Determination of Scalp Vascular Topography by Laser Doppler Flowmetry and Comparison of Vascular Damage by Different Blades in Hair Transplantation.

BACKGROUND: Although necrosis is a rare complication in hair transplantation, it is extremely traumatic for both the patient and surgeon and also has potential medicolegal consequence. Studies have shown that ischemia in the recipient bed is related to tissue damage caused by the instruments used and the number of grafts per cm². OBJECTIVE: We aimed to measure the effects of different instruments on circulation by dividing the recipient area of hair grafts of the same person into 2 sides as right and left. METHODS AND MATERIALS: Sapphire percutaneous blade was used on the right side, and a handmade razor slit was used on the left side in 12 male patients with consent. Subsequently, vascularity was evaluated with laser Doppler flowmetry. RESULTS: Scalp vascularity has so far only been evaluated with macroanatomic studies in the literature. First, the authors evaluated the effect of local anesthesia and adrenaline-containing swelling fluids on vascularity with a Laser Doppler Flowmeter. Afterward, the tissue damage caused by sapphire percutaneous blades and handmade blades (obtained from razor blades) were quantitatively analyzed and compared with each other. CONCLUSIONS: Our results showed that handmade razor blades caused significantly less tissue damage.

Perioperative Analgesic Efficacy of Yamamoto New Scalp Acupuncture for Canine Mastectomy Combined with Ovariohysterectomy: a Randomized, Controlled Clinical Trial.

Background: Yamamoto New Scalp Acupuncture (YNSA) is a therapy based on the stimulation of points on the scalp and applied to treat different states of pain. Objectives: To investigate the analgesic efficacy of YNSA for dogs undergoing radical unilateral mastectomy with ovariohysterectomy. Methods: Twenty-four dogs were randomly distributed into two treatments (n = 12, per group): bilateral stimulation of basic B, D, and E points (YNSA group) and no application of acupuncture (control group). All dogs were sedated with morphine; anesthesia was induced with propofol and maintained with isoflurane. Fentanyl was intraoperatively administered to control cardiovascular responses to surgical stimulation. Postoperative pain was assessed using an interactive visual analog scale (IVAS) and the short-form of the Glasgow Composite Pain Scale (CMPS-SF). Morphine was administered as rescue analgesia. Data were analyzed using t-tests, Fisher's exact test, Mann-Whitney U test, and Friedman test (p < 0.05). Results: Intraoperatively, the number of dogs requiring supplemental analgesic and the number of doses of fentanyl were lower in the YNSA group than in the control group (p = 0.027-0.034). The IVAS pain scores recorded from 0.5 h to 1 h post-extubation in the YNSA group were lower than those in the control group (p = 0.021-0.023). Postoperative rescue analgesia and CMPS-SF pain scores did not differ between the groups. Conclusion: YNSA decreases intraoperative fentanyl requirements and provides minimal postoperative analgesic benefits to dogs undergoing unilateral mastectomy with ovariohysterectomy.

Assessment and Treatment Outcomes of Persistent Radiation-Induced Alopecia in Patients With Cancer.

