Secondary Procedures In Patients Research Articles

Total rebuilding of the ear after unsatisfactory initial microtia reconstruction: 30-year experience using autogenous costal cartilage framework

This study describes the author's experience with long-term follow-up analysis of secondary procedures in patients with unsatisfactory initial microtia reconstruction. A total of 134 patients who underwent secondary operations between 1992 and 2021 were reviewed by examining medical records and photographic data. A total of 110 patients followed between 6 months and 26 years (average 33.2 months) were included for evaluation of aesthetic outcomes. Primary reconstruction was performed with costal cartilage in 113 patients, porous polyethylene implant in 7 patients, silicone implant in 6 patients, and others in 8 patients. The major external features at the time of the secondary reconstruction were lump (91 cases), deficient convolution (19 cases), and no framework with scarred mastoid skin (22 cases). All secondary reconstructions were performed with an autogenous costal cartilage framework. The framework was covered using temporoparietal fascia flap techniques in 118 patients, mastoid skin coverage technique in 12 patients, and others in 4 patients. One major complication (exposure of cartilage framework due to partial necrosis of fascial flap) and three minor complications (loss of moderate-sized full-thickness skin, grafted on the fascia) were recorded. The average score given for aesthetic outcomes, rated on a four-point Likert scale (i.e., 1 = poor, 2 = fair, 3 = good, and 4 = excellent) was 3.17 (median 3.00). A total of 42% of the patients were rated excellent and 36% were rated good.

Outcomes of Secondary Arthroscopic Distal Clavicle Resection for Shoulders With Symptomatic Acromioclavicular Joint Arthropathy After Isolated Rotator Cuff Repair With Complete Tendon Healing.

Recent meta-analyses have advised against distal clavicle resection (DCR) as an adjuvant procedure during rotator cuff repair (RCR), whether performed routinely or in shoulders diagnosed with symptomatic acromioclavicular joint (ACJ) arthropathy. However, the efficacy of DCR as a secondary procedure in patients with persistent pain attributed to symptomatic ACJ arthropathy remains unknown. To evaluate outcomes of secondary DCR in patients with failed nonoperative treatment of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing. Case series; Level of evidence, 4. Between 2008 and 2018, the senior surgeon performed isolated RCR in 1935 patients, of which 23 (1.2%) presented with ACJ pain and discomfort at ≥12 months after the index RCR, despite complete healing of repaired tendons. Those 23 patients underwent secondary DCR, as ACJ arthropathy was confirmed clinically and radiographically. Clinical assessment before DCR included the Subjective Shoulder Value (SSV) and pain at rest. Clinical assessment at >12 months after DCR included the SSV, pain at rest, Constant-Murley score, range of motion, and satisfaction. Pre- and post-DCR SSV and pain scores were compared. Of the initial cohort, 5 patients did not consent to the use of their data, leaving 18 patients aged 53.3 ± 7.6 years (mean ± SD; range, 39-68 years) for outcome assessment. At a mean follow-up of 7.0 ± 3.1 years after DCR, the SSV significantly improved from 58.7 ± 17.2 to 76.1 ± 20.2 (P < .001), and the pain at rest significantly decreased from 4.7 ± 1.5 to 2.8 ± 1.9 (P < .001). At final follow-up, the Constant-Murley score was 70.2 ± 21.0. Of 18 patients, 15 had none or mild residual pain (0-2; 83%), while 3 had substantial residual pain (5 or 6; 17%). Only 1 of the 3 patients with substantial residual pain had a poor SSV score (20 points) and was against opting for DCR in retrospect. No patient had infections or gross ACJ instability after DCR. Secondary DCR for cases of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing reduced pain in 83% of patients, and 94% were satisfied and would undergo secondary DCR again.

Total Knee Arthroplasty for Osteoarthritis Is Uncommon after Intralesional Curettage in Giant Cell Tumor of Bone.

