An anatomic study of the temporoparietal fascial flap

OBJECTIVE

To clarify the neurovascular relationships in the temporoparietal fascial flap and to access its possible use as a sensate free of a pedicled flap.

DESIGN

Anatomic dissections (gross) and examinations (histologic) were performed on 10 fresh cadaver heads.

SETTING

Academic tertiary care facility, Boston, Mass.

MAIN OUTCOME MEASURES

To determine the relationship of the sensory innervation (the auriculotemporal nerve) to the vascular supply (the superficial temporal artery) of the temporoparietal fascial flap, in addition to determining safe incisions and the level of flap elevation that will preserve the sensory supply to the flap.

RESULTS

There is a consistent relationship of the auriculotemporal nerve to the superficial temporal artery allowing for auriculotemporal nerve preservation with standard flap elevation techniques and easy nerve identification in this cadaveric study.

CONCLUSION

A clear understanding of the anatomic pattern allows for the potential creation of a sensate fascial flap or vascularized nerve graft that would add a potential additional dimension to this fascial flap.

[Atelocollagen/hydroxylapatite composite material as bone defect filler in an experiment on rats]

Many types of biomaterials are used as skeletal bone fillers in reconstructive surgery. An attention is paid to hydroxyapatite due to its high biocompatibility with the surrounding tissue. The paper deals with the testing of new collagen/hydroxyapatite composite material applied to the bone defect on os parietale of rats. The composite material was prepared from the bovine atelocollagen dispersion and the dispersion of hydroxyapatite. Collagen serves as a matrix in which the particles of hydroxyapatite are anchored. The composite presents the advantage that after the saturation with physiological solution it is compact and can be shaped. The composite material was implanted in the form of plate into six male Wistar rats to the ground bed on the surface of os parietale. The implants were taken out after four moths. The macroscopic finding of soft tissue, bones and implants gave evidence about good healing without any undesirable reaction. This was also confirmed by the histological observations. Collagen was resorbed and the rest of the material strongly adhered to the bone. The marked osteocytes were present in the zone of the newly formed bone and the dividing line between new and old bone was clear. The experimental results give preconditions to the clinical use of this new composite implant material the structural improvement of which is in progress. (Fig. 2, Ref. 12.)

Effect of stopping fluoride administration on the distribution profiles of fluoride in three different kinds of rat bones

The aim of this work was to explore the reduction of fluoride concentrations in the skeleton after stopping experimental fluoride administration. Fluoride was administered to the rats at varying doses (0, 50, 100 ppm in drinking water) and for different lengths of time (4, 13, 25 weeks). A series of fluoride concentrations across the full thickness of humerus, parietal bone, and vertebra arch in rats were measured by means of an abrasive micro-sampling technique. The distribution profiles of fluoride from periosteal to endosteal surfaces, which were apparently related to the histological structure of these bones, were U shaped in the humerus, V shaped in the parietal bone, and W shaped in the vertebra arch. The average fluoride concentrations in the bones increased significantly with each increasing dose and length of fluoride administration. The relative increments were similar between the different regions or the different bones. After stopping fluoride administration, on the other hand, the relative reduction of the average fluoride concentrations in the bones were 30-100%. They were greatly related to the length after stopping fluoride administration and the dose and length of fluoride administration, but also dependent upon the type of bone and the region examined.

Temporal dynamics of healing in rabbit cranial defects using guided bone regeneration

PURPOSE

The objective of this study was to histologically evaluate the early stages of bone regeneration using rabbit calvaria defects in conjunction with guided tissue regeneration.

MATERIALS

A semilunar cutaneous-periosteal flap was raised on the forehead of four rabbits exposing the top of the skull. A standardized transosseous skull defect (> or = 15 mm in diameter) was made in the area of the right parietal bone with a rotating round bur. Care was taken not to damage the underlying dura. A flat expanded polytetrafluoroethylene (ePTFE) membrane was placed to cover the defect. The membrane was tightly adapted, extending at least 4 mm onto intact bone, and the flap was sutured. One, 2, 3, and 5 weeks later, the specimens were removed and processed using standard, undecalcified, hard-tissue histologic techniques. Contact radiographs were also taken.

