The parietal foramen anatomy: studies using dry skulls, cadaver and in vivo MRI.

OBJECTIVE: The aim of this study was to describe the anatomical features encountered in the parietal foramen in a series of 178 human bones and 123 head MRI examinations. A cadaveric specimen was also dissected to demonstrate the trajectory of a superficial scalp vein through the parietal foramen as far as the dura mater. A literature review was performed regarding prevalence of parietal foramen in different populations. METHODS: Totally, 178 paired adult bones were used to investigate the presence, shape and number of the parietal foramina. In addition, 123 brain MRI examinations were also studied. RESULTS: The parietal foramina were encountered in 75/89 (84.3%) skulls [32/38 (84.2%) in women vs. 43/51 (84.3%) in men, p > 0.05]. The parietal foramen was present bilaterally in 44.73% of females and 54.9% of males. Regarding unilaterality of the parietal foramen, a right or left laterality was observed in female 21% right versus 18% left; and 16% versus 14% (left) in males (p > 0.05). The accessory parietal foramen was present in the right parietal in 2.6% and in 7.9% on the left side of the females, while 5.9% and 3.9% of the males on the right or left sides, respectively. The parietal foramina located in the proximity of the sagittal suture (male 7.1 ± 2.5 mm vs. female, 7.4 ± 2.7 mm). There was a positive correlation between the right and left parietal foramina regarding the distance from the median line. The distance from a foramen to the contralateral one was 16 ± 4 mm in men and 18 ± 5 mm in women, respectively (p > 0.05). CONCLUSION: No major differences were encountered between sexes regarding the anatomical features of parietal foramen.

Giant scalp arteriovenous malformation.

Arteriovenous malformations (AVMs) of the scalp are rare lesions. The clinical picture presents with complaints of increased scalp, scalp disfigurement, pain and neurological symptoms. Its origin can be congenital or traumatic. We present a case of giant scalp AVMs and its management, followed by a brief literature review on the subject. The diagnosis of scalp AVMs is based on physical examination and confirmed by internal and external carotid angiography or computed tomographic angiography (CTA). Surgical excision is especially effective in scalp AVMs, and is the most frequently used treatment modality.

Giant scalp arteriovenous malformation / Malformação arteriovenosa gigante de escalpo

SUMMARY Arteriovenous malformations (AVMs) of the scalp are rare lesions. The clinical picture presents with complaints of increased scalp, scalp disfigurement, pain and neurological symptoms. Its origin can be congenital or traumatic. We present a case of giant scalp AVMs and its management, followed by a brief literature review on the subject. The diagnosis of scalp AVMs is based on physical examination and confirmed by internal and external carotid angiography or computed tomographic angiography (CTA). Surgical excision is especially effective in scalp AVMs, and is the most frequently used treatment modality.

RESUMO Malformações arteriovenosas (MAV) do couro cabeludo são lesões raras. O quadro clínico apresenta-se com queixas de aumento do couro cabeludo, desfiguração do couro cabeludo, dor e sintomas neurológicos. A origem pode ser congênita ou traumática. Apresentamos um caso de MAV gigante de couro cabeludo e o tratamento adotado, seguindo-se uma breve revisão da literatura. O diagnóstico das MAV de couro cabeludo baseia-se no exame físico e é confirmado pela angiografia carótida interna e externa ou angiografia por tomografia computadorizada. A excisão cirúrgica é especialmente eficaz em MAV de couro cabeludo e é a modalidade de tratamento mais frequentemente utilizada.

Métodos de vigilância fetal intraparto / Methods of intrapartum fetal surveillance

A avaliação do bem-estar fetal durante assistência ao trabalho de parto é um dos principais objetivos da Obstetrícia. O método mais utilizado para essa avaliação é a monitorização eletrônica fetal contínua. Em razão de sua limitada capacidade diagnóstica, outros métodos complementares têm sido investigados para esse fim, como a ausculta intermitente, a estimulação digital no escalpe fetal, a oximetria de pulso, o eletrocardiograma fetal e a coleta de amostras de sangue do couro cabeludo fetal. Após revisão da literatura, foi concluído que são necessários mais estudos para determinar a verdadeira utilidade, na prática clínica, dos métodos complementares à monitorização eletrônica fetal contínua para avaliação fetal intraparto.