Giant cell tumor of bone (GCTB) is most often treated with intralesional curettage; however, periarticular lesions have been shown to increase risk for osteoarthritis. Additionally, the location of these lesions may occasionally preclude a joint-sparing procedure in recurrent tumors. This study sought to investigate rates of secondary arthroplasty in long-term follow-up of knee GCTB. Cases of knee GCTB treated at our institution were reviewed. Rates of recurrence and secondary arthroplasty were recorded, and Kaplan-Meier survival analyses were performed. The records of 40 patients were reviewed. Local recurrence occurred in 25% of patients. The 1-, 5-, and 10-year recurrence-free survival (RFS) probability was 87.4% (95% CI, 77.0-97.7), 72.4% (95% CI, 57.6-87.2), and 72.4% (95% CI, 57.6-87.2), respectively. Function improved after surgery with a mean preoperative MSTS score of 14.9 (standard deviation [SD] 8.4) and mean postoperative MSTS score of 25.1 (SD 5.6) (p <0.001). Three patients had evidence of radiographic osteoarthritis at the last follow-up though they did not require arthroplasty. Arthroplasty was performed as a secondary procedure in six patients. Five patients underwent arthroplasty for recurrent tumors after initial treatment with curettage and one patient underwent patellar arthroplasty for osteoarthritis after initial treatment with an allograft composite arthroplasty. Arthroplasty is performed as a secondary procedure in patients with GCTB at a relatively infrequent rate and more often for cases of recurrent disease than for osteoarthritis. Overall, patients treated for GCTB have improved functional outcomes after surgery than before. Large, multi-institutional studies may be required to assess the incidence of secondary osteoarthritis requiring arthroplasty as this was an infrequent finding in our cohort.

Submuscular transposition of the ulnar nerve for persistent or recurrent cubital tunnel syndrome: Results of a prospective case series

Submuscular transposition (SMT) of the ulnar nerve is frequently performed as secondary procedure in patients with persistent or recurrent cubital tunnel syndrome (CuTS) despite previous surgery. Good results have been reported for this surgical strategy, but mainly in small retrospective case series. The goal of the present study is therefore to analyze the results prospectively using a patient-reported outcome measure (PROM): patient-rated ulnar nerve evaluation (PRUNE). SMT of the ulnar nerve was performed in 30 consecutive patients who were referred because of persistent or recurrent CuTS despite previous surgery. Objective outcome was measured in the outpatient clinic using the Likert scale. The PRUNE questionnaire was obtained pre-operatively, 6 weeks, 3 months, 6 months, and 12 months after the surgery. Simultaneously, 20 patients with primary surgery for CuTS, that underwent simple decompression, were followed. Good outcome (Likert 1 or 2) was obtained in 67% after SMT for persistent/recurrent CuTS and 85% after decompression as primary surgical treatment. PRUNE scores were significantly decreased in both groups at all follow-up moments after surgery compared with pre-operative for the total questionnaire and subscales "pain," "sensory/motor symptoms," and "specific activities." In both groups, PRUNE score remained stable until 12 months of follow-up. This prospective study confirms previous results from retrospective studies showing that SMT is an effective surgical option for persistent or recurrent CuTS. Prospective (randomized controlled) trials are needed to compare the effectiveness of SMT to the surgical alternative of subcutaneous transposition of the ulnar nerve.

Layered Mastopexy with Augmentation in Muscle Splitting Biplane: A Modification for Lower Pole Safety and Stability.

Single-stage mastopexy with augmentation is a commonly performed procedure. The single-stage procedure can be performed in primary cases or a secondary procedure in patients with previous history of augmentation, mastopexy or mastopexy with augmentation. The procedure is challenging and not without its risks. A retrospective chart review of all consecutive cases of layered mastopexy with augmentation mammoplasties, carried out from September 2015 to August 2019, was performed. All patients had their implants placed in muscle splitting pocket first and access for the pocket was closed prior to the commencement of mastopexy. During the period of 4years, 102 consecutive layered mastopexy with augmentations were performed in muscle splitting plane. Of these 102 patients, 74 (72.5%) patients had it as a primary and 28 (27.5%) as a secondary procedure. Of these 102 patients, 53 (52.0%) had textured, 37 (36.3%) had smooth and 12 (11.8%) had microtextured implants and 72 (70.6%) patients had high profile and 30 (29.4%) had medium profile implants. Same size implant was used in 89 patients with a mean of 298cc, and 13 patients had different size implants with a mean of 362cc on the right and 395cc on the left. In current study, bilateral periareolar, vertical scar cat's tail and Wise pattern mastopexies were performed in 11, 51 and 27 patients, respectively. Of the 102 patients, 5 had unilateral right periareolar, 5 unilateral right vertical scar cat's tail, 2 unilateral left periareolar and 1 patient had a combination of periareolar and vertical scar combination. There was no nipple loss or periprosthetic infection. There was a minor wound breakdown seen in 4 (3.9%), haematoma in 2 (2.1%), nipple sensation loss in 2 (2.1%) and 12 (11.8%) had layered mastopexy as a part of a combined procedure. Revision was performed in 6 (6.5%), drains were used in 14 (13.7%), and 92 (90.2%) had the procedure performed as a day case. Layered mastopexy with augmentation is a safe procedure with added stability and safety to lower pole of the breast as well as nipple-areolar complex. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Secondary Salvage of the Unsatisfactory Microtia Reconstruction.