RESULTS

Bone growth increased with time, starting at the borders of the defect. At 1 week, trabeculae of woven bone grew into the highly vascularized loose connective tissue occupying the defect. Two weeks postsurgery, isolated islands of new bone were detected in this connective tissue. Subsequently, neighboring small islands merged to form large islands. In later stages, the primary trabeculae of woven bone were reinforced by layers of regularly deposited lamellar bone.

CONCLUSION

Rabbit calvaria defects treated by guided tissue regeneration heal by ingrowth of woven bone from the defect margins and by formation of bony islands within the defect area. Bone healing showed the histophysiological characteristics of intramembranous bone.

Extratrigeminal ice-pick status

We describe six patients with an identical type of headache, consisting of short episodes (lasting around 1 week) of daily attacks of ice-pick-like pain, recurring every minute in the same points of the scalp. In all of them, the pain was felt outside the cutaneous area of the trigeminal nerve (retroauricular, parietal, and occipital regions). All patients were examined in the emergency department of a general hospital over a period of 7 years because of these acute headaches. None of them had a history of migraine. Although this pain is identical to idiopathic stabbing headache, it differs from it by its temporal profile (in "status"), its posterior (extratrigeminal) location, and its lack of association with migraine. While the bouts were usually severe and recurred in two patients, all had a self-limited benign course and responded promptly to indomethacin.

Maxillary and mandibular reconstruction using calvarial bone grafts and Branemark implants: a preliminary report

A review of 24 patients reconstructed with calvarial bone grafts and 93 Branemark implants (Nobelpharma, Chicago, IL) revealed an overall success rate of 91.4%. Two grafting techniques were used. A vertical grafting technique with delayed implant placement had an 86% success rate in 13 patients who had 50 implants placed. The average follow-up for this group was 31 months. A horizontal grafting technique with immediate implant placement had a success rate of 98%. This group included 13 patients who had 43 implants placed at the time of their bone grafting procedure. Two patients had a combination of grafting techniques. The average follow-up for this group was 18 months. A patient questionnaire revealed a high percentage and degree of satisfaction.

Bulky plasmacytoma of the bone with intracranial invasion

A 56-year-old man with left anterior chest pain showed two well-defined tumors in the left anterior chest wall and left parietal region. A large osteolytic lesion in the parietal bone and several punched-out lesions in the temporal bone were revealed by a skull X-ray examination. He showed monoclonal gammopathy (IgG, kappa type) and Bence Jones proteinuria, but no proliferation of plasma cells was observed in the bone marrow. The tissue specimens from both lesions consisted of abnormal plasma cells, indicating plasmacytoma. Although a bulky intracranial plasmacytoma was present, the patient did not exhibit intracranial hypertensive symptoms, or neurological abnormalities.

Oscillations in inositol 1,4,5-trisphosphate and diacyglycerol induced by vitamin D3 metabolites in confluent mouse osteoblasts

