Handheld Doppler Detection and Light Illumination for Vascular Mapping in Nasal Reconstruction.

BACKGROUND: The application of the expanded forehead flap in nasal reconstruction has the advantage of being able to provide a sufficient amount of flap and can provide good aesthetic results. For an expanded forehead flap to survive, there must be adequate arterial supply and venous return. Despite this, limited studies have been conducted on preoperative vascular mapping and the design of the expanded forehead flap for nasal reconstruction. In this article, the authors present a technique of hand-held Doppler detection with light illumination for vascular mapping. PATIENTS AND METHODS: The study included patients who underwent total nasal reconstruction with expanded forehead flaps between May 2016 and April 2021. The design of the flap was based on the result of preoperative vascular detection by hand-held Doppler detection assisted by light illumination. RESULTS: A total of 32 patients underwent total nasal reconstruction with an expanded forehead flap. The distal part of the flap became necrotic 1 week after the surgery in 2 patients. Following dressing changes and the administration of antibiotics, the distal flap in these patients survived well. No complications were reported in the long term. CONCLUSIONS: Hand-held Doppler detection combined with light illumination is a convenient and effective preoperative design method for nasal reconstruction with an expanded forehead flap. All flaps survived well in the long term. LEVEL OF EVIDENCE: Level IV.

Comparative analysis of original face and skin-warped average face images for the scoring of skin attributes.

OBJECTIVES: Representative of a panel, an average face image could be used to analyse/display skin changes while alleviating image rights constraints. Therefore, we used landmark-based deformation (warping) of individual skin images onto their panel's average face, evaluating this approach's relevance and possible limits. METHODS: An average front face image was constructed from images of 71 Japanese women (50-60 years old). After warping individual skin images onto this average face, the resulting skin-warped average faces were presented to three experts who graded: forehead wrinkles, nasolabial fold, wrinkle of the corner of the lips, pore visibility and skin pigmentation homogeneity. Two experts estimated subjects' age. Results were compared to gradings performed on original images. RESULTS: Inter-expert grading shows excellent to good correlation whatever image type: from 0.918 (forehead wrinkles) to 0.693 (visibility of pores). Correlations between scoring of both image types are almost always higher than inter-expert correlations (maximum: 0.939 for forehead wrinkles-minimum: 0.677 for pore visibility). Frequencies of grades/ages are similar when scoring original and skin-warped average face images. Experts scores are similar in 90.6%-99.3% of the cases. Average deviations upon scoring both image types are smaller than average inter-expert deviations on original images. CONCLUSIONS: Scoring facial characteristics in original images and skin-warped average face images show an excellent agreement, even for perceived age, a complex feature. This opens the possibility of using this approach to grade facial skin features, monitor changes over time, and to valorise results on a face deprived of image rights.

Subcutaneous fat infiltration into the dermal layer induces wrinkle formation.

BACKGROUND: Wrinkles appear with aging, producing an aged impression, but the mechanism of wrinkle formation has not yet been fully elucidated. We recently reported that subcutaneous fat infiltrates into the dermal layer with aging and impairs skin elasticity, but the contribution of this process to wrinkle formation is still unclear. PURPOSE: We aimed to clarify the contribution of dermal fat infiltration to wrinkle formation by analyzing the relationship between them in the forehead of female volunteers. METHODS: We measured the severity of fat infiltration in the forehead of 29 middle-aged female volunteers by means of ultrasonography. Fixed wrinkles present when the eyes were closed and wrinkles transiently formed when the eyes were open were evaluated using a photograph-based 6-grade evaluation system for each type of wrinkle. RESULTS: Fat infiltration at the forehead area was observed similarly to that in the cheek area as we reported previously. We found that opening the eyes induced the formation of stable transient wrinkles, the grade of which was significantly related to fat infiltration severity. Furthermore, fat infiltration was also significantly related to the severity of fixed wrinkles. Moreover, the severity of transient wrinkles was significantly related to that of fixed wrinkles. CONCLUSIONS: Our results suggest that fat infiltration into the dermal layer enhances transient wrinkle formation during facial expression by impairing the ability of the skin to resist deformation, thereby promoting fixed wrinkle formation. Therefore, fat infiltration is a critical cause of wrinkle formation.