Because auricular reconstruction is a complex and relatively uncommon procedure, there are many patients that have had disappointing reconstructions. This study describes the authors' large experience with secondary procedures in patients with unsatisfactory or failed initial ear reconstruction. A prospectively maintained database of all consecutive patients who underwent secondary total ear reconstruction from March of 1991 to December of 2017 was reviewed. Demographic data and outcomes were assessed. Patients with acquired absence of the ear were not included. There were 144 microtia patients that met the inclusion criteria. Patient age at the time of the secondary reconstruction ranged from 3 to 59 years. Follow-up duration ranged from 1 to 21 years. Primary reconstruction was performed with rib cartilage in 91 patients, porous polyethylene implant in 47 patients, prosthesis in four patients, and irradiated cadaver rib cartilage in two patients. All secondary reconstructions were performed with porous polyethylene implants. The alloplastic framework was covered with a temporoparietal fascia flap in 76 patients, an occipital fascia flap in 64 patients, and a free fascia flap in four patients (two radial forearm flaps in the same patient, one contralateral temporoparietal fascia flap, and one lateral arm flap). Fourteen patients (10 percent) had complications requiring revision surgery. Secondary surgery was successful in all but one patient. These data represent the largest series of secondary total ear reconstructions. The use of a porous polyethylene implant is an ideal method for these patients because of its minimal morbidity and relatively low complication rate. Therapeutic, IV.

Surgical Outcomes of Microcatheter-assisted Trabeculotomy as a Secondary Procedure in Patients with Primary Congenital Glaucoma.

PURPOSE:To investigate the efficacy and safety of illuminated microcatheter-assisted trabeculotomy as a secondary procedure in patients with primary congenital glaucoma (PCG).METHODS:This retrospective case series included patients with PCG who underwent trabeculotomy using an illuminated microcatheter with the intent of catheterizing the full circumference of Schlemm's canal in a single procedure. Success was defined as intraocular pressure (IOP) ≤21 mmHg, with or without the use of glaucoma medications. Clinical examination data were collected for up to 36 months postoperatively.RESULTS:Surgery was performed on 16 eyes of 16 patients. The mean patient age was 75.1 ± 69.4 months (range: 4.0–216.0 months). Complete catheterization was achieved in 11 of the 16 eyes (69%), whereas partial catheterization was achieved in five of the 16 eyes (31%). All eyes had previously undergone surgery for PCG. The mean follow-up duration was 20.3 ± 9.0 months (range, 12.0–36.0 months). IOP was reduced from a mean of 31.8 ± 6.6 mmHg preoperatively to 15.6 ± 3.7 mmHg at the final follow-up (P < 0.001). The mean preoperative number of glaucoma medications was 3.9 ± 0.5, which was reduced to 1.1 ± 1.6 at the final follow-up (P = 0.001). Ten (62.5%) of the 16 eyes did not require glaucoma medication by the final follow-up. Early transient postoperative hyphema occurred in six eyes (37.5%). No other complications were noted. All corneas were clear at the final follow-up.CONCLUSION:Ab externo circumferential trabeculotomy using an illuminated microcatheter may be safe and effective as a secondary surgical option for children with PCG after unsuccessful glaucoma surgery.

