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For some time, in-silico models to address substance transport into and through the skin are gaining more and more importance in different fields of science and industry. In particular, the mathematical prediction of in-vivo skin absorption is of great interest to overcome ethical and economical issues. The presented work outlines a strategy to address this problem and in particular, investigates in-vitro and in-vivo skin penetration experiments of the model compound flufenamic acid solved in an ointment by means of a mathematical model. Experimental stratum corneum concentration-depth profiles (SC-CDP) for various time intervals using two different in-vitro systems (Franz diffusion cell, Saarbruecken penetration model) were examined and simulated with the help of a highly optimized three compartment numerical diffusion model and compared to the findings of SC-CDPs of the in-vivo scenario. Fitted model input parameters (diffusion coefficient and partition coefficient with respect to the stratum corneum) for the in-vitro infinite dose case could be used to predict the in-use conditions in-vitro. Despite apparent differences in calculated partition coefficients between in-vivo and in-vitro studies, prediction of in-vivo scenarios from input parameters calculated from the in-vitro case yielded reasonable results., (Copyright © 2015 Elsevier B.V. All rights reserved.)

This work investigates in vitro finite dose skin absorption of the model compounds flufenamic acid and caffeine experimentally and mathematically. The mass balance in different skin compartments (donor, stratum corneum (SC), deeper skin layers (DSL), lateral skin parts and acceptor) is analyzed as a function of time. For both substances high amounts were found in the lateral skin compartment after 6h of incubation, which emphasizes not to elide these parts in the modeling. Here, three different mathematical models were investigated and tested with the experimental data: a pharmacokinetic model (PK), a detailed microscopic two-dimensional diffusion model (MICRO) and a macroscopic homogenized diffusion model (MACRO). While the PK model was fitted to the experimental data, the MICRO and the MACRO models employed input parameters derived from infinite dose studies to predict the underlying diffusion process. All models could satisfyingly predict or describe the experimental data. The PK model and MACRO model also feature the lateral parts., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Multiphoton microscopy has become popular in studying dermal nanoparticle penetration. This necessitates studying the imaging parameters of multiphoton microscopy in skin as an imaging medium, in terms of achievable detection depths and the resolution limit. This would simulate real-case scenarios rather than depending on theoretical values determined under ideal conditions. This study has focused on depth profiling of sub-resolution gold nanoparticles (AuNP) in reconstructed (fixed and unfixed) and human skin using multiphoton microscopy. Point spread functions (PSF) were determined for the used water-immersion objective of 63×/NA = 1.2. Factors such as skin-tissue compactness and the presence of wrinkles were found to deteriorate the accuracy of depth profiling. A broad range of AuNP detectable depths (20-100 μm) in reconstructed skin was observed. AuNP could only be detected up to ∼14 μm depth in human skin. Lateral (0.5 ± 0.1 μm) and axial (1.0 ± 0.3 μm) PSF in reconstructed and human specimens were determined. Skin cells and intercellular components didn't degrade the PSF with depth. In summary, the imaging parameters of multiphoton microscopy in skin and practical limitations encountered in tracking nanoparticle penetration using this approach were investigated., (Copyright © 2012 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

The aims of this work were to increase the photostability and to reduce the skin permeation of tretinoin through nanoencapsulation. Tretinoin is widely used in the topical treatment of various dermatological diseases such as acne, psoriasis, skin cancer, and photoaging. Tretinoin-loaded lipid-core polymeric nanocapsules were prepared by interfacial deposition of a preformed polymer. Carbopol hydrogels containing nanoencapsulated tretinoin presented a pH value of 6.08±0.14, a drug content of 0.52±0.01 mg g(-1), pseudoplastic rheological behavior, and higher spreadability than a marketed formulation. Hydrogels containing nanoencapsulated tretinoin demonstrated a lower photodegradation (24.17±3.49%) than the formulation containing the non-encapsulated drug (68.64±2.92%) after 8h of ultraviolet A irradiation. The half-life of the former was seven times higher than the latter. There was a decrease in the skin permeability coefficient of the drug by nanoencapsulation, independently of the dosage form. The liquid suspension and the semisolid form provided K(p)=0.31±0.15 and K(p)=0.33±0.01 cm s(-1), respectively (p≤0.05), while the samples containing non-encapsulated tretinoin showed K(p)=1.80±0.27 and K(p)=0.73±0.12 cm s(-1) for tretinoin solution and hydrogel, respectively. Lag time was increased two times by nanoencapsulation, meaning that the drug is retained for a longer time on the skin surface., (Copyright © 2011 Elsevier B.V. All rights reserved.)