For the last 5 years, attention has focused on the nongenomic effects of 1,25-(OH)2D3, but considerably less is known about the mechanisms of the nonnuclear actions of 24,25-(OH)2D3. The present study examines and compares the rapid (5-90 s) effects of 100 pM to 10 nM 24,25-(OH)2D3, 10 pM to 1 nM 1,25-(OH)2D3, and 1-100 nM 25-OHD3 on the formation of inositol phosphates and lipids in confluent mouse osteoblasts. 24,25-(OH)2D3 and 25-OHD3 effects were dose dependent; those of 1,25-(OH)2D3 were dose dependent in a bell-shaped manner. The two dihydroxylated metabolites induced a multiphasic response in inositol 1,4,5-trisphosphate (IP3) formation with three stimulation peaks; the IP3 response to 25-OHD3 was monophasic. The amplitude of the IP3 response to 24,25-(OH)2D3 was greater and its oscillation period was slower than that induced by 1,25-(OH)2D3. The diacylglycerol (DAG) responses to secosteroids showed two stimulation peaks that appeared at different times depending on the secosteroid used. Pretreatment with neomycin totally inhibited the first DAG response; neomycin had no effect on the second peak of DAG induced by 25-OHD3, whereas it partially blocked the second response of DAG to 24,25-(OH)2D3 and 1,25-(OH)2D3. These data show for the first time that 24,25-(OH)2D3 can modulate phospholipid metabolism in confluent mouse osteoblasts as early as 5-10 s. The first pathway used by all three secosteroids is that of the hydrolysis of phosphatidylinositol 4,5-bisphosphate via phospholipase C activation, leading to the formation of the two second messengers, IP3 and DAG, since neomycin totally blocked the response. Thus, the action of these secosteroids on the osteoblast membrane may also implicate several steps of the phosphatidylcholine cycle, according to the metabolite tested. Finally, these data point to a direct interaction of vitamin D metabolites with specific membrane recognition moieties.

The release of tissue inhibitor of metalloproteinases by calvarial bone explants and its immunolocalization

Tissue inhibitors of metalloproteinases (TIMPs) play an important role in the regulation of the activity of matrix metalloproteinases (MMPs) such as collagenase, stromelysin and gelatinase. Although it has been shown that upon culturing bone tissue releases relatively large amounts of TIMP, little is known as to the source of the inhibitor. In an attempt to investigate this in more detail calvarial bone explants from young rabbits were cultured in serum-free medium. The explants were cultured with or without adhering periosteum. In some experiments solitary periosteal fragments were maintained in the absence of bone. Media were analyzed for the presence of TIMP by immunoblotting and ELISA as well as for their capacity to inhibit the activity of collagenase. In addition, TIMP was immunolocalized in cryosections of the explants. The data demonstrated that bone-conditioned medium contained significantly more (2-10 times) collagenase inhibitor than periosteum-conditioned medium. Removal of the (convex and/or concave) periosteum from the calvariae did not significantly affect the amount of inhibitor released. Immunoblots and ELISA showed the presence of TIMP in the media, being more in bone- than in periosteum-conditioned medium. In immunolabeled cryosections TIMP appeared to be present in osteoblast-like cells lining both the outer bone surface as well as the endosteal spaces. Label was also found in a number of osteocyte lacunae. The periosteum was almost negative. It is suggested that TIMP contributes to the regulation of MMP-activity involved in the remodeling and turnover of bone.

Modified coronal incision: distribution of stress in the scalp and cranium

Coronal incision or bitemporal incision is useful for wider visualization in craniofacial surgery. In volume-expanding surgery such as fronto-orbital advancement, however, the incisional scar in the temporal scalp is often undesirably wide and conspicuous. We modified the coronal incision to avoid the widened scar. Further, we analyzed the resulting stress distribution using the finite element method (FEM) to determine whether or not the modification we adapted was effective. The modified method of coronal scalp incision that we used for craniofacial surgery is practical and technically easy. FEM analysis showed that our method was effective in terms of mechanical strength. The simulated surgical craft model is presented and is concluded to be beneficial for further analysis in craniofacial surgery.

[Cerebral salt wasting syndrome secondary to head injury: a case report]

A case of cerebral salt wasting syndrome secondary to head injury is reported here. A 4-year-old boy was admitted to our hospital with head injury. Neurological examination revealed no abnormal findings other than consciousness disturbance. Plain skull X-ray demonstrated a linear fracture of the bilateral parietal bones, and CT scan demonstrated subarachnoid hemorrhage of the tentorium of the cerebellum. He gradually improved, but on the 6th day deterioration of consciousness developed. At that time CT scan demonstrated no abnormal findings. Biochemical analysis showed hyponatremia (116mEq/L) with increased natriuresis. Although a high dose of NaCl was supplied, serum sodium levels did not normalize. So we suspected that SIADH might be causing the hyponatremia, and water restriction was started. He lost 1 kg in body weight over 3 days, but serum sodium levels remained low (118mEq/L) with increased natriuresis. We found that the hyponatremia was caused by cerebral salt wasting syndrome, so we treated the patient with fludrocortisone acetate. Consciousness disturbance improved two days after the medication with fludrocortisone acetate, and serum sodium levels became normal (137mEq/L) on the 27th day. The administration of fludrocortisone acetate was able to be stopped two months after admission, and then the patient was discharged without any neurological deficits. We discussed in detail the diagnosis and the treatment of cerebral salt wasting syndrome.

