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When large portions of the internal orbit are destroyed (two to four walls), standard bone-grafting techniques for immediate and late orbital reconstruction may not yield predictable eye position. Critical bone support is most often deficient inferomedially. CT analysis of orbital volume in cases where eye position was unsatisfactory reveals that displacement of bone grafts is one mechanism of the unsatisfactory result. Other mechanisms include undercorrection and bone-graft resorption. In order to minimize postoperative bone-graft displacement, titanium implants were used to span large defects in the internal orbit to provide a platform for bone-graft support. Twenty-six implants were placed in immediate and 12 were placed in late orbital reconstructions. More reliable bone-graft position resulted. Two late infections have occurred resulting in implant removal in a 3-year period.

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Visualization during exploration of the orbit is hampered by herniation of orbital fat around the malleable retractor in posterior orbital dissection. A thin stiff disc of plastic sheeting, placed between the dissected orbital soft tissue contents and the malleable retractor, reduces prolapse of fat around the edges of the orbital retractor. The technique is utilized in acute fracture treatment and in late orbital reconstruction. The malleable retractor, placed below the plastic disc, may be easily taken in and out of the orbit with reduced damage of fat and enhanced visualization. Retractor damage to fat is reduced and visualization enhanced. The plastic sheet may be inserted over an intact posterior bony "ledge" in floor fractures, allowing accurate placement of bone grafts under direct visualization. Additionally, the use of a segment of flexible rubber sheeting sewed over a subciliary incision margin reduces traction injury, drill and cautery damage to eyelid skin.

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Use of rigid fixation in facial skeletal reconstruction has had a resurgence in popularity. Miniplates and screws to rigidly fix fractures, control occlusal osteotomies, and even congenital craniofacial osteotomies, have revolutionized facial reconstructive surgery. In facial fractures, where restoration of preinjury facial appearance is the goal, rigid fixation has added a new treatment potential, providing immediate three-dimensional stability of the fracture reduction.

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Using real-time, two-dimensional echocardiographic techniques, we recently studied six consecutive patients with acute myocardial infarction complicated by rupture of the posterior interventricular septum. Each patient experienced an inferior wall myocardial infarction, with a prior anteroseptal infarction in one. In each case, the clinical course was punctuated by the onset of heart failure and a low output state prior to, or coincident with, the appearance of a pansystolic murmur. During two-dimensional echocardiographic study, all six were found to have a discrete aneurysm of the posterior interventricular septum. Septal dyskinesis produced bulging of the interventricular septum far into the right ventricular cavity during systole. Our findings suggest that (1) septal dyskinesis and aneurysm formation may be a valuable sign in diagnosing ventricular septal performation; (2) the reported incidence of postinfarction septal aneurysm at surgery or autopsy may significantly underestimate its true frequency; and (3) septal dyskinesis must by considered as a contributing factor to the compromised hemodynamic status of patients with postinfarction ventricular septal rupture.

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Two patients had a typical sounding cardiac friction rub after placement of a temporary transvenous pacemaker. Absence of myocardial perforation was documented in one patient during thoracotomy for placement of an epicardial electrode and in the other with an electrogram recorded from the pacemaker as it was being withdrawn. The rubs disappeared during pacemaker removal. These cases are believed to represent endocardial friction rubs resulting from contact of the pacing wire with the endocardium.

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Two patients who presented by scalar ECG with an A-V junctional tachycardia were demonstrated during an electrophysiologic evaluation to have an atrial tachycardia without P waves in the surface ECG. Case 1 had an atrial tachycardia that conducted through the A-V node with a Wenckebach block. Atrial activity was recorded only from the proximal portion of the coronary sinus and from right atrial areas near the tricuspid valve. Case 2 had an atrial tachycardia that abruptly began and terminated following carotid sinus massage. Atrial activity was recorded only in the coronary sinusos, and pacing at that site resulted in atrial capture, with Wenckebach conduction to the ventricles. These observations demonstrate that an atrial tachycardia without P waves can simulate A-V junctional tachycardia with or without Weckebach block. Such findings may have a bearing on some important electrophysiologic concepts such as the origin of A-V junctional rhythms and the need for atrial participation in A-V nodal re-entry.

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