The skin is a large and accessible area of the body, offering the possibility to be used as an alternative route for drug delivery. In the last few years strong progress has been made on the developing of nanoparticulate systems for specific applications. The interaction of such small particles with human skin and their possible penetration attracted some interest from toxicological as well as from drug delivery perspectives. As size is assumed to play a key role, the aim of the present work was to investigate the penetration profile of very small model particles (approximately 4 nm) into excised human skin under conditions chosen to mimic the in vivo situation. Possible application procedures such as massaging the formulation (5 to 10 minutes) were analyzed by non-invasive multiphoton- and confocal laser scanning microscopy (MPM, CLSM). Furthermore, the application on damaged skin was taken into account by deliberately removing parts of the stratum corneum. Although it was clearly observed that the mechanical actions affected the distribution pattern of the QDs on the skin surface, there was no evidence of penetration into the skin in all cases tested. QDs could be found in deeper layers only after massaging of damaged skin for 10 min. Taking these data into account, obtained on the gold standard human skin, the potential applications of nanoparticulate systems to act as carrier delivering drugs into intact skin might be limited and are only of interest for partly damaged skin.

The investigation of drug penetration into the stratum corneum (SC) by tape-stripping requires an accurate measure of the amount of SC on each tape-strip in order to determine the depth inside the SC. This study applies infrared densitometry (IR-D) to in vitro tape-stripping using the novel Squame Scan(R) 850A. The device had recently been shown to provide accurate measurements of the SC depth for tape-stripping in vivo. Furthermore, the suitability of IR-D for determining the endpoint of tape-stripping, i.e. complete SC removal, was tested. The SC depth was computed from the IR-D data of sequential tape-strips and compared to the results of a protein assay as gold standard. IR-D provided accurate depth results both for freshly excised skin and for skin stored frozen for up to 3 months. In addition, the lower limit of quantification of IR-D indicates the complete removal of the SC (less than 5% of the total SC remaining) and can be used for adjusting the number of tapes applied in situ. Therefore, IR-D is an accurate, fast and non-destructive method for SC depth determination.

The objective of this work was to develop a simple and inexpensive transdermal formulation containing Nortriptyline Hydrochloride (NTH) for smoking cessation support therapy. Hydroxypropyl-methyl-cellulose was chosen as polymer and a mixture of transdermal enhancers (selected from previous research) was incorporated. The formulations were characterised in terms of appearance, thickness, uniformity of NTH content, release and skin permeation. Release studies demonstrated controlled release for four formulations. Diffusion studies were performed through human heat separated epidermis (HHSE) using Franz Diffusion Cells (FDC). Patches provided different fluxes varying from 20.39+/-7.09 microg/(cm(2) h) to 256.19+/-94.62 microg/(cm(2) h). The penetration profiles of NTH within the stratum corneum (SC) and deeper skin layers (DSL) were established after three administration periods (3 h, 6 h, and 24 h). Skin changes induced by the application of the patches were observed by confocal laser scanning microscopy (CLSM). The highest flux obtained would provide the recommended doses for smoke cessation support therapy (25-75 mg per day) with a 2 cm x 2 cm patch or a 3.5 cm x 3.5 cm patch, respectively, without skin damage evidence.

Purpose: To investigate mechanisms of compound-corneocyte interactions in a combined experimental and theoretical approach., Materials and Methods: Experimental methods are presented to investigate compound-corneocyte interactions in terms of dissolution within water of hydration and protein binding and to quantify the extent of the concurrent mechanisms. Results are presented for three compounds: caffeine, flufenamic acid, and testosterone. Two compartmental stratum corneum models M1 and M2 are formulated based on experimentally determined input parameters describing the affinity to lipid, proteins and water. M1 features a homogeneous protein compartment and considers protein interactions only via intra-corneocyte water. In M2 the protein compartment is sub-divided into a cornified envelope compartment interacting with inter-cellular lipids and a keratin compartment interacting with water., Results: For the non-protein binding caffeine the impact of the aqueous compartment on stratum corneum partitioning is overestimated but is successfully modeled after introducing a bound water fraction that is non-accessible for compound dissolution. For lipophilic, keratin binding compounds (flufenamic acid, testosterone) only M2 correctly predicts a concentration dependence of stratum corneum partition coefficients., Conclusions: Lipophilic and hydrophilic compounds interact with corneocytes. Interactions of lipophilic compounds are probably confined to the corneocyte surface. Interactions with intracellular keratin may be limited by their low aqueous solubility.