Importance: Persistent radiation-induced alopecia (pRIA) and its management have not been systematically described. Objective: To characterize pRIA in patients with primary central nervous system (CNS) tumors or head and neck sarcoma. Design, Setting, and Participants: A retrospective cohort study of patients from January 1, 2011, to January 30, 2019, was conducted at 2 large tertiary care hospitals and comprehensive cancer centers. Seventy-one children and adults diagnosed with primary CNS tumors or head and neck sarcomas were evaluated for pRIA. Main Outcomes and Measures: The clinical and trichoscopic features, scalp radiation dose-response relationship, and response to topical minoxidil were assessed using standardized clinical photographs of the scalp, trichoscopic images, and radiotherapy treatment plans. Results: Of the 71 patients included (median [range] age, 27 [4-75] years; 51 female [72%]), 64 (90%) had a CNS tumor and 7 (10%) had head and neck sarcoma. Alopecia severity was grade 1 in 40 of 70 patients (56%), with localized (29 of 54 [54%]), diffuse (13 of 54 [24%]), or mixed (12 of 54 [22%]) patterns. The median (range) estimated scalp radiation dose was 39.6 (15.1-50.0) Gy; higher dose (odds ratio [OR], 1.15; 95% CI, 1.04-1.28) and proton irradiation (OR, 5.7; 95% CI, 1.05-30.8) were associated with greater alopecia severity (P < .001), and the dose at which 50% of patients were estimated to have severe (grade 2) alopecia was 36.1 Gy (95% CI, 33.7-39.6 Gy). Predominant trichoscopic features included white patches (16 of 28 [57%]); in 15 patients, hair-shaft caliber negatively correlated with scalp dose (correlation coefficient, -0.624; P = .01). The association between hair density and scalp radiation dose was not statistically significant (-0.381; P = .16). Twenty-eight of 34 patients (82%) responded to topical minoxidil, 5% (median follow-up, 61 [interquartile range, 21-105] weeks); 4 of 25 (16%) topical minoxidil recipients with clinical images improved in severity grade. Two patients responded to hair transplantation and 1 patient responded to plastic surgical reconstruction. Conclusions and Relevance: Persistent radiation-induced alopecia among patients with primary CNS tumors or head and neck sarcomas represents a dose-dependent phenomenon that has distinctive clinical and trichoscopic features. The findings of this study suggest that topical minoxidil and procedural interventions may have benefit in the treatment of pRIA.

High-voltage electric stimulation of the donor site of skin grafts accelerates the healing process. A randomized blinded clinical trial.

INTRODUCTION: Severe burns benefit from skin grafting, and grafting surgery is of great importance in the treatment of these injuries. As a result, there is formation of an additional wound at the donor site, which is painful and susceptible to infection. However, the therapeutic approach to these problems at donor sites for skin grafting is insufficiently explored in the literature. AIM: To evaluate electrical stimulation of the donor sites of burn patients treated by grafting surgery. METHODS: This work evaluated 30 donor sites of cutaneous graft burn patients treated with high-voltage electrical stimulation. Subjects were randomized into two groups: electrical stimulation (GES), treated with electrostimulation (50min, 100Hz, twin pulses 15 us, monophasic), and the sham group (GS), treated by the same procedures but without current. Pain was assessed by visual analog scale daily before and after the electrical stimulation. The time elapsed until complete epithelization was evaluated (time of primary dressing detached spontaneously). Skin temperature was measured by thermography. The characteristics of donor sites were qualitatively evaluated using images and the plug-in CaPAS® (Carotid Plaque Analysis Software). RESULTS: The results showed a significant decrease in pain, which was absent on the third day in the GES and the sixth day in the GS. The time the primary dressing detached spontaneously in days decreased (p<0.05) (4.7±0.2) compared to the GS group (7.0±1.3). Donor site healing characteristics such as vascularization, pigmentation, height, the quantity of crust formed, irregularities, and the quality of healing was better in the GES; moreover, homogeneity and inertia of the images confirmed higher healing quality. CONCLUSION: As a result of the study, the technology shows promise and merits a larger study with objective assessments and different physical variables.

One of the Earliest Accounts of Head Wounds in Firdaws al-Hikma by al-Tabari from the 9th Century.

OBJECTIVE: To present the first Arabic text on suturing scalp wounds. METHODS: A related section entitled "On the wounds in the head" from the book Firdaws al-Hikma (Paradise of the Wisdom) written by al-Tabari in the 9th century was identified and analyzed. This work was one of the earliest medical compendiums in the Islamic world during the medieval period. A printed copy of Firdaws al-Hikma edited by Muhammad Zubayr al-Siddiqi was examined, and findings were compared with relevant knowledge in the literature. RESULTS: A notable part of this text is based on appropriate closure of scalp wounds using sutures. Before this work, only the well-known Indian medical book Susruta-Samhita had mentioned closure of scalp wounds using sutures. In his work, al-Tabari recommended using materials made of silk or linen for suturing. He additionally proposed some recipes that have a coating feature that prevents bleeding from the wound after it was closed properly. He also dealt with persistent swelling and provided formulas for solving the problem with special compositions. CONCLUSIONS: Firdaws al-Hikma is a noteworthy work in the history of medicine, and it includes a unique chapter on head wounds. To the best of our knowledge, this is the first mention of suturing scalp cuts in Arabic literature and the second reference in medical literature after the Indian work Susruta-Samhita.