Secondary Procedures Following Iliac Branch Device Treatment of Aneurysms Involving the Iliac Bifurcation: The pELVIS Registry

Purpose: To evaluate the incidence and reasons for secondary procedures in patients treated with iliac branch devices (IBDs) for isolated iliac aneurysm or aortoiliac aneurysms involving the iliac bifurcation. Methods: Between January 2005 and December 2015, 575 surgical-high-risk patients (mean age 72.0±8.4 years; 558 men) with isolated iliac aneurysms (n=79) or aortoiliac aneurysms involving the iliac bifurcation (n=496) were treated with placement of 650 ZBIS or Gore IBDs (75 bilateral) in 6 European centers. The primary outcome was procedure-related reinterventions for occlusion or high-grade (>70%) stenosis of the bridging device, occlusion of the ipsilateral common or external iliac artery (EIA), type I/III endoleak, rupture, or infection following IBD implantation. Clinical and radiological data were analyzed based on preset definitions of comorbidities, aneurysm morphology, intraoperative variables, and follow-up strategies. Results: Nine (1.6%) reinterventions were performed within 30 days for occlusion or endoleak. Among 10 (1.5%) occluded EIAs ipsilateral to a deployed IBD, 6 underwent a reintervention with additional stent placement after thrombolysis (n=4) or a femorofemoral or iliofemoral crossover bypass (n=2). Three of 14 patients with early type I endoleak had a reintervention for an insufficient proximal sealing zone (stent-grafts in 2 common iliac arteries and 1 bifurcated endograft). Mean clinical and radiological follow-up were 32.6±9.9 and 29.8±21.1 months, respectively. Forty-two (7.3%) patients underwent reinterventions in the follow-up period. The overall postoperative reintervention rate was 8.9%. Both external and common iliac segments occluded in 30 (4.6%) IBDs; 2 patients had a crossover bypass and 14 were treated with endovascular techniques. In the other 14 patients, no specific treatment was performed. Seven (1.2%) patients with isolated EIA occlusion were treated during follow-up. Nineteen of the overall 28 patients with type I endoleak underwent endovascular repair. The other 9 were under radiological surveillance due to less significant (<5 mm) sac increase. No reintervention was performed to recanalize 11 (1.6%) occluded internal iliac arteries. Conclusion: Midterm experience with placement of IBDs is associated with a low incidence of secondary procedures due to type I endoleaks and occlusions. The main reasons for reinterventions seem to be short proximal sealing zone and poor conformability of the ZBIS device in elongated EIAs.

Role of Drain Placement in Major Hepatectomy: A NSQIP Analysis of Procedure-Targeted Hepatectomy Cases.

The value of drain placement in hepatic surgery has not been conclusive. The aim of this study was to determine whether drain placement during major hepatectomy was associated with negative postoperative outcomes and whether its placement reduced the need for secondary procedures. The American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Hepatectomy Database was used to identify patients who underwent major hepatectomy. Patients were divided into two groups based on the placement of a drain during the procedure. Propensity score-matched cohorts of patients who underwent major hepatic resection with or without drain placement were created accounting for patient characteristics. The primary outcomes were 30-day postoperative complications including bile leak, post-hepatectomy liver failure, and invasive intervention as well as mortality and readmission. A total of 1005 patients underwent major hepatectomy; 500 patients (49.8%) had prophylactic drains placed at the conclusion of the procedure. Drain placement was associated with any complication (p<0.001), blood transfusion (p<0.001), renal insufficiency (p=0.02), bile leak (p<0.001), invasive intervention (p=0.02), length of stay (p=0.001), and readmission (p<0.001). In the matched cohort, drain placement was associated with any complication (p<0.001), blood transfusion (p<0.001), superficial surgical site infection (SSI) (p=0.028), bile leak (p<0.001), and longer length of stay (0.03). In addition, placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention (p=0.21) (Table2). In multivariate analysis, drain placement was independently associated with any complication (p<0.001), blood transfusion (p=0.02), bile leak (p<0.001), invasive intervention (p=0.011), superficial surgical site infection (SSI) (p=0.039), and hospital readmission (p=0.005) (Table3). Placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention (p=0.15). Drain placement after major hepatectomy may lead to increased postoperative complications including bile leak, superficial surgical site infection, and hospital length of stay and does not decrease the need for secondary procedures in patients with bile leaks.

Maxillomandibular Fixation by Plastic Surgeons: Cost Analysis and Utilization of Resources.

