter exceeded 5.5 cm. The average time interval between the two operations was 8.2 +/- 5.4 years. Mean aortic clamp and visceral ischemic times were 39.7 +/- 14.7 and 33.5 +/- 12.8 minutes, respectively. RESULTS: The in-hospital mortality rate was 12.2%. Complications included oliguric kidney failure in 11.4% and paraplegia in 4.1%. These results compare favorably with previous studies. CONCLUSION: On the basis of the significant prevalence of subsequent proximal aortic aneurysms and the high mortality rate associated with their rupture, we recommend resection of the entire infrarenal aorta during abdominal aortic aneurysm replacement, followed by long-term surveillance with biannual computed tomography or magnetic resonance imaging scanning of the chest and abdomen. Early diagnosis is facilitated by a high index of suspicion and allows surgical intervention to occur before life-threatening rupture. Both emergency and elective proximal aortic surgery in these patients can be performed with acceptable levels of morbidity and mortality.