Which one is more effective for analgesia in infratentorial craniotomy? The scalp block or local anesthetic infiltration.

OBJECTIVES: The most painful stages of craniotomy are the placement of the pin head holder and the skin incision. The primary aim of the present study is to compare the effects of the scalp block and the local anesthetic infiltration with bupivacaine 0.5% on the hemodynamic response during the pin head holder application and the skin incision in infratentorial craniotomies. The secondary aims are the effects on pain scores and morphine consumption during the postoperative 24h. METHODS: This prospective, randomized and placebo controlled study included forty seven patients (ASA I, II and III). The scalp block was performed in the Group S, the local anesthetic infiltration was performed in the Group I and the control group (Group C) only received remifentanil as an analgesic during the intraoperative period. The hemodynamic response to the pin head holder application and the skin incision, as well as postoperative pain intensity, cumulative morphine consumption and opioid related side effects were compared. RESULTS: The scalp block reduced the hemodynamic response to the pin head holder application and the skin incision in infratentorial craniotomies. The local anesthetic infiltration reduced the hemodynamic response to the skin incision. As well as both scalp block and local anesthetic infiltration reduced the cumulative morphine consumption in postoperative 24h. Moreover, the pain intensity was lower after scalp block in the early postoperative period. CONCLUSION: The scalp block may provide better analgesia in infratentorial craniotomies than local anesthetic infiltration.

Efficacy and Safety of a Lidocaine and Ropivacaine Mixture for Scalp Nerve Block and Local Infiltration Anesthesia in Patients Undergoing Awake Craniotomy.

BACKGROUND: Mixtures of various local anesthetics, such as lidocaine and ropivacaine, have been widely used. However, their efficacy and safety for scalp nerve blocks and local infiltration during awake craniotomy have not been fully elucidated. METHODS: We prospectively investigated 53 patients who underwent awake craniotomy. Scalp block was performed for the blockade of the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, greater occipital, and lesser occipital nerves with a mixture containing equal volumes of 2% lidocaine and 0.75% ropivacaine, including 5 µg/mL of epinephrine. Infiltration anesthesia was applied at the site of skin incision using the same mixture. The study outcomes included changes in heart rate and blood pressure after head pinning and skin incision, and incidence of severe pain on emergence from anesthesia. Total doses and plasma concentrations of lidocaine and ropivacaine were measured at different time points after performing the block. RESULTS: The heart rate and blood pressure after head pinning were marginally, but significantly, increased when compared with baseline values. There were no significant differences in heart rate and blood pressure before and after the skin incision. Nineteen percent of the patients (10/53) complained of incisional pain at emergence from anesthesia. The highest observed blood concentrations of lidocaine and ropivacaine were 1.9±0.9 and 1.1±0.4 µg/mL, respectively. No acute anesthetic toxicity symptom was observed. CONCLUSIONS: Scalp block with a mixture of lidocaine and ropivacaine seems to provide effective and safe anesthetic management in patients undergoing awake craniotomy.

A plant-derived wound therapeutic for cost-effective treatment of post-surgical scalp wounds with exposed bone.

