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Observations on temporal aspects of bone-conduction clicks: real head measurements.

To further elucidate nuances of bone-conduction (BC) stimulation, particularly as they may pertain to BC-elicited auditory brainstem responses (ABRs), real head measurements were made of vibratory responses to BC clicks. A miniature accelerometer was held firmly against the skull near a bone vibrator applied to the mastoid, to the opposite mastoid, and to the forehead. Measurements also were made with the vibrator applied to the forehead and the accelerometer placed on a mastoid. The measured vibrations were compared among conditions within and across subjects. The results demonstrate that vibration picked up in the immediate vicinity of the vibrator, roughly mimics the temporal and spectral characteristics of the click observed on an artificial mastoid. However, probing at sites remote to the bone vibrator suggested the introduction of a propagation-like delay as well as low-pass filtering. These findings support observations of previous researchers who demonstrated phase differences between vibrations recorded at different points on the skull, further demonstrating the complexities of skull vibration. Latency differences of ABR responses obtained with forehead versus mastoid placements, for example, cannot be attributed merely to the difference in efficiency between sites of stimulation demonstrated audiometrically. While the real head observations do not permit determination of the actual vibratory lag at the cochlea, they do permit the deduction that a comparable onset delay occurs in BC as in air-conduction stimulation via supra-aural earphones.

Acoustic Stimulation↗

[Physiological evaluation of the resultant activity of school children working with computers].

The schoolchildren who had achieved high results in computer learning tasks showed a regular nature of changes in autonomic parameters, which was in concordance with steps taken in goal-oriented activity. Those with low results displayed higher and disconcorded changes in autonomic parameters, which were interpreted as a predisposition to emotional stress when learning computer tasks. The high-result schoolchildren made fewer errors in reaction-time tasks and signal differential tasks and spent less time in decision-making. They also differed from low-result schoolchildren by showing a higher frequency of beta-rhythm ECCG from forehead derivations and prevalent alpha-rhythm and also a higher proportion of teta-rhythm in the spectra of the forehead, central and parietal derivations as well as a higher coherence of alpha-rhythm from the forehead and parietal derivations of the left hemisphere.

Adolescent↗

Phantom face: conscious correlate of neural reorganization after removal of primary sensory neurones.

A patient in whom mandibular and maxillary parts of right trigeminal ganglion were removed experienced referred sensations after stimulation of the right hand and right forehead. She described them either as parallel to the perception at the actual stimulation site or as coming uniquely from a (non-existent) stimulation of denervated territory. The latter occurred in 6-19% of stimulations performed on the right forehead and on digits 1, 3 and 4 of the right hand. Thumb stimulations were localized on the right side of the face, stimulations of right forehead, middle and ring fingers more precisely on right cheek. Referred sensations were present on postoperative day 7 and had a more real-like quality than 5 days later.

Brain Mapping↗

The extended browlift.

The endoscopic extended browlift adds to the armamentarium against aging, serving as an excellent stand alone procedure in the younger patient in whom the lower face and neck are minimally affected. It accomplishes a repositioning of the orbital portion of the orbicularis oculi muscle thereby minimizing resection of eyelid skin, muscle, and fat. Its lift of the malar pad causes a pleasing transition onto the upper face blending nicely into the lower face. In more advanced aging, the extended browlift serves as a powerful adjunct to procedures on the eyelids, lower face, and neck. It corrects troublesome orbital festoons and malar bags and reduces the upper third of the nasolabial fold. Its transition effect in the lower face has allowed an alternative procedure with more limited SMAS-skin undermining to be performed in smokers. The primary disadvantage of the procedure is the necessity of thoroughly understanding and familiarizing oneself with the somewhat confusing temporal anatomy, the location of the retaining ligaments of the cheek, and the relationship of the facial nerve to the deep plane. A failure to recognize and release the retaining structures will limit significantly the outcome of the procedure. Careless or misdirected dissection over the zygomaticus major muscle may directly injure the muscle or the nerve branches to the orbicularis oculi muscle. Forty-two patients who underwent an endoscopic extended browlift now have been followed from 6 to 18 months. The patient representing the first endoscopic attempt had unilateral weakness of the forehead and bitemporal fat atrophy. The forehead weakness resolved at 4 weeks postoperatively. The temporal fat atrophy was corrected at 1 year postoperatively with micro fat grafts. A second patient done as a demonstration at another institute had forehead weakness and excessive tension on one side. The weakness and tension reportedly resolved at 3 months. No patients have had permanent weakness. The most frequent occurrence following the procedure was the return of brow asymmetry that was present before surgery. Attempts at correcting this preoperative finding were generally unsuccessful.