The evaluation of intrapartum fetal well-being is one of the main objectives of Obstetrics. The most used method for this assessment is the continuous electronic fetal monitoring. Because of their limited diagnostic capabilities, other complementary methods have been investigated for evaluation of intrapartum surveillance, as intermittent auscultation, digital fetal scalp stimulation, pulse oximetry, fetal electrocardiogram and fetal scalp blood sample. After a review of articles, we concluded that more studies are needed to determine the true usefulness in clinical practice of complementary methods to continuous electronic fetal monitoring for intrapartum fetal monitoring.

Low-level laser therapy on the viability of skin flap in rats subjected to deleterious effect of nicotine.

OBJECTIVE: The purpose of this study was to evaluate the effect of 830-nm laser in blocking the action of nicotine on the viability of skin flap. BACKGROUND DATA: The authors have analyzed the deleterious effect of cigarette smoke or nicotine on the skin flap alone with evidence of increased skin necrosis in the flap. MATERIALS AND METHODS: Twenty-four Wistar-albino rats were divided into three groups of eight animals each: Group 1 (control), subjected to a surgical technique to obtain a flap for cranial base, laser irradiation simulation, and a subcutaneous injection of saline; Group 2, similar to Group 1, with subcutaneous injection of nicotine (2 mg/kg/day) for a period of 1 week before and 1 week after surgery; and Group 3, similar to Group 2, with skin flaps subjected to a λ 830-nm laser irradiation. The laser parameters used were: power 30 mW, beam area 0.07 cm(2), irradiance 429 mW/cm(2), irradiation time 84 sec, total energy 2.52 J, and energy density 36 J/cm(2). The laser was used immediately after surgery and for 4 consecutive days, in one point at 2.5 cm of the flap cranial base. The areas of necrosis were examined by two macroscopic analyses: paper template and Mini-Mop(®). The pervious blood vessels were also counted. RESULTS: The results were statistically analyzed by ANOVA and post-test contrast orthogonal method (multiple comparisons), showing that the laser decreased the area of necrosis in flaps subjected to nicotine, and consequently, increased the number of blood vessels (p < 0.05). CONCLUSIONS: The laser proved to be an effective way to decrease the area of necrosis in rats subjected to nicotine, making them similar to the control group.

Open frontal lift: a conservative approach.

This study aimed to demonstrate that during an open frontal lift, transection of the galea is not necessary. The forehead is elevated, and the ptotic brow is raised after a strip of skin or scalp is removed by folding of the galea. The marcation is penciled on the skin according to the amount of skin--scalp the surgeon estimates it is necessary to remove. Local anesthesia is profusely injected, separating all layers and facilitating surgery. The skin is stripped off the galea, and then through a small incision in the middle, a large dissector separates the galea from the periosteum of the forehead and temporal regions. This dissection can be completed from the temporal area or from the blepharoplasty incisions. With a long pair of scissors, the orbital borders are reached and opened perpendicularly to the bone, releasing the fascia and muscle attachments from the orbital rim without anything being cut. During the coronal approach, once the scalp and forehead are completely mobile, the galea is folded with a continuous running 3/0 Vicryl suture, which after five or six big bites is strongly pulled to fold the galea. The wound then is sutured without tension using staples. When the incision is precapillary, the folding is fixed with Vicryl 3/0 uncolored thread, and the skin is sutured with mononylon 6/0. Complementary corrugator transections are performed from the blepharoplasty incision or by use of the endoscope. With the coronal approach, the surgery requires about 20 min, whereas the precapillary approach requires about 40 min. When only the skin is removed, bleeding is scarce and frontal postoperative edema is minimal. The author has used these techniques in 22 precapillary cases and the intracapillary procedure in 28 cases, some of which had a 4-year follow-up period. With the precapillary approach, temporary paresthesia occurred in some cases, but in all cases, sensibility was recovered within the first 2 to 6 months. With this simple and brief technique, the galea is not transected, no branches of the sensitive nerves are sectioned, and temporal and frontal arteries and veins that supply the scalp are not interrupted. Thereafter, wound healing is fast, allowing a quick recovery without areas of permanent numbness. As a result of this technique, the position of the eyebrows is the same as when frontal lifts are performed with transection of the galea and eversion of the flap, but without the side effects.