BACKGROUND: To evaluate efficacy and cost-effectiveness of a plant-derived wound dressing (ONE), a mixture of hypericum oil (Hypericum perforatum L.) and neem oil (Azadirachta indica A. Juss.), in scalp wounds with exposed bone. PATIENTS AND METHODS: All patients with scalp wounds with exposed bone, following the excision of skin tumors, and treated with ONE in 2011 were included. Time of healing, wound size, area of exposed bone, ease of handling, pain, and complications were evaluated. Costs of dressings and nursing time were compared with those cited in literature for other treatment modalities. RESULTS: Fifteen consecutive patients with a mean age of 76.87 ± 10.3 years (59-90 years) were analyzed. The mean wound size was 10.9 ± 6.84 cm(2) (0.4-22.6 cm(2)) with 4.8 ± 5.9 cm(2) (0.3-20.7 cm(2)) of exposed bone. The time of complete healing by secondary intention was 8.1 (4-20) weeks. Rapid formation of granulation tissue was observed which after 4 weeks covered the entire exposed bone surface in 11 of 15 cases (73%). Dressing change was simple with no pain reported; no infections or other complications occurred. Using ONE for a mean healing time of 56.7 days resulted in mean costs of EUR 423.73, which is substantially lower than those published for fascia lata, negative pressure therapy, or collagen matrix followed by skin grafting (EUR 1,612.82, EUR 4,411.80 and EUR 1,503.72, respectively). CONCLUSION: This retrospective, non-controlled analysis supports ONE as a simple-to-use and safe treatment option for scalp wounds with exposed bone. Treatment costs compare favorably to those published for other treatment modalities.

Total scalp replantation salvaged by changing the recipient vein.

Successful replantation of the avulsed scalp has been reported by a number of authors, and there seems almost no doubt that each single superficial temporal artery and vein is enough to feed and drain the whole scalp if the amputee is not severely torn. As the venous problem is the most common cause of failure, efforts have been made to anastomose reliable veins for drainage. We report a case of total scalp avulsion that was, at first, fed and drained by a superficial temporal artery and an ipsilateral supraorbital vein. Congestion progressed slowly, and exploration revealed patent venous anastomosis without apparent thrombosis. Congestion was relieved when the recipient was changed to superficial temporal vein using a vein graft, leading to complete survival of the scalp. We propose the importance of the capacity of recipient vein, in addition to the anastomotic patency, for successful replantation of the whole scalp. We assume that the capacity of a small caliber recipient vein may be limited even in full dilatation, and the importance of the competent recipient vein should not be overlooked in a large amputee replantation or a large free flap surgery.

The latest innovations in hair transplantation.

Hair restoration began as a result of the fortuitous finding by Dr. Norman Orentreich that hair follicles taken from an area of nonbalding scalp could be implanted into an area of male pattern hair loss and continue to grow terminal hair. Since that time, hair transplants have progressed from the use of large plugs to the use of follicular units (normally occurring clusters of hairs). This has allowed surgeons to create undetectable results in cases of androgenetic alopecia and well as other conditions associated with hair loss. Advances continue in hair restoration technique ranging from surgical approach to instrumentation and ways to enhance growth. In this article, the more recent surgical and medical innovations in hair reconstruction are reviewed.

A case of misdiagnosed squamous cell carcinoma due to alternative medical misadventure--time for tightening regulation?

We present a patient with locally advanced squamous cell carcinoma that had grown significantly during 16 months of intensive alternative therapy. The alternative medicine practitioner allegedly repeatedly reassured the patient that her condition was benign and advised against seeking conventional medical treatment. Due to the delayed presentation, the patient required extensive surgery and postoperative adjuvant radiotherapy. This case highlights the risks of alternative therapy in the place of proven conventional medical treatment and emphasises the limitations of current regulation of complementary and alternative medicine in New Zealand.

Reconstruction of cheek skin defects by the 'Yin-Yang' rotation of the Mustardé flap and the temporoparietal scalp.