Adult↗

Strength and histological characteristics of periosteal fixation to bone after elevation.

BACKGROUND: Loss of brow elevation in the early postoperative period has been well documented; however, there has been no study quantifying the minimum time necessary to achieve lasting brow elevation. Previous work in our laboratory has demonstrated that complete readherence of periosteum to bone can take 12 weeks to occur after periosteal elevation. The correlation between adherence and the development of strength has never been examined. OBJECTIVE: To correlate histological characteristics of raised forehead periosteum with the strength of the periosteum-bone union postoperatively. SUBJECTS: Eighteen New Zealand white rabbits. METHODS: Rabbit foreheads were elevated in a subperiosteal plane and the flap reapproximated with chromic sutures. Animals were killed at 14, 28, 45, 63, or 84 days postoperatively, and all tissue superficial to the periosteum removed. The tension required to avulse sections of periosteum was then measured. Skulls were then sectioned and prepared for histological analysis of remaining periosteum. Avulsion forces and histological findings were compared with those unoperated-on controls. RESULTS: The forces necessary to avulse periosteum in the 14- and 28-day groups were significantly lower than for control animals; values at 45, 63, and 84 days were not significantly different from control animals. Healing periosteum displayed varying degrees of thickness, cellularity, edema, and vascular congestion. These features peaked at 28 days postoperatively then gradually resolved to near-control values by 84 days. Significant periosteal-to-bone contact did not appear until 45 days postoperatively. CONCLUSION: Our results promote the use of methods of brow fixation that support mobilized soft tissues for a minimum of 6 weeks, until the elevated periosteum has significantly readhered to the underlying bone.

Animals↗

Anatomical guides to precisely localize the frontal branch of the facial nerve.

OBJECTIVE: To define the relationship between the frontal branch of the facial nerve and a series of blood vessels that are encountered during endoscopic forehead procedures. DESIGN: Anatomical study using 6 fresh cadavers (12 sides). RESULTS: In 11 of 12 dissected specimens, the blood vessels in the temporal region were found to lie within 2 mm of the frontal branch of the facial nerve. CONCLUSIONS: We believe that a series of veins encountered during endoscopic forehead procedures provide the surgeon with the ability to identify the precise location of the frontal branch of the facial nerve. During endoscopic surgery, these vessels are found in a plane between the deep temporal fascia (below) and the superficial temporal fascia (above). We believe that these vessels can be thought of as arrows pointing superiorly to a frontal branch of the facial nerve as it courses through the superficial temporal fascia.

Endoscopy↗

Midforehead lift.

Ptosis of the brow-glabellar tissues with or without vertical and horizontal wrinkling accompanies aging in other areas of the face. The direct browlift is effective in elevating and shaping brow tissues, but leaves a scar at the brow-forehead juncture and does little for glabellar deformity. The coronal forehead lift allows the correction of brow-glabellar ptosis and wrinkling with camouflage of the scar in the scalp. Male pattern hairline, thinning hair, or a high hairline may contraindicate this approach. Our technique for treating these patients is the midforehead lift. We review the anatomical considerations, patient selection, and surgical technique, showing representative cases.

Aged↗

Dura mater for soft-tissue augmentation. Evaluation in a rabbit model.

Irradiated human dura mater, a commercially available preparation of dura mater (Tutoplast), and irradiated rabbit dura mater were implanted in subcutaneous pockets in the pinna and forehead of New Zealand white rabbits and evaluated for their usefulness in soft-tissue augmentation at 3 months and 6 months. Postoperatively, no evidence of erythema, purulence, hematoma or seroma formation, wound dehiscence, graft extrusion, or flap necrosis was noted. Irradiated human dura mater was well tolerated by the host and elicited a mild cellular inflammatory response. The graft was well preserved, infiltrated by fibrous connective tissue, and fixed in place in the pinna sites. Forehead grafts were surrounded by a capsule of host tissue and were intact. Dura mater seems to be useful for soft-tissue augmentation. Tutoplast may give good results clinically. Because this represents a short-term evaluation, long-term clinical results are needed to define the potential of dura mater grafts.

Animals↗

Skin color variation in eastern Nepal.