Anatomic Variations of the Lateral Branch of the Supraorbital Nerve Observed in Endoscopic Forehead Surgery.

Surgeons dissect carefully in the medial third of the supraorbital rim to preserve the supraorbital nerve (SON) during surgical forehead rejuvenation. However, the anatomic variations of SON exit from the frontal bone have been researched in cadaver or imaging studies. In this study, we report a variation in the lateral branch of SON observed in an endoscopic view during forehead lifts. A retrospective review of 462 patients who underwent endoscopy-assisted forehead lifts between January 2013 and April 2020 was performed. Data, including the location, number, and form of the exit point and thickness of SON and its lateral branch variant, were recorded and reviewed intraoperatively, utilizing high-definition endoscopic assistance. Thirty-nine patients and 51 sides were included, and all patients were female, with a mean age of 44.53 (18-75) years. This nerve exited a foramen in the frontal bone ~8.82 ± 2.79 mm lateral to SON and ~1.89 ± 1.34 mm from the supraorbital margin vertically. Observed thickness variations of the lateral branch of SON included 20 small, 25 medium, and 6 large nerves. This study revealed various positional and morphologic variations of the lateral branch of SON in an endoscopic view. Thus, surgeons can be alerted of the anatomic variations of SON and establish careful dissection during procedures. In addition, the findings of this study will be useful in planning nerve blocks, filler injections, and migraine treatments in the supraorbital region.

An Exploration of the Anatomy of the Forehead of Asians and Its Relationship With Forehead Lines Based on Ultrasound Imaging.

BACKGROUND: A profound understanding of the various frontal tissues' morphology and their relationship with forehead lines can efficiently guide clinical treatment. OBJECTIVES: The authors explored the relationship between frontal anatomy and frontal lines. METHODS: We measured the thickness and shape of tissues in different regions of the forehead of 241 Asians. Then, we analyzed the relationship between the types of frontalis muscle and frontal lines, as well as the relationship between the frontal anatomical structures and the production of frontal lines. RESULTS: We classified the types of frontalis muscle into 3 categories comprising 10 subtypes. The skin (0.78 mm vs 0.90 mm, P < .05), superficial subcutaneous tissue (0.66 mm vs 0.75 mm, P < .05), and frontalis muscle thickness (0.29 mm vs 0.37 mm, P < .05) of people with obvious dynamic forehead lines were significantly thicker than those of people without significant dynamic forehead lines. However, no significant difference in the deep subcutaneous tissue thickness was found between people with and without static forehead lines (1.36 mm vs 1.34 mm, P < .05). CONCLUSIONS: This study shows the relationship between the frontal structure and frontal lines. Therefore, these results can provide references for treating frontal lines, to a certain extent.

Sagittal Position of the Upper Incisor in Relation to the Forehead in Peruvian Individuals with Different Skeletal Relationships.

AIM: The aim of this study was to determine the sagittal position of the upper incisor considering Andrews' analysis based on the position of the forehead in Peruvian individuals with different skeletal relationships. MATERIALS AND METHODS: This retrospective, cross-sectional study included 212 lateral head radiographs of Peruvian individuals (males: 85, mean age 21.38 ± 6.88, and females: 127, mean age 21.18 ± 6.95), with different skeletal relationships (Class I group = 96, Class II group = 57, Class III group = 59). The values of the ANB, SNA, SNB angles as well as the forehead anterior limit line (FALL) and goal anterior limit line (GALL) points were identified in the radiographs, and then a vertical line was drawn in each point to determine if the upper incisor was positioned forward (protruded), backward (retruded) or within (adequate) these lines. Two trained and calibrated investigators performed all the measurements. The Chi-square test was used to evaluate associations. A p-value < 0.05 was considered statistically significant. RESULTS: Overall, the sagittal position of the upper incisor showed a significant association with the sagittal skeletal relationship (p = 0.001). The upper incisors showed an adequate position (41.7%), protruded position (56.10%), and retruded position (42.40%), for Class I, II, and III skeletal relationships, respectively, as highest percentages in each Class. Statistical significance was found for females only (p = 0.005). CONCLUSION: Skeletal Class I mainly showed an adequate position of the upper central incisor, whereas for Class II a protruded position was most frequently found, and Class III presented a retruded position. CLINICAL SIGNIFICANCE: Andrews' analysis based on the position of the forehead in Peruvian individuals is a valuable tool for orthodontic diagnosis. How to cite this article: Bazán-Mendoza JR, Arias-Modesto PB, Ruíz-Mora GA, et al. Sagittal Position of the Upper Incisor in Relation to the Forehead in Peruvian Individuals with Different Skeletal Relationships. J Contemp Dent Pract 2023;24(11):821-825.

