A retrospective analysis was carried out on the records of 317 patients operated on by the senior author (S.A.W.) for orbital fractures between 1975 and 2007. Two hundred forty of the patients had been previously operated on elsewhere and required further correction (posttraumatic, postsurgical orbital deformity). A smaller group of patients (n = 77) were operated on primarily. The two groups were not, of course, similar, because the posttraumatic, postsurgical orbital deformity group had been operated on by a variety of surgeons with varying levels of experience and ability, and the group of patients operated on primarily had a larger percentage of fractures in the pediatric age group, because of the practice being partially based in a children's hospital, and a larger percentage of severe, compound orbital injuries, because of statewide referrals. Nevertheless, a number of causes for reoperation seen in the posttraumatic, postsurgical orbital deformity group were not seen in the primarily operated group. These included lower eyelid retraction attributable to use of the subciliary incision, displacement and extrusion of alloplastic materials, and fixation of fractures in a nonreduced position. These differences validate, in the authors' opinion, the application of the basic principles of craniofacial reconstruction set forth by Paul Tessier, listed in the text, to both the primary and secondary treatment of posttraumatic orbital deformities.

Background:Surgical treatment of pressure ulcers is challenging for high recurrence rates. Deepithelialized flaps have been used previously with the aim to eliminate shearing forces and the cone of pressure (COP) effect. The goal of this study is to adopt a standardized protocol and evaluate if 2 different flap techniques affect outcomes.Methods:The novel COP flap is illustrated. Twenty patients were prospectively treated with flap coverage over a 36-month period. According to the flap type, patients were assigned to 2 groups: group 1 with 11 patients treated with the COP flap and group 2 with 9 patients treated with conventional flap without anchoring technique. We adopted a standardized protocol of debridement, tissue cultures, and negative-pressure wound therapy. Rotation fasciocutaneous flaps were used for both groups and mean follow-up was 19 months. The COP flap is a large deepithelialized rotation flap inset with transcutaneous nonabsorbable bolster sutures. The 2 groups were comparable for demographics and ulcer location and size (P < 0.05). Five patients showed positive cultures and were treated with antibiotics and negative-pressure therapy before surgery.Results:Recurrence rates were 12% in the COP flap group and 60% in the conventional flap coverage group (P < 0.001). Results were compared at 16-month follow-up.Conclusions:The COP flap significantly reduces recurrences and eliminates shearing forces, suture ripping, and tension on superficial soft-tissue layers. The technique can be applied to both ischial and sacral pressure sores. The flap provides padding over bony prominence without jeopardizing flap vascularity.

Opitz syndrome is a rare genetic disorder which has been well defined; however, the surgical treatment of the anomalies has not been codified. The objective is to review the literature and describe the surgical priorities in the treatment of Opitz syndrome. This report is unique in the fact that it describes a surgical approach to the treatment of the deformities. Better outcomes are achieved with preoperative analysis of the deformities and surgical planning. Simultaneous soft tissues and bony reconstruction with grafts can achieve long lasting results and decrease recurrence rates.