BACKGROUND AND PURPOSES: When the skin's laxity is limited, the preauricular cutaneous defect resulting from the Mustardé cheek rotation flap for the coverage of suborbital skin defects is very difficult to close even with a large undermining of the cervicofacial skin. The rotation of the temporoparietal scalp in an opposite direction compared to the Mustardé flap or the 'Yin-Yang' rotation of these flaps is interesting for two reasons: it allows an easy closure of this preauricular defect with a limited facial undermining and it suspends with efficiency the Mustardé flap at the temporal area avoiding the lower lid's ectropion. MATERIAL AND METHODS: From September 2001 to April 2005, nine patients aged between 35 and 78 years old, with no facial skin laxity, have benefited from this technique to cover suborbital defects secondary to excision of basal cell carcinomas with a mean diameter of 6 cm. The design of the Mustardé flap was classical but the skin undermining stopped at the mandible's lower border. The triangular preauricular defect has served as a geometrical base to design an opposite temporoparietal rotation flap which is undermined under the galea. RESULTS: This technique has allowed an easy primary closure of all these defects. No complications were reported. With a mean follow up of 36 months the aesthetic quality of these reconstructions was satisfying and there was no malposition of the lower lid. CONCLUSION: This is a good technique for the simple coverage of medium-sized suborbital skin defects.

Victim's scalp on the killer's head. An unusual case of criminal postmortem mutilation.

A case of unusual postmortem mutilation of a victim's body is presented. After killing his father, the son decapitated his body and dissected the scalp free, forming a mask of the father's head and neck. The young man wore the scalp-mask over his own head to imitate the father. The motive of the murder was revenge, and the postmortem mutilation was the realization of the perpetrator's fantasies, symbolically representing a penalty for the reprehensible past life of his father.

Cranial reconstruction for metastatic breast cancer.

All women with advanced breast cancer who are medically stable despite their disease are candidates for tumor extirpation and reconstruction. Advanced breast cancer today is incurable, and many prognostic factors can be used to try to predict a clinical course and response to therapy; however, no guidelines are available. Our case report most likely represents a metastasis to the calvarium with intracranial extension, reported to occur in about 3 percent of primary breast cancer patients. As demonstrated here, tumor ablation with immediate, one-stage reconstruction of large scalp defects is possible without the need for free tissue transfer or a delay in adjuvant therapy. Local tissue rearrangement has been employed for coverage of defects up to 50 percent of the cranium. The resulting donor defects can be closed with split-thickness skin grafts over pericranium. Serial tissue expansion and rearrangement can be used secondarily to replace skin grafts with hair-bearing scalp. Bony defects can be managed with either autogenous or alloplastic materials. Split-calvarial bone grafts can be harvested from the same operative field and cover small to medium-sized defects. Other sources of autogenous grafts include split ribs and iliac bone. Metals, calcium ceramics, and polymers such as methylmethacrylate can be used to cover intracranial contents and restore calvarial contour when defects are large or when autogenous material is not available. Palliation from tumor burden, prevention of pathologic fracture and oncologic emergencies, controlling pain, and enhancing quality of life are the goals of the oncologic and reconstructive surgeons in cases of advanced breast cancer. These goals are becoming even more important as new forms and combinations of chemotherapy, radiation, and gene therapy are extending the life expectancy of women with breast carcinoma.

Prevention and treatment of wide scar and alopecia in the scalp: wedge excision and double relaxation suture.

The visible linear scar of the scalp is a cosmetically serious complication of a scalp incision in scalp surgery, forehead lift, and craniofacial surgery, especially on the temporal scalp. Its causes are cicatrical alopecia and scar widening. To solve this problem, we performed the wedge excision of the scalp and the double relaxation suture of the galea in 2 patients undergoing facial surgery through the coronal approach and in 15 patients with scalp alopecia ranging from 0.5 to 3.0 cm in width. The wedge excision using the beveling incision at an angle of 30 degrees to the hair follicles preserves the deep hair follicles of the flap margins and allows the hair to grow into the scar, eventually preventing cicatricial alopecia and camouflaging the linear scar. The double relaxation suture of the trimmed galea with nonabsorbable suture with or without the relaxation incision minimizes skin tension for a long time, eventually preventing scar widening. This procedure was followed by the superficial skin suture for maintaining the skin sutures for a long time and avoiding the injury of the superficial hair follicles. In all patients, we observed an excellent cosmetic result of unnoticed scar line without complications during the follow-up period of 10 weeks to 6 months.