Reconstrucción de cuero cabelludo / Scalp reconstruction

Este artículo de actualización revisa en primer término, brevemente la historia de la reconstrucción de cuero cabelludo y la anatomía en aquellos detalles que son importantes para el cirujano que asume el compromiso de efectuar una reconstrucción de cuero cabelludo. A continuación, se revisa las técnicas quirúrgicas generalmente aceptadas y uso frecuente que pueden aplicarse de acuerdo a la profundidad y l extensión de la pérdida del cuero cabelludo. Por último, se destaca la importancia de realizar siempre una buena planificación en el diseño y manejo de los colgajos utilizados para evitar la pérdida de un recurso de tejidos siempre limitado

Osteogaleal pedicle flap of the occipital region for head and neck reconstruction--anatomic study.

OBJECTIVE: This study was conducted to assess the anatomic viability of an occipital osteogaleal pedicle flap for head and neck reconstruction. DESIGN: Anatomic study in cadavers. METHOD: We studied anatomic details in 50 fresh adult cadavers (100 sides). The dissections were realized after total posterior galea exposition, silicone injection of occipital vessels, and mobilization of the osteogaleal flap, with a 8 x 8-cm square of galea and a 2.5 x 7-cm rectangle of outer-table calvarial bone. RESULTS: Occipital artery obstruction = 4%; artery diameter = 2.69 mm (mean); occipital artery length = 134.25 mm (mean); occipital vein running close to the artery = 93%; area of occipital vessel network on galea = 148.77 cm2 (mean); thickness of outer-table bone graft = 6.07 mm (mean); pedicle length = 116.63 mm; and success in rotation to nose (82%), mandible (70%) and cricoid region (100%). CONCLUSIONS: We concluded that the pedicle osteogaleal occipital flap has favourable anatomic characteristics for its use in head and neck reconstruction.

[Autoimmune thrombocytopenia and pregnancy]. / Púrpura trombocitopénica autoinmune y embarazo.

Autoimmune thrombocytopenic purpura PTA, occurs more commonly in women during the reproductive years. Consequently, physicians frequently must manage pregnant patients with PTA. The management of the mother is simplified because an important measure of platelet count, is readily available. However the management of the fetus is more difficult because no definitive maternal treatment to prevent fetal thrombocytopenia has been successful. The performance of percutaneous umbilical blood sampling or fetal scalp sampling allow the determination of fetal platelet before delivery. If a fetal thrombocytopenia of less than 50,000 mm3 is detected, cesarean section is indicated to avoid intracranial hemorrhage in the fetus.

Estudo clínico da lepra do couro cabeludo

O A. examina os aspectos clínicos sob os quais se apresenta a lepra do couro cabeludo. Esta se evidencia, nos 16 casos que observou, por eritema e infiltração, máculas e nódulos lepromatosos (em um caso), que determinam a alopecia. Distúrbios da sensibilidade térmica estavam presentes em todos os casos, senso mais raros os de dolorosa e táctil. Em nenhum caso observou nódulos de reação leprótica. Sôbre a localização das lesões põe em relêvo a frequencia da alopecia leprosa na região temporal; suas observações concordam com as de Mitsuda e Nagai, que verificaram serem conservados os cabelos na frente da orelha, sôbre o percurso da artéria temporal superficial. Discute ainda se as lesões lepróticas aparecem em zonas primitivamente calvas ou se elas mesmas determinam a calvície: das suas observações parece-lhe que os bacilos se instalam mais facilmente nas regiões da cabeça, onde existe a calvície; por outro, também podem invadir territórios em que os cabelos estão presentes.