Mathematical modeling of skin transport is considered a valuable alternative of in-vitro and in-vivo investigations especially considering ethical and economical questions. Mechanistic diffusion models describe skin transport by solving Fick's 2nd law of diffusion in time and space; however models relying entirely on a consistent experimental data set are missing. For a two-dimensional model membrane consisting of a biphasic stratum corneum (SC) and a homogeneous epidermal/dermal compartment (DSL) methods are presented to determine all relevant input parameters. The data were generated for flufenamic acid (M(W) 281.24g/mol; logK(Oct/H2O) 4.8; pK(a) 3.9) and caffeine (M(W) 194.2g/mol; logK(Oct/H2O) -0.083; pK(a) 1.39) using female abdominal skin. K(lip/don) (lipid-donor partition coefficient) was determined in equilibration experiments with human SC lipids. K(cor/lip) (corneocyte-lipid) and K(DSL/lip) (DSL-lipid) were derived from easily available experimental data, i.e. K(SC/don) (SC-donor), K(lip/don) and K(SC/DSL) (SC-DSL) considering realistic volume fractions of the lipid and corneocyte phases. Lipid and DSL diffusion coefficients D(lip) and D(DSL) were calculated based on steady state flux. The corneocyte diffusion coefficient D(cor) is not accessible experimentally and needs to be estimated by simulation. Based on these results time-dependent stratum corneum concentration-depth profiles were simulated and compared to experimental profiles in an accompanying study.

The literature exhibits high variation in results from drug permeation experiments across human skin. Our purpose was to investigate the influence of human skin specimens, consisting of different skin layers and resulting from different skin preparation techniques, on the in vitro permeation of a model drug, i.e. flufenamic acid (FFA). FFA permeation across human (1) trypsin-isolated stratum corneum, (2) heat-separated epidermis and (3) dermis, (4) dermatomized skin and (5) full-thickness skin (FTS) from either a hydrophilic or lipophilic donor was investigated in Franz-type diffusion cells. Cumulative permeated drug amounts were plotted versus time, and a fit to Fick's 2nd law of diffusion was performed. Since performing skin diffusion experiments in the laboratory is time consuming and expensive, especially when using FTS, we also investigated the possibility of calculating the resistances of composite skin layers from the diffusion resistances of the individual skin layers. Due to short lag time, practical handling and economic preparation, heat-separated epidermis appears to be superior in human skin in vitro permeation experiments compared to separated stratumcorneum sheets, dermatomized skin and FTS. Furthermore, we found a good correlation between calculated and experimental resistances which underlines that calculation of the total diffusion resistance of composed skin preparations from resistances of individual skin layers is legitimate and useful. Considering our findings, improved interpretation of literature data and more consistent results for future permeation experiments are possible., ((c) 2008 S. Karger AG, Basel)

Essential oils are widely used in pharmaceutical and cosmetic preparations e.g. as fragrance, active ingredient or penetration enhancer. However, reports on skin absorption are rare. Therefore, the aim of our study was to investigate the capability of terpinen-4-ol, the main compound of Australian tea tree oil (TTO), to permeate human skin. In static Franz diffusion cells permeation experiments with heat separated human epidermis were carried out using infinite dosing conditions and compared to liberation experiments. The flux values of three different semisolid preparations with 5% TTO showed the rank order semisolid O/W emulsion (0.067 microl/cm2 h) > white petrolatum (0.051 microl/cm2 h) > ambiphilic cream (0.022 microl/cm2 h). In comparison to the flux value obtained with the native TTO (0.26 microl/cm2 h), the flux values are remarkably reduced due to the lower amount of terpinen-4-ol. P(app) values for cream (2.74+/-0.06 x 10(-7) cm/s) and native TTO (1.62+/-0.12 x 10(-7) cm/s) are comparable whereas white petrolatum (6.36+/-0.21 x 10(-7) cm/s) and semisolid O/W emulsion (8.41+/-0.15 x 10(-7) cm/s) demonstrated higher values indicating a penetration enhancement. No relationship between permeation and liberation was found.