The purpose of this paper is to provide skin color data on several endogamous groups of eastern Nepal and to demonstrate genetic microdifferentiation in skin color. Skin reflectance measures were taken at the upper inner arm and forehead sites, using the British DSL Model 99 Reflectance Spectrophotometer fitted with blue, green, and red filters. Measurements on 484 males representing six endogamous groups (Jirel, Sunwar, Sherpa, Tamang, Brahman, Chetri) were utilized. After adjusting for group-specific age effects, multivariate likelihood ratio permutation tests were used to assess ethnic differences in skin reflectance means and covariance matrices. Ethnic group membership had a highly significant effect on skin color at the upper inner arm site and at the forehead site. Differential tanning responses among groups were also detected and may represent the influence of genotype-environment interaction on reflectance traits. Mahalanobis distance analysis revealed patterns of microdifferentiation that are inconsistent with oral historical accounts. Little support was found for the ethnohistorical belief that Jirels are a hybrid group descended from Sunwars and Sherpas, even though this scenario is supported by linguistic, anthropometric, and dermatoglyphic data. We suggest that while reflectometric studies of skin pigmentation may be useful in assessing the macrodifferentiation of human populations, the use of skin color in differentiation studies at the local population level needs to be carefully evaluated.

Adolescent↗

Alternatives in nasal reconstruction ("five flaps and a graft").

Five pedicle flaps and one auricular composite graft deserve increased use and attention in nasal reconstructive surgery. All have in common the high possibility of superior functional and esthetic results while requiring the payment of a minimum penalty of tissue sacrifice. A composite graft of conchal cartilage and adherent post-auricular skin serves well in the saddle nose deformity of childhood, creating satisfactory tissue augmentation and recreating cartilaginous support for the airway. The sublabial mucosa of the upper lip provides superior tissue for pedicle flap repair of nasal septal perforations. Tunneled through a small oronasal fistula, the flap is elevated and transposed as a one-stage procedure. No closure of the donor site is required. Forehead flaps derived from the precise midline or the non-hair-bearing bay of forehead skin (the sickle flap), are useful, non-delayed flaps carrying considerable tissue of superior color match to nasal defects. A major advantage is the excellent camouflage possible at either donor site area. When nasal reconstruction of greater dimensions becomes necessary, the scalping flap is advantageous. Flap reliability is of a high order, and flap blood supply is unequaled.

Cartilage↗

Effects of variation in physical effort on frontalis EMG activity.

The physiological mechanisms underlying forehead muscle biofeedback for stress reduction are not well understood. A common hypothesis considers the frontales to be "key muscles" uniquely indexing the degree of tension present in the general musculature. We tested this hypothesis under conditions ranging from relaxation to maximum physical effort. The hypothesis was not supported. Changes in forehead muscle activity were limited primarily to reflecting changes in head and neck muscle tension.

Adult↗

Capillary refill time in term neonates: bedside assessment.

Capillary refill time (CRT) is yet to be established as a specific clinical sign of peripheral circulation in neonates. This study was conducted to assess the influence of four body sites used for measurement, interobserver variability, sex, birth weight, age at assessment and room temperature on CRT recorded in healthy term neonates, at bedside. Two observers measured CRT in four different body sites (forehead, chest, palm and heel) of each of 155 healthy term neonates. Significant differences occurred between the mean CRT recorded by the two observers in forehead (mean +/- SD: 2.62 +/- 0.8 s and 1.88 +/- 0.57 s; p < 0.001), palm (2.99 +/- 0.61 s and 2.75 +/- 1.12 s; p < 0.05) and heel (3.08 +/- 0.79 s and 4.24 +/- 1.84 s; p < 0.001). Only CRT in chest (2.7 +/- 0.42 s and 2.62 +/- 0.74 s) produced no significant differences in the means with a statistically significant and clinically fair, but not strong, interobserver agreement (r = 0.4; p < 0.001). No significant associations occurred between CRT and sex or birth weight. The associations of chest CRT with age at assessment (r = -0.23; p < 0.01) and room temperature (r = 0.27; p < 0.01) were clinically not important. In conclusion, CRT in neonates needs to be validated further before it can be useful as a specific clinical sign of peripheral circulation.

Analysis of Variance↗

Orientation of the body response to galvanic stimulation as a function of the inter-vestibular imbalance.