Forehead Flap Templates for Nasal Reconstruction Digitally Developed From 2D and 3D Images.

ABSTRACT: The forehead flap is the gold standard procedure for nasal reconstruction to address a partial or complete rhinectomy. Traditionally, the three-dimensional (3D) nasal defect is manually templated intraoperatively to design the two-dimensional (2D) flap shape on intact morphology. In this clinical study, digital preoperative planning is used to template with computer-assisted design and manufacturing. Preoperative digital templates were implemented for 3 representative patients (1 in Supplementary Digital Content, http://links.lww.com/SCS/D60). This includes designs for a hemi-rhinectomy case from 3D mirroring, a partial total rhinectomy case generated from a 3D scan, and a total rhinectomy case generated from a 3D morphable model based on a prepathology 2D photo. Digital unwrapping flattened the patient's 3D nasal geometry designs to 2D skin flap shapes. Finally, the 2D designs were printed as traceable intraoperative templates at a 1:1 scale. This clinical study demonstrates the application of digital 3D preoperative templating to improve workflow for nasal reconstruction.

Early division of the paramedian forehead interpolated flap using cutaneous ultrasound.

BACKGROUND AND OBJECTIVES: The paramedian forehead flap is an interpolated flap, consisting of the transfer of tissue from the forehead region to the nasal area, irrigated by the supratrochlear artery. Traditionally, the vascular pedicle is divided at between 14 and 21 days. However, this time could be overestimated. Our objective is to demonstrate that the paramedian forehead flap can be divided before that set out in the literature and to demonstrate the usefulness of cutaneous ultrasound to determine the optimal time for division. PATIENTS AND METHODS: A prospective observational study, including patients who required nasal defect reconstruction with a paramedian forehead flap, was designed. The inclusion criteria were: nasal tip, dorsum or alar skin defects following oncological surgery, larger than 2 cm. Twelve patients were included. A retrospective cohort was used to perform a cost reduction analysis. RESULTS: The average time to flow, measured by ultrasound, was 6.6 days. The average number of days to division of the pedicle was 6.9 days. No serious complications were reported. CONCLUSIONS: The paramedian forehead flap can be divided before the traditional reported time. Ultrasound is a reliable and cost-effective technique to determine and individualize pedicle division time.

X-linked frontometaphyseal dysplasia with severe scoliosis and spinal cord compromise in an Indian boy.

Frontometaphyseal dysplasia (FMD) is a rare genetic disorder with morphological abnormalities of the skeletal and extra skeletal tissues. It belongs to the group of otopalatodigital spectrum disorders. Here we report a 12-year-old boy from India with features of frontometaphyseal dysplasia who had severe scoliosis with neurological complications due to spinal cord compromise. Clinical examination of his mother also revealed mild features of FMD. The manuscript highlights the clinical presentation of the disorder and discusses the clinical heterogeneity of the otopalatodigital spectrum disorders.

Forehead Widening in Nonsyndromic Scaphocephaly Operated After 12 Months of Age.