Comparison of regenerative capacity elicited by demineralized bone matrix of different embryonic origins

In the cranio-maxillo-facial field, extensive research has been conducted to find substitutes for autogeneic bone as a grafting material. The present study examined the effect of demineralized allogeneic bone material of membranous and enchondral origin compared with autogenous bone chips on the healing response in rabbit skull defects. The demineralized bone matrix (DBM) was bioassayed in a critical-size defect rat model. Four trephined calvarial defects were created in each of 14 adult rabbits and the experimental materials implanted into three defects leaving the fourth defect empty for control purposes. The results were assessed by light microscopy and contact radiography after periods of 4 and 15 weeks. The DBM of both origins displayed extensive osteoinductive capacity and early bone production significantly exceeded that of the two control groups. The embryological origin implied minor effects on the initial regenerative response and bone marrow redevelopment. The clinical significance of these findings is discussed.

The vascular anatomy of the galeal flap in the interparietal and midline regions

The potential extension of the galeal flap in the interparietal area was studied on 17 fresh human cadaver heads by intravascular dye injection technique. It was demonstrated that an ipsilateral superficial temporal artery that supplies the galeal flap does not cross the midline or anastomose with the contralateral superficial temporal artery but ensures the survival of a flap extended up to 1 cm proximal to the sagittal suture line. The width of the temporoparietal flap can be extended up to 15 cm, depending on the vascular pattern of the superficial temporal artery. When required, the lateral extension may provide the required soft-tissue bulk despite the reduced flap length.

[Plasma cell tumor of the parieto-occipital bone; a case report]

Plasmacytoma originating in the cranial bone is a rare disease. A report is presented of a case of plasmacytoma originating in the parieto-occipital region. The patient was a 62-year-old male with palpation of a parieto-occipital mass as chief complaint. He showed no neurological deficit. Ig-G in the serum was 2240 mg/dl, and M-protein (n-type) was demonstrated in the serum. Bence-Jones protein was negative and bone marrow was normal. Skull X-ray showed osteolytic change in the parieto-occipital region. CT scan and MRI demonstrated a markedly enhanced mass extending from the epidural to the subcutaneous space at the parieto-occipital region. Common carotid angiography showed remarkable tumor stain flowing from the occipital artery, the superficial temporal artery, and the middle meningeal artery. Following embolization of the bilateral occipital artery, parieto-occipital horse shoe scalp incision was done. The tumor was elastic soft and bled easily around the margin of destroyed bone. Subtotal removal of the tumor was accomplished. The removed surgical specimen of the tumor was found to be plasmacytoma. The patient's postoperative course was favorable and no neurological deficit was found. Laboratory studies revealed a remarkable reduction of Ig-G in the serum to 1170 mg/dl. Six months after the operation, no signs of recurrence were seen on CT scan. Plasmacytoma originating in the cranial bone is so rare that only 18 cases have been reported to date. In these cases, laboratory studies have shown no evidence of anemia, Bence-Jones protein in urine, and abnormality of the bone marrow which are characteristic of multiple myeloma.(ABSTRACT TRUNCATED AT 250 WORDS)

On the role of cyclic AMP as a mediator of bone resorption: gamma-interferon completely inhibits cholera toxin- and forskolin-induced but only partially inhibits parathyroid hormone-stimulated 45Ca release from mouse calvarial bones