Maxillomandibular fixation (MMF) can be performed using various techniques. Two common approaches used are arch bars and bone screws. Arch bars are the gold standard and inexpensive, but often require increased procedure time. Bone screws with wire fixation is a popular alternative, but more expensive than arch bars. The differences in costs of care, complications, and operative times between these 2 techniques are analyzed. A chart review was conducted on patients treated over the last 12 years at our institution. Forty-four patients with CPT code 21453 (closed reduction of mandible fracture with interdental fixation) with an isolated mandible fracture were used in our data collection. The operating room (OR) costs, procedure duration, and complications for these patients were analyzed. Operative times were significantly shorter for patients treated with bone screws (P < 0.002). The costs for one trip to the OR for either method of fixation did not show any significant differences (P < 0.840). More patients with arch bar fixation (62%) required a second trip to the OR for removal in comparison to those with screw fixation (31%) (P < 0.068). This additional trip to the OR added significant cost. There were no differences in patient complications between these 2 fixation techniques. The MMF with bone screws represents an attractive alternative to fixation with arch bars in appropriate scenarios. Screw fixation offers reduced costs, fewer trips to the OR, and decreased operative duration without a difference in complications. Cost savings were noted most significantly in a decreased need for secondary procedures in patients who were treated with MMF screws. Screw fixation offers potential for reducing the costs of care in treating patients with minimally displaced or favorable mandible fractures.

Balloon Dilation of the Ureter: A Contemporary Review of Outcomes and Complications

During ureteroscopy ureteral balloon dilation may be necessary to allow for passage of endoscopic instruments or access sheaths. We assessed the efficacy and complications associated with ureteral balloon dilation. We retrospectively reviewed the records at 2 institutions from 2000 to 2012 to identify patients who underwent ureteral balloon dilation during ureteroscopic treatment of upper tract stones. An 18Fr balloon dilator was used in all cases. Patients with documented ureteral stricture, radiation therapy or urothelial cancer were excluded from analysis. Primary outcomes were the stone-free rate, operative complications, balloon dilation failure and the postoperative ureteral stricture rate. Complications were divided into intraoperative and postoperative groups according to the Satava and Clavien-Dindo classifications, respectively. A total of 151 patients fulfilled study criteria. Median followup was 12 months. The stone-free rate was 72% and median time to first postoperative imaging was 2.8 months. Balloon dilation failed in only 8 patients (5%). Eight intraoperative ureteral perforations (5%) were identified, which were managed by a ureteral stent in 7 patients and a percutaneous tube in 1. Endoscopic re-treatment was required in 4 patients with Satava 2b postoperative complications. The postoperative complication rate was 8% (11 cases). A single ureteral stricture was attributable to balloon dilation. In this contemporary review balloon dilation of the ureter before endoscopic treatment of stone disease was associated with a high success rate and few complications. Ureteral balloon dilation may decrease the need for a secondary procedure in patients undergoing ureteroscopy to manage proximal ureteral and intrarenal stones.

Survival and Secondary Surgery Following Lower Extremity Replantation

The limited and inconsistent literature exists on survival and secondary surgery following lower limb replantation. The purpose of this study was to review our institutional experience in lower extremity replantation to quantify survival and characterize secondary surgeries. We performed a retrospective chart review of all lower extremity replantations at our institution between 2000 and 2012. The mean follow-up period was 2.6 years. Patient, injury, and surgical demographics as well as replantation survival, secondary surgical procedures, and complications were recorded. A total of 22 lower extremity replantations were performed with 45% survival (n = 10). Secondary surgeries were common with an average of six per patient (range 2-11). Early secondary procedures included debridements (19 of 22 patients, 86%) and soft tissue coverage (15 of 22 patients, 68%). The average initial hospitalization was 45 days (range 19-90) and time to final secondary procedure in patients with surviving replantation was 1.5 years (range 18 d-3.5 y). Late secondary surgeries were aimed at either aesthetic or functional enhancement. The most common complication was deep infection in 18 of 22 patients (82%) and infection was felt to be the cause of replantation failure in all cases. We found a modest survival following lower extremity replantation with several secondary surgeries in each case. Infection complicated the majority of cases and free tissue transfer was often required for wound coverage. Early secondary surgeries were aimed at debridement and soft tissue coverage while late secondary surgeries were aimed at either aesthetic or functional enhancement.