AIM AND SCOPE: Our standard management is to operate isolated sagittal synostosis around 4 months of age because of morphological and cognitive outcomes. However, some patients present late and the likelihood of spontaneous remodeling is low in isolated sagittal craniosynostosis operated on after 12 months of age with a limited technique. The preliminary result of a modified technique for forehead remodeling and subtotal calvarial remodeling in nonsyndromic scaphocephalic children with late presentation is presented. PATIENTS AND METHODS: All patients older than 1 with isolated sagittal synostosis assessed between 2011 and 2015, over 1 year of age at the time of surgery, with available pre and postoperative computed tomography-scans, were retrospectively included into the study. The following parameters were collected: (1) age at surgery, (2) duration of the procedure, (3) surgical technique, (4) fronto-nasal angle before and after surgery and (5) forehead width before and after surgery. RESULTS: Ten patients aged between 15 months and 6 years were retrospectively included. Delayed surgery was due to late presentation or initial parental reluctance. All patients presented with a transversal narrowing of the forehead and an anterior bulge. Mean age at surgery was 28 months and mean follow up was 23 months (1-4 years). Measurements showed significant improvement of both the fronto-nasal angle and the width of the forehead. CONCLUSIONS: Late-presenting scaphocephalic patients operated on after 12 months of age require forehead remodeling to achieve satisfactory aesthetic results. Modified forehead remodeling by splitting the forehead sagittally into 2 symmetrical halves and adding a midline bone strip is a safe and feasible way to widen the forehead. Long term follow-up is needed to assess this modified technique.

Laser speckle contrast imaging of forehead cutaneous blood flow during carotid endarterectomy as a potential non-invasive method for surrogate monitoring of cerebral perfusion.

Monitoring cerebral perfusion is important for goal-directed anesthesia. Taking advantage of the supply of the supraorbital region and Glabella from the internal carotid artery (ICA), we evaluated changes in cutaneous blood flow using laser speckle contrast imagining (LSCI) as a potential method for indirect real-time monitoring of cerebral perfusion. Nine patients (8 men, mean age 70 years) underwent eversion carotid endarterectomy under local anesthesia. Cutaneous blood flow of the forehead was monitored using LSCI. During clamping of the common carotid artery (CCA), ipsilateral supraorbital region and Glabellas cutaneous blood flow dropped from 334 ± 135 to 221 ± 109 AU (p = 0.023) (AU: arbitrary flux units) and from 384 ± 151 to 276 ± 107 AU (p = 0.023), respectively, whilst the contralateral supraorbital region cutaneous blood flow remained unchanged. The supraorbital cutaneous blood flow did not change significantly following reperfusion of the external carotid artery (ECA) (221 ± 109 to 281 ± 154 AU; p = 0.175) and ICA (281 ± 154 to 310 ± 184 AU; p = 01). A comparable trend for Glabella followed ECA (276 ± 107 to 342 ± 170 AU; p = 0.404) and ICA (342 ± 170 to 352 ± 191 AU; p = 01) reperfusion. In patients undergoing carotid endarterectomy under local anesthesia, LSCI of the supraorbital and Glabella regions reflected clamping of the CCA but did not distinguish reperfusion of the ICA from that of the ECA.

Ultrasonography Analysis of Vessels Around the Forehead Midline.

BACKGROUND: Filler injection into the glabella is well known to be a highly dangerous procedure due to the high risk of embolism and intravascular injection. Although it is conventional practice to insert the cannula into the middle of the forehead to perform injections into the glabella or radix, vascular structures can be observed in this region during anatomic dissection procedures. OBJECTIVES: The aim of this study was to characterize the blood vessels around the forehead midline in order to provide crucial anatomic information for ensuring the safety of noninvasive procedures involving the forehead and glabella. METHODS: Ultrasonography image scanning was performed at the following 4 points on the forehead midline: trichion (P1), metopion (P2), halfway point between metopion and glabella (P3), and glabella (P4). The courses and locations of vessels were identified and classified according to their proximity to the forehead midline. RESULTS: Vessels coursing within 0.75 cm either side of the forehead midline were found in 34% to 50% of individuals. Arteries running near the forehead midline tended to be dominant on the right side of the forehead except in the P4 area. About half of the individuals had vessels in the P4 area, of which 96.7% were veins. CONCLUSIONS: The present results indicate that there are superficial vessels running close to the midline of the forehead. This anatomic information can explain the higher incidence of vascular complications during conventional aesthetic procedures. To ensure safety, the cannula entry point or needle puncture point for glabella augmentation should be reconsidered.