We proposed to study and quantify the anteroposterior component, on top of the lateral one, of the body sway induced by different configurations of galvanic vestibular stimulation (GVS) in order to advance the understanding of the orientation of the response. Four stimulation configurations were used in two separate experiments: monaural, binaural, and opposite double monaural in the first experiment (11 subjects); monaural and double monaural in the second (13 subjects). The postural response of the subjects, standing with their eyes closed, to the stimulus (0.6 mA, 4 s) was assessed by measuring the displacement of the center of pressure (CoP) using a force platform. As usual, binaural GVS induced a strictly lateral deviation of the center of pressure. The opposite double monaural condition induced a similar lateral sway to that obtained in the binaural mode, although with a very different stimulation configuration. Monaural GVS induced an oblique, stereotyped deviation in each subject. The anteroposterior component comprised a forward deviation when the anode was on the forehead and a backward deviation when the anode was on the mastoid. The lateral component, directed towards the anode as in the binaural design, was twice as large in the binaural than in the monaural mode. The second experiment showed that double monaural stimulation elicited an anteroposterior deviation (backwards when the anode was on the mastoids and forwards when it was on the forehead) that was equivalent to the addition of two complementary monaural configurations. The present results show that monaural stimulation activates one side of the vestibular apparatus and induces reproducible, stereotyped deviations of the CoP in both the anteroposterior and lateral plane. Secondly, binaural GVS appears to result from the addition of two complementary monaural stimulations. Lateral components of the response to each stimulation, being in the same direction, are summed, whilst anteroposterior components, being in opposite directions, cancel each other out. The opposite happens when both labyrinths are polarized in the same way, as in the double monaural configuration. We suggest that the orientation of the response to GVS is a function of the imbalance between right and left vestibular polarization, rather than a function of the actual position of the electrodes.

Electric Stimulation↗

Long-term prospective follow-up of botulinum toxin treatment for facial rhytides.

Some wrinkles and unsightly facial expressions are due to hyperactivity of the underlying facial musculature. Clostridium botulinum type A exotoxin reversibly paralyzes selected muscles and is a safe, helpful adjunct to many other treatments for facial rejuvenation. Fifty-two patients were treated and all data recorded in a prospective fashion. Only areas requested by the patient were treated. The dosage and dilution given in each area were carefully noted and all patients had pretreatment and posttreatment photographs. The effect of botulinum toxin injections on the horizontal brow rhytides was recorded by measuring the distance from the frontal hairline to the superior edge of the eyebrow in the mid-pupillary line. Patients were followed for one to three years (mean 16.3 months). One patient was not responsive to botulinum toxin in spite of repeated injections. Three further patients required touch-up injections two weeks after the initial treatment due to a weak initial response. Repeat injections were required every three to six months (mean 4.05) to maintain the desired improvement. Asymmetry of the brow was seen in two patients and corrected with further administration of botulinum toxin. Twenty-five patients had their forehead rhytides injected and the appropriate measurements taken. Brow ptosis occurred in 22 of the 25 patients and varied 1-6 mm with a mean value of 2.3 mm. This difference was statistically significant (paired t-test p <0.001). Two patients reported dryness and flakiness of the frontal area after injections. No cases of eyelid ptosis or hypersensitivity were seen. Botulinum toxin injections are safe and all undesired effects are reversible. Great care has to be taken not to aggravate the degree of brow ptosis. Injection of the forehead depressors minimizes the risk of brow ptosis. Careful planning of injection sites and doses avoids a mask-like upper face. The use of botulinum toxin provides a useful adjunct to laser and surgical procedures for facial rejuvenation.

Adult↗

Current methods for brow fixation: are they safe?

BACKGROUND: No single technique for fixation of the scalp after forehead-lift is universally accepted. Complications such as alopecia, loss of elevation, implant palpability, paresthesia, and dural injury are possible with the variety of techniques used currently. This anatomic study was designed to evaluate the thickness of the calvarium at selected points used in brow fixation. The depth of cranial penetration necessary for currently used techniques is measured and compared. METHODS: In a study of 14 fresh adult cadavers, calvarial thickness was measured at selected points (A-F) used in various brow-lifting procedures. This was accomplished by drilling holes in selected points and using a depth gauge to measure thickness. Immediately adjacent to selected points, the cranium is prepared for brow fixation using the following techniques: cortical tunnels, 2.0-mm screw fixation (10, 12, and 14 mm), the Mitek 2.0-mm Quickanchor screw, and the Endotine 3.5 Forehead Device. The depths required for adequate fixation and the potential for cranial penetration through the inner table with all the standard techniques are compared. RESULTS: Depth analysis by mean values showed that sites posterior to the coronal suture (points C-F) were thickest. Depth analysis of sites stratified by gender showed that mean values for the thickness of female skulls were greater than those for males. A review of fixation methods found that cortical tunnels at 45 degrees angles never penetrated the inner table in any of the 14 skulls. Mitek screws never penetrated the inner table, and one Endotine post penetrated the inner table on the left side of one cadaver skull. After placement of 10-, 12-, and 14-mm miniscrews at each of the sites, it was found that three penetrated the inner table. The penetrations all were at far lateral sites, posterior to the coronal suture. CONCLUSION: Variation in skull thickness exists among cadaver specimens at different sites on the skull. In this study, thickness increased medially and posteriorly. Women tended to have thicker skulls than men, and age was not a major variable. This is consistent with findings in previous work. Given the unpublished reports of inner table penetration, with cerebrospinal fluid leak after invasive brow fixation, it behooves the surgeon to keep in mind the anatomy of the calvarium and its nuances.