EndoAnchor Placement in Thoracic and Thoracoabdominal Stent-Grafts to Repair Complications of Nonalignment

To report our early experience in repairing incomplete sealing or nonalignment of thoracic or thoracoabdominal stent-grafts using EndoAnchors. Six patients (5 men; mean age 67 years, range 56-76) with thoracic or thoracoabdominal aortic stent-grafts and persistent type I endoleak (n=4), stent-graft migration (n=2), partial stent-graft infolding (n=2), and/or side branch malperfusion (n=1) were treated using the Heli-FX Aortic Securement System. Stent-graft or uncovered stent extension did not improve alignment in 3 patients prior to the use of EndoAnchors. Intended fixation of the proximal stent-graft in the aortic arch (n=1) and the proximal (n=3) or distal (n=2) descending thoracic aorta was achieved in all 6 patients using 28 EndoAnchors (3-7 per patient). Two to 4 EndoAnchors were placed at the site of the nonalignment and an additional 2 to 4 to fix the entire circumference of the stent-graft. The majority of the EndoAnchors were delivered successfully at the first attempt, but 5 required reapplication during the same intervention (no EndoAnchors were lost). No additional balloon dilation or other adjunctive maneuver was required for improvement of thoracic stent-graft fixation after the deployment of the EndoAnchors. The intraoperative and early postoperative periods were uneventful in 5 patients; however, one TAAA patient with a fenestrated aortic arch stent-graft suffered from multiple visceral and cerebral infarctions and died 4 weeks later. During the mean 11-month follow-up (range 5-22), no stent-graft migration or EndoAnchor dislocation has been observed. There have been no periaortic hematomas or side branch complications. Although the number of patients treated so far is small, the Heli-FX Aortic Securement System seems to be a feasible and safe treatment option for primary or secondary procedures in patients with complications of proximal or distal thoracic stent-graft nonalignment. However, extensive endovascular interventions in the proximal aortic arch should be performed with caution because of an increased risk of severe embolic events.

Double Capsules

Sir:FigureWe read with great interest the article entitled “Breast Implant Complication Review: Double Capsules and Late Seromas” by Hall-Findlay published in the January issue of the Journal.1 In the article, Hall-Findlay underlines the problem of a double capsule around a breast implant and its correlation with aggressively textured implants. We would like to present our small but significant experience with this problem. In our department, we perform more than 100 breast reconstructions with implants each year. Periprosthetic capsule represents the common reaction of the body to breast implants, and its contracture is the most frequent indication for reoperation in patients who receive implants for reconstructive or cosmetic purposes.2–5 The double-capsule formation around the implant instead seems to be a rare complication.1 In our past 4 years' experience in breast reconstructive surgery, only 10 patients were found to have a double capsule around the implant. Three of these patients were symptom free and the double capsule was an incidental finding. In the remaining seven patients, the surgery was performed for implant rotation or dislocation. The implants in all 10 of the patients were positioned under the pectoralis muscle. In all cases, after the peripheral capsule was opened, a second capsule was found surrounding the implant. All implants removed were Biocell textured surface implants. After complete capsulectomy along with removal of old implants, polyurethane-covered breast implants of the same size were implanted in the same pocket. We use these implants for secondary procedures in patients who have had recurrent problems with other types of implants. Despite the greater care required in preparing the pouch, polyurethane-covered breast implants proved highly successful at reducing the incidence of capsular contracture for at least 10 years because of their high degree of adhesiveness to the adjacent tissues.2 Capsules always adhere to the polyurethane implants, making separation difficult. We agree with the author's practice in saying that, as in our experience, the Biocell textured implant's capsule adheres less than the polyurethane implant's capsule, and it can be more easily separated during surgery with simple finger dissection. It is also likely true that, in one's everyday life, a minor trauma can lead to detachment of the capsule, a late seroma formation, and subsequent predisposition to double capsule onset, especially in more aggressive textured prostheses.1 In long-term controls, within 5 years, no issue has been reported in patients who have received polyurethane implants. DISCLOSURE The authors have no conflicts of interest to disclose. Mario Dini, M.D., Ph.D. Valentina Giordano, M.D. Allesandro Quattrini Li, M.D. Andrea Mori, M.D. Simone Napoli, M.D. Department of Plastic and Reconstructive Surgery, University of Florence, Florence, Italy