Safe Glabellar Wrinkle Correction With Soft Tissue Filler Using Doppler Ultrasound.

BACKGROUND: Glabellar wrinkle corrections are usually performed by injecting botulinum toxin and hyaluronic acid fillers. The glabella is one of the most dangerous locations for filler injection because of possible visual complications. OBJECTIVES: The aim of this study was to use Doppler ultrasound to determine the anatomic relation between glabellar wrinkles and the supratrochlear artery pathway, perform safe hyaluronic acid filler injection to correct glabellar wrinkles, and determine the efficacy of the procedure. METHODS: From January 2019 to July 2019, 42 patients (74 glabellar wrinkle lines; 32 bilateral and 10 unilateral wrinkles) were evaluated. Glabellar wrinkle lines were corrected with hyaluronic acid filler. Doppler ultrasound was used to avoid the supratrochlear artery. RESULTS: Among the 74 wrinkle lines, the supratrochlear arteries were located either at the glabellar wrinkle lines (30/74, 41%) or lateral to the glabellar wrinkle lines (44/74, 59%). In the latter 44 wrinkles, fillers were injected into the subdermal layer of the glabellar wrinkle lines. In the 30 wrinkles where supratrochlear artery was located at the glabellar wrinkle lines, the artery was located at the deep subcutaneous layer in 24 and at the subdermal layer in 6; thus, filler injection was not performed. CONCLUSIONS: The supratrochlear artery may be located either at or lateral to the glabellar wrinkle lines. When performing glabellar wrinkle correction, Doppler ultrasound can be used to confirm the location of the supratrochlear artery before filler injection, which helps in avoiding vascular complications.

The Change of Plane of the Supratrochlear and Supraorbital Arteries in the Forehead-An Ultrasound-Based Investigation.

BACKGROUND: Injecting soft tissue fillers into the deep plane of the forehead carries the risk of injection-related visual compromise due to the specific course of the arterial vasculature. OBJECTIVES: The aim of this study was to investigate the 2- and 3-dimensional location of the change of plane of the deep branch of the supratrochlear and supraorbital artery, respectively. METHODS: A total of 50 patients (11 males and 39 females; mean age, 49.76 [13.8] years, mean body mass index, 22.53 [2.6] kg/m2) were investigated with ultrasound imaging. The total thickness and the distance of the arteries from the skin and bone surface were measured with an 18-MHz broadband compact linear array transducer. RESULTS: The deep branch of the supraorbital artery changed plane from deep to superficial to the frontalis muscle at a mean distance of 13 mm (range, 7.0-19.0 mm) in males and at 14 mm (range, 4.0-24.0 mm) in females and for the deep branch of the supratrochlear artery at a mean distance of 14 mm in males and females (range, 10.0-19.0 in males, 4.0-27.0 in females) when measured from the superior orbital rim. CONCLUSIONS: Based on the ultrasound findings in this study, it seems that the supraperiosteal plane of the upper and lower forehead could be targeted during soft tissue filler injections because the deep branches of both the supraorbital and supratrochlear arteries do not travel within this plane. The superficial plane of the lower forehead, however, should be avoided due to the unpredictability and inconsistent presence of the central and paracentral arteries.

The role of near-infrared fluorescence imaging with indocyanine green dye in pedicle division with the paramedian forehead flap.

The paramedian forehead flap is considered the gold standard for nasal reconstruction following oncologic surgery. During the 21-day delay in two-stage surgery protocols, many patients report considerably reduced quality of life because of the pedicle. This prospective case series study examined the usefulness of near-infrared (NIR) fluorescence with indocyanine green (ICG) for flap perfusion assessment and identified variables associated with time to flap perfusion. Ten patients (mean age 75.3 ± 11.6 years) with diagnosis of basal cell carcinoma (n = 9) or squamous cell carcinoma (n = 1) underwent intravenous indocyanine injection and NIR fluorescence imaging for assessment of flap vascularisation 2 to 3 weeks after stage 1 surgery. NIR fluorescence imaging showed 90% to 100% perfusion areas in all patients after 14 to 21 days. Early pedicle division occurred in two patients on postoperative days 14 and 16. One minor complication (wound healing disorder) was seen following flap takedown after 14 days. There were no associations between time to flap perfusion and defect size or flap area. NIR fluorescence imaging with ICG dye is a useful method for non-invasive perfusion assessment when used in conjunction with clinical assessment criteria. However, a decision for early pedicle division may raise risk of complications in specific patient groups and must therefore be made with great care.