Dissecting microscope versus magnifying loupes with transillumination in the preparation of follicular unit grafts. A bilateral controlled study.

BACKGROUND: The increasing importance that hair transplant surgeons are placing on maintaining the integrity of the naturally occurring follicular unit has generated great interest in finding the ideal method of graft dissection. OBJECTIVE: The present study attempts to compare two popular dissecting techniques: the dissecting microscope, and magnifying loupes with transillumination, in the preparation of follicular unit grafts. METHODS: Donor strips from 41 patients were used in a prospective, bilateral controlled fashion to compare the two different dissecting techniques. RESULTS: Microscopic dissection produced a 17% greater yield of hair as compared with magnifying loupes with transillumination. CONCLUSION: The results of this study show an increase in the yield of follicular unit grafts, as well as the total amount of hair harvested from the donor strip, when using the dissecting microscope as compared with magnifying loupes with transillumination. This increase was observed when only the latter part of the dissecting procedure was studied. When complete microscopic dissection is used, the advantage should be even more significant.

Micrograft and minigraft megasession hair transplantation results after a single session.

The purpose of this article is to share observations made after performing 90 consecutive micrograft and minigraft megasessions for the treatment of male pattern baldness. Micrograft means grafts with 1 or 2 hairs, minigrafts are those with 3 or 4 hairs, and a megasession is a procedure in which more than 1000 micrografts and minigrafts are inserted in a single session. Between March of 1994 and June of 1996, the author performed 90 consecutive micrograft and minigraft megasessions on 86 men and 4 women ranging from 21 to 67 years of age (average age, 42 years). The surgical team consisted of three surgical assistants and a plastic surgeon. Today, usually between 1500 and 2000 grafts per session are performed in about 4 to 6 hours, with up to 2495 grafts done in a single session. All procedures were done under intravenous sedation and local anesthesia. A donor horizontal ellipse of scalp is harvested from the occipital area; the grafts are made out of it and then inserted through small slits. The procedure has been found to be safe and predictable with natural and aesthetically pleasing results, and there were no serious complications. The only complication found in this group was self-resolving inclusion cysts (ingrown hairs) occurring in 9 of 90 patients (10 percent). Even though the hair density achieved in a single megasession is limited, there is a high level of patient satisfaction: 83 of 85 patients were satisfied (97.65 percent).

The tumescent technique facilitates hair micrografting.

Micrografting for hair restoration has become increasingly popular because of the natural results it can achieve. The procedure is often performed under local anesthesia or local anesthesia with sedation. To achieve adequate anesthesia, supraorbital and supratrochlear nerve blocks are often performed as well as infiltration of the donor and recipient areas via multiple needle injections. These nerve blocks and multiple injections are associated with significant discomfort and may need to be repeated if anesthesia is inadequate. In addition, because of the rich vascularity of the scalp, donor site and recipient bed bleeding are often encountered, making the procedure more difficult and increasing postoperative bruising and morbidity. In an attempt to alleviate these difficulties and increase patient comfort, the tumescent technique was employed in 50 consecutive micrografting procedures. The ability to achieve anesthesia in the donor and recipient beds without the need for additional nerve blocks was evaluated. The ability of the tumescent technique to minimize bleeding and subsequent postoperative ecchymosis and morbidity was analyzed. The findings of this study suggest the tumescent technique is useful in facilitating hair micrografting. It consistently achieves excellent anesthesia in both donor and recipient sites without the need for multiple needle injections or nerve blocks. The duration of anesthesia is significant, allowing completion of the procedure and offering prolonged postoperative anesthesia as well. Bleeding can be minimized using the tumescent technique for both donor site harvesting and the micrografting procedure itself.