Aged↗

Urocanic acid isomers: relation to body site, pigmentation, stratum corneum thickness and photosensitivity.

Urocanic acid (UCA), present in the stratum corneum as trans-UCA, absorbs ultraviolet (UV) radiation and isomerizes to cis-UCA. Cis-UCA has been demonstrated to initiate suppression of selected immune responses in several experimental systems. Topical application of UCA-containing products reduces UV-induced erythema, but a role for endogenous UCA in photoprotection has not been reported. In this study the relationship between UCA isomers, pigmentation, minimal erythema dose (MED), and stratum corneum thickness was investigated. Pigmentation, concentration of total UCA, and the percentage present as the cis-isomer was measured in 36 healthy subjects, skin type I-IV, at six UV-exposed and nonexposed body sites: forehead, chest, back, outer upper arm, inner upper arm, and buttock. The MED was determined by phototesting on buttock skin, and a punch biopsy for measurement of stratum corneum thickness was taken adjacent to the site of the phototest. The percentage of cis-UCA was significantly higher in UV-exposed than on nonexposed areas. A small intraindividual variation in total UCA was found, being high on the buttock and the arm, lowest on the forehead. The subject to subject variation of total UCA was considerable at all body sites. No correlation was found between total UCA and MED, skin type, pigmentation, or stratum corneum thickness.

Adolescent↗

Detection of hyperbilirubinaemia in jaundiced full-term neonates by eye or by bilirubinometer?

UNLABELLED: The aim of this study was to compare predictions of hyperbilirubinaemia by eye, performed by trained physicians and nurses, with predictions obtained using two commercial bilirubinometers. Jaundice was assessed in 92 white and 48 non-white healthy full-term neonates using three non-invasive methods and by total serum bilirubin as the reference method. Clinical assessment of cephalocaudal progression of jaundice was carried out independently by a physician and by nurses. Simultaneously, the Minolta Airshields JM-102 was applied on the sternum, the BiliCheck on both the forehead and the sternum, and finally, serum bilirubin concentrations were determined. The Minolta JM-102 showed the best performance with r2 = 0.90, an intraclass correlation coefficient (ICC) of 0.93, and a 95% confidence interval (CI) of +/- 4 units (approx. 56 micromol/l). The BiliCheck performed slightly better on the forehead than over the sternum with r2=0.90, an ICC of 0.88, and a CI of +/- 62 microtmol/l. Assessment of jaundice by eye was least accurate with r2 = 0.74, an ICC of 0.67, and a CI of +/- 1.5 zones (corresponding to 75 Lmol/l). Skin pigmentation and ambient light both adversely affected noninvasive bilirubin estimation. CONCLUSION: All three non-invasive methods are well suited for estimation of serum bilirubin but show large confidence intervals. In healthy term newborns, hyperbilirubinaemia (>250 Lmol/l) can be safely ruled out by eye if jaundice does not reach the abdomen or the extremities (Kramer zones 1 and 2), with < 22 units ( < 230 micromol/l) for the Minolta JM-102, or with a cut-off of 190 microlmol/l for the Bili-Check. If these respective thresholds are exceeded, serum bilirubin concentrations should be measured.

Bilirubin↗

Betel chewing increases the skin temperature: effects of atropine and propranolol.

Although betel chewing produces sweating, facial flush and a warm sensation of the body, objective documentation of the temperature effect has not been available. In this report, the skin temperature of the ear and forehead was recorded before and during betel chewing in healthy betel chewers. Betel chewing produced a mean temperature increase of 2 degrees C and 0.5 degree C, respectively, for the ear and forehead. This hyperthermic response was almost completely abolished by atropine and partially inhibited by propranolol. The present data suggest that both sympathetic and parasympathetic mechanisms are involved in the skin thermal response to betel chewing.

Areca↗