Role of TFA-1 adhesive forehead sensors in predicting fluid responsiveness in anaesthetised children: A prospective cohort study.

BACKGROUND: The TFA-1 adhesive forehead sensor is a newly developed pulse oximeter for the measurement of the plethysmographic variability index (PVI) at the forehead, and for the rapid detection of changes in oxygen saturation during low perfusion. OBJECTIVES: We evaluated the ability of the TFA-1 sensor to predict fluid responsiveness in children under general anaesthesia. DESIGN: Prospective cohort study. SETTING: Single tertiary care children's hospital. PATIENTS: Thirty-seven children aged 1 to 5 years under general anaesthesia and requiring invasive arterial pressure monitoring. MAIN OUTCOME MEASURES: The baseline PVI of TFA-1 and finger sensors, respiratory variation of aorta blood flow peak velocity (ΔVpeak) and stroke volume index (SVI) obtained using transthoracic echocardiography were assessed. After fluid loading of 10 ml kg crystalloids over 10 min, SVI was reassessed. Responders were defined as those with an increase in SVI greater than 15% from the baseline. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive ability of the PVI of TFA-1 and finger sensors and ΔVpeak for fluid responsiveness. RESULTS: Seventeen (56.6%) patients responded to volume expansion. Before fluid loading, the PVI of TFA-1 and finger sensors and ΔVpeak (mean ±â€ŠSD) of the responders were 11.2 ±â€Š4.4, 11.4 ±â€Š5.1 and 14.8 ±â€Š3.9%, respectively, and those of the nonresponders were 7.4 ±â€Š3.9, 8.1 ±â€Š3.6 and 11.0 ±â€Š3.3%, respectively. ROC curve analysis indicated that the PVI of TFA-1 and finger sensors and ΔVpeak could predict fluid responsiveness. The areas under the curve were 0.8 [P = 0.00; 95% confidence interval (CI) 0.60 to 0.91], 0.7 (P = 0.02; 95% CI 0.53 to 0.87) and 0.8 (P = 0.00; 95% CI 0.59 to 0.91), respectively. The cut-off values for the PVI of TFA-1 and finger sensors and ΔVpeak were 6.0, 9.0 and 10.6%, respectively. CONCLUSION: The PVI of TFA-1 forehead sensor is a good alternative, but is not superior to the finger sensor and ΔVpeak in evaluating fluid responsiveness in mechanically ventilated children under general anaesthesia. CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov, NCT03132480.

Localization and Topography of the Arteries on the Middle Forehead Region for Eluding Complications Following Forehead Augmentation: Conventional Cadaveric Dissection and Ultrasonography Investigation.

Forehead augmentation with filler injection is one of the most dangerous procedures associated with iatrogenic intravascular injection resulting in the severe complications. Nonetheless, few studies have determined the explicit arterial localization and topography related to the facial soft tissues and landmarks. Therefore, this study aimed to determine an arterial distribution and topography on the middle forehead region correlated with facial landmarks to grant an appropriate guideline for enhancing the safety of injection. Nineteen Thai embalmed cadavers were discovered with conventional dissection and 14 Thai healthy volunteers were investigated with ultrasonographic examination on the middle forehead. This study found that at the level of mid-frontal depression point, the transverse distance from the medial canthal vertical line to the superficial and deep branches of supraorbital artery were 9.1 mm and 15.1 mm, respectively. Whereas the depths from the skin of these arteries were 4.1 mm and 4.3 mm, respectively. Furthermore, the frontal branch of superficial temporal artery was detectable in 42.1% as an artery entering the forehead area. At the level of lateral canthal vertical line, the vertical distance of frontal branch was 31.6 mm, and the depth from skin of the artery was 2.7 mm. In conclusion, a proper injection technique could be performed based on an intensive arterial distribution and topography, and ultrasonographic examination before the injection is also suggested in order to restrict the opportunity of severe complications.