The effects of gamma-interferon (gamma-IFN) on bone resorption and cyclic AMP formation stimulated by parathyroid hormone (PTH), forskolin, and cholera toxin have been studied in cultured neonatal mouse calvarial bones. Bone resorption was assessed by the release of 45Ca from prelabeled mouse calvarial bone fragments. Cyclic AMP formation was quantified by analyzing the amount of the nucleotide in calvarial bone tissue. gamma-IFN completely blocked the 45Ca release response to forskolin and cholera toxin in 96 h cultures. In contrast, the 45Ca release response to PTH was only partially inhibited, an effect that was seen over a wide range of PTH concentrations. The inhibitory effect of gamma-IFN was dose dependent, with a threshold for action at 10 U/ml. Forskolin-stimulated 45Ca release could only be inhibited when gamma-IFN was added simultaneously with forskolin; gamma-IFN added to bones prestimulated with forskolin had no effect. The inhibitory effect of gamma-IFN on PTH-stimulated 45Ca release was seen first after a time lag of 48 h. In contrast calcitonin caused an inhibition after only 3 h. PTH and cholera toxin stimulation of radioactive calcium release was also inhibited by gamma-IFN in bones treated with indomethacin. gamma-IFN inhibited forskolin-induced 45Ca release in bones treated with the mitotic inhibitor hydroxyurea. No effect of gamma-IFN on cyclic AMP formation induced by PTH, cholera toxin, or forskolin could be seen. These data show that gamma-IFN inhibits forskolin- and cholera toxin-induced bone resorption by a mechanism unrelated to prostaglandin production or mitotic activity.(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro studies on bone resorption in neonatal mouse calvariae using a modified dissection technique giving four samples of bone from each calvaria

Bone resorption in a modified bone culture system, based on incubation of small fragments from neonatal mouse calvarial bones, has been studied. Four bone fragments were dissected out from each mouse calvaria and were thereafter cultured in CMRL 1066 medium in plastic multiwell dishes. Bone resorption was assessed by 45Ca release from prelabeled bones. The rate of bone resorption in response to parathyroid hormone (PTH) was less in the anterior part of the calvaria compared to the posterior part. After removing the anterior region, four parietal bone fragments that showed identical basal and PTH-stimulated release of 45Ca could be dissected out from each mouse. Excretion of lactate dehydrogenase and beta-glucuronidase was the same in bones cultured submerged or on grids. Uptake of [3H]thymidine in bones cultured submerged was 54% of [3H]thymidine uptake in bones cultured on grids. Dose-response curves, established by using parietal bone fragments, showed that the sensitivity and the magnitude of the increase in 45Ca release seen after stimulation with PTH, prostaglandin E2, and 1 alpha-hydroxyvitamin D3 were the same for bones cultured submerged or on grids. The 45Ca release in response to stimulation with PTH, prostaglandin E2, and 1 alpha-OHD3 was the same in calvarial fragments cultured submerged and those previously obtained with calvarial halves cultured on grids. Thus, even though the rate of DNA synthesis was slower in bones cultured submerged, the rate and the magnitude of resorption were the same in bones cultured on grids or submerged. These data show that it is possible to perform studies on bone resorption with small fragments of neonatal mouse parietal bones.

[Syphilitic arthro-osteitis]

We report a black female with past history of sexual promiscuity who developed arthroosteitis of clavicula and sternoclavicular joint and cranial osteitis during secondary syphilis. Spirochaeta were identified in the material from osteoarticular biopsy. The patient was treated with benzathine penicillin, 2,400,000 U weekly for three weeks. There was a complete clinical recovery. We emphasize the uncommon occurrence of osteoarticular involvement in secondary syphilis and the exceptional character, according to the literature, of the finding of spirochaeta in the biopsy material. We discuss the differential diagnosis and we review the literature on secondary syphilis. We suggest that syphilis should be considered in the differential diagnosis of any acute arthritis or osteitis, particularly when the involved joint is the sternoclavicular and the patient is sexually promiscuous.