BackgroundOrbital resorbable mesh plates are adequate to use for isolated floor and medial wall fractures with an intact bony buttress, but are not recommended to use for large orbital wall fractures that need load bearing support. The author previously reported an orbital wall restoring surgery that restored the orbital floor to its prior position through the transnasal approach and maintained temporary extraorbital support with a balloon in the maxillary sinus. Extraorbital support could reduce the load applied on the orbital implants in orbital wall restoring surgery and the use of resorbable implants was considered appropriate for the author’s orbital wall restoring technique.MethodsA retrospective review was conducted of 31 patients with pure unilateral orbital floor fractures between May 2014 and May 2018. The patients underwent transnasal restoration of the orbital floor through insertion of a resorbable mesh plate and maintenance of temporary balloon support. The surgical results were evaluated by the Hertel scale and a comparison of preoperative and postoperative orbital volume ratio (OVR) values.ResultsThe OVR decreased significantly, by an average of 6.01% (p< 0.05) and the preoperative and postoperative Hertel scale measurements decreased by an average of 0.34 mm with statistical significance (p< 0.05). No complications such as buckling or sagging of the implant occurred among the 31 patients.ConclusionThe use of resorbable mesh plate in orbital floor restoration surgery is an effective and safe technique that can reduce implant deformation or complications deriving from the residual permanent implant.

We report a case of free flap deterioration which may have been induced by pressure gradient resulting from cranial defect overlying a ventriculoperitoneal shunt (VP shunt). The patient, male and aged 78, had a VP shunt operation for progressive hydrocephalus. Afterwards, the scalp skin flap surrounding the VP shunt collapsed and showed signs of necrosis, exposing part of the shunt catheter. After covering the defect with a radial forearm free flap, the free flap site showed signs of gradual sinking while the vascularity of the flap remained unimpaired. An agreement was reached to remove the shunt device and observe the patient for any neurological symptoms, and after the shunt was removed and the previous cranial opening filled with fibrin glue by Neurosurgery, we debrided the deteriorated flap and provided coverage with 2 large opposing rotational flaps. During 2 months' outpatient follow-up no neurological symptoms appeared, and the new scalp flap displayed slight depression but remained intact. The patient has declined from any further follow-up since.

Intentional pesticide poisoning is not uncommonly encountered in emergency care settings, and the route of administration is generally oral. We present a peculiar case of intravenous pesticide injection and the prolonged management of upper extremity necrosis that ensued. A man who had injected an unidentified pesticide into his antecubital vein was admitted for acute renal failure and left arm cellulitis. After vital status stabilization, the patient was referred for cellulitis management. A febrile inflammatory draining wound was centered on the antecubital fossa. Incisional drainage and fasciotomy revealed thick pesticide-smelling mucoserous fluid and liquifaction necrosis following the course of thrombosed and sclerotic vessels. Serial surgical debridement and negative pressure wound therapy allowed local skin flap coverage. However, a large post-discharge seroma developed and the patient was re-admitted for nearly a month of additional wound management which finally achieved successful recovery with full range of motion of the arm and hand. Intravenously injected pesticide is poorly cleared by local tissues and can cause abscess formation and liquifactory necrosis. Recognition of the poisoning agent and early initiation of fasciotomy and serial debridement is necessary for successful wound management of the involved extremity.

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