Basal Cell Carcinoma Arising over a Venous Malformation of the Forehead Communicating with the Endocranial Veins.

INTRODUCTION: An increasing number of skin cancer arising over vascular anomaly has been reported in literature. In such cases, the oncologic radicality required to threat skin malignancies may be in contrast with the safety needed when dealing with vascular malformation. As a result, treatment of this association may be insidious and treacherous and imposes a sound knowledge and carefulness. MATERIALS AND METHODS: The authors report on a case of a 77-years-old woman affected by a basal cell carcinoma (BCC) arising over a vascular malformation of forehead. Preoperative radiological imaging revealed an underlying venous malformation (VM) communicating with intracranial district. Patient underwent sclerotherapy of the VM with gelified ethanol in order to reduce potentially fatal bleeding during surgery and, on the other hand, any leakage of the sclerosant in the intracranial veins. Excision of the BCC was then performed without complications. RESULTS: Neither intra-operative nor post-operative complications were observed. Current 3-years follow-up shows no recurrence of BCC whilst the residual VM is stable and clinically silent. CONCLUSIONS: Mechanisms leading to the onset of skin cancers over venous malformations are still unclear. However, association between these 2 conditions may be underestimated with possible catastrophic consequences. Thorough knowledge of vascular malformations and a multidisciplinary approach is of the uttermost importance when dealing with such clinical challenges.

Protruding Meningioma of the Forehead With Extensive Hyperostosis Mimicking Skull Osteoma.

Meningioma is the most common intracranial benign tumor in adults. Hyperostosis accompanies about 4.5% of meningiomas. The authors report a rare case of hyperostotic meningioma that may have been misdiagnosed as giant osteoma.A 42-year male visited our clinic due to an egg-sized, hard mass on his left forehead. The mass suspected to be giant osteoma was about 4.2 × 4.0 cm sized, hard, non-movable, and non-tender. But based on radiologic findings, the mass was diagnosed as meningioma with extensive hyperostosis.Without neurologic symptoms, the diagnosis of meningioma associated with hyperostosis can be challenging and be misdiagnosed as fibrous dysplasia and osteoma by simple examination without enhanced CT and MRI.Therefore, although osseous lesions are strongly suspected to be osteomas, surgeons should consider other diagnoses, and if necessary, use contrast enhanced CT or MRI to differentiate these bony lesions.

Anatomical and Ultrasonography-Based Investigation to Localize the Arteries on the Central Forehead Region During the Glabellar Augmentation Procedure.

Glabellar augmentation is one of the most popular cosmetic procedures but can entail severe complications caused by inadvertent intravascular injection of filler. Nevertheless, few studies have investigated the arteries on the glabellar and central forehead regions. The aim of this study was to correlate the topography and location of the arteries in this area with anatomical landmarks to propose a safety guideline. Two methods were used to investigate the glabellar and central forehead areas: dissection of 19 Thai embalmed cadavers, and ultrasonographic examination of 14 healthy Thai volunteers. At the level of the glabellar point, the horizontal distances from the midline to the arteries were 4.7 mm (central artery), 7.8 mm (paracentral artery), and 14.7 and 19.2 mm (superficial and deep branches of supratrochlear artery). The depths from the skin of the arteries were 3.1 mm (central artery), 4.8 mm (paracentral artery), and 4.2 and 5.9 mm (superficial and deep branches of supratrochlear artery). The periosteal artery was detected in 71.1% as a branch of either the superior orbitoglabellar or the supratrochlear artery. It ran in the supraperiosteal layer for a short course and penetrated the periosteum above the superciliary ridge or above the medial eyebrow, adhering tightly to the bony surface. This study suggests a safe injection technique for the glabella based on a thorough knowledge of arterial distribution and topography and color Doppler ultrasonographic examination prior to the injection, which is recommended to minimize the risk of severe complications. Clin. Anat. 33:370-382, 2020. © 2019 Wiley Periodicals, Inc.