Secondary Procedures After Aortic Aneurysm Repair With Fenestrated and Branched Endografts

To investigate the secondary procedures in patients with previous endovascular aortic repair by fenestrated or branched stent-grafts for aneurysms involving the renal and visceral vessels. Between January 2001 and May 2010, 107 consecutive high-risk patients (97 men; mean age 73 years, range 50-86) with aortic aneurysms involving the renal and visceral arteries were treated with endovascular techniques. A custom-made Zenith graft was used in all patients. All secondary graft-related procedures performed in the perioperative period and during follow-up were analyzed. Estimates of survival, freedom from migration/type I endoleak, and freedom from any device-related secondary procedures were assessed with Kaplan-Meier analyses. The 30-day mortality rate was 1.9%. During follow-up (mean 25 months, range 1-94), 34 secondary procedures were performed in 28 (26.2%) patients for 6 (17.6%) limb graft stenoses/thromboses (5.6% of 107 cases), 8 (23.5%) in-stent visceral vessel stenoses/occlusions (7.5% of 107 cases), 8 (23.5%) migrations/type I endoleaks with/without visceral stent fractures (7.5% of 107 cases), and 12 (35.3%) type III endoleaks (9.3% of 107 cases). The mean interval between the primary and secondary procedures was 12.9 months (range 1-68). In 26 (76.5%) of 34 cases, a secondary endovascular procedure was performed; in the remaining 8 (23.5%) cases, the complication was treated surgically. The secondary procedure was unsuccessful in 9 cases of visceral vessel compromise (failure to cannulation, stent fracture/migration, in-stent stenosis/occlusion). Estimated 3-year survival was 77%, while the 3-year rate for freedom from any device-related secondary procedure was 75.5%. The incidence of early and late complications requiring a secondary procedure after treatment with fenestrated or branched devices was not negligible. Endoleak type III represented the most common cause for reintervention during follow-up. Secondary procedures performed for visceral vessel compromise had high rates of treatment failure. Accurate preoperative planning, the advent of new materials/techniques, and strict follow-up could be the key factors to improving the results of fenestrated or branched stent-graft interventions and to reduce the rate of secondary procedures.

Long-lasting complications with the use of polyurethane-covered breast implants

Polyurethane-covered breast implants have been recommended by some authors for aesthetic and reconstructive procedures, since with these implants the incidence of capsular contracture is insignificant and risks of implant displacement or exposure are reduced. Reports on the use of these implants focus merely on aesthetic aspects, and risks associated with disintegration and incorporation of the polyurethane-coating are often overlooked. The authors have observed several complications associated with the use of these prostheses; two cases of long-lasting complication are described, which are ascribed to difficult removal of infected fragments of the coat and to delayed foreign body reaction to polyurethane. The authors believe that the hazards associated with these implants outweigh their advantages for primary use, but suggest their use for secondary procedures in patients who have had recurrent problems with smooth implants.

Dandy-Walker syndrome: analysis of 21 cases.

During the years 1950 to 1978, a total of 21 cases of Dandy-Walker syndrome were seen at the Vancouver General Hospital. Apart from hydrocephalus, the associated brain anomalies included agenesis of the corpus callosum in four cases, occipital meningocele in two and aqueductal stenosis in one patient. Systemic malformations were present in four patients and included two cases of cleft palate, one of polycystic kidneys and one of congenital rubella syndrome. The over-all mortality was 48 per cent, but has declined since 1965. Of the 12 cases treated surgically, only four have died. The number of shunt revisions was high (about two per patient). Of the 11 survivors, three have normal intelligence, four show mild mental retardation, and four are moderately to severely retarded. The differential diagnosis, clinical course and surgical therapy are discussed. It is recommended that double shunting of a lateral ventricle and of the enlarged fourth ventricle should be the primary procedure in cases associated with aqueductal stenosis or occlusion, and should be the secondary procedure in patients who exhibit recurrence of increased pressure in the posterior fossa after simple shunting of a lateral ventricle.