The suitability of transepidermal water loss (TEWL) measurements in vitro as a barrier integrity test for human heat separated epidermis (HSE) was investigated. A model system consisting of a Teflon membrane mounted in Franz diffusion cells (FDC) filled with phosphate buffer saline (PBS) was set up. The membrane was used intact and punctured with a needle (up to five holes). After each puncturing the TEWL was measured. Only the TEWL of intact and punctured membrane differed significantly regardless of the number of holes. From three donors intact human HSE and punctured HSE were compared and no significant difference of the TEWL was found. Permeation experiments with flufenamic acid (FFA) showed a significantly higher diffusion rate through punctured HSE. TEWL and drug permeation were compared for skin stripped three, seven and 15 times prior to heat separation to an intact control group. Only the TEWL values of intact HSE and HSE stripped 15 times differed significantly. However, seven and 15 times stripping resulted in significantly higher diffusion rate. In conclusion, TEWL measurements can detect severe damage of the stratum corneum (SC) but not small changes, which nevertheless may already influence drug diffusion. Therefore, TEWL measurements appears to be of limited use as a barrier integrity test for human HSE in in vitro test systems.

The effect of the inclusion of flufenamic acid in poly(lactide-co-glycolide) nanoparticles on the transport of flufenamic acid into excised human skin was investigated. Penetration and permeation data were acquired using two different in vitro test systems: the Saarbrucken penetration model, where the skin acts as its own receptor medium, and the Franz diffusion cell, where the receptor medium is a buffer solution. For the stratum corneum, no differences were found between nanoencapsulated and free drug. Drug accumulation in the deeper skin layers and drug transport across human epidermis were slightly delayed for the nanoencapsulated drug compared to the free drug after shorter incubation times (<12 h). In contrast, after longer incubation times (>12 h), the nanoencapsulated drug showed a statistically significantly enhanced transport and accumulation (p < 0.05). Additionally, nanoencapsulated flufenamic acid was visualized by multiphoton fluorescence microscopy. Particles were found homogeneously distributed on the skin surface and within the dermatoglyphs, but no nanoparticles were detected within or between the corneocytes., (Copyright (c) 2006 S. Karger AG, Basel.)

The effect of various vehicles (polyacrylate gels and wool alcohol ointments) on the penetration of flufenamic acid into excised human skin was investigated. Physico-chemical properties of the formulations were examined and discussed. Penetration data was gathered using two different in vitro test systems: the Saarbruecken penetration model (SB-M) and the Franz diffusion cell (FD-C). With wool alcohol ointments, drug concentration in the formulation was the decisive parameter for drug liberation and penetration. The incorporation of water into wool alcohol ointment led to increased drug amounts within the deeper skin layers (DSL), especially after longer incubation times. The drug concentration within the stratum corneum (SC) was not influenced by the bleeding effect of lipophilic, liquid components of the various wool alcohol ointments. With polyacrylate gels different results for liberation and penetration were observed. These results could be related to the effects of the drug concentration within the formulation and the penetration enhancers incorporated into the gels. Especially the effects of penetration enhancers clearly illustrated that liberation experiments do not predict the situation in the skin, but make experiments with a biological barrier essential. The high water content of the gels led to hydration of the skin specimen for the SB-M and the FD-C and therefore, in contrast to previous findings, comparable data were obtained in the penetration studies with both models. Furthermore, the quasi steady-state drug amount in the SC could be calculated for all formulations using an equation derived from a Michaelis-Menten kinetics. The data from both test systems were linearly correlated to each other. In addition, a direct linear relationship between the SC drug amount and the drug amount in the DSL was found as long as the quasi steady-state drug amount in the SC was not reached. A combination of all results might offer the chance to reduce the costs and to simplify the development of a new drug formulation., (Copyright 2004 Elsevier B.V.)

Investigations to determine pH profiles across human stratum corneum (SC), in vivo as well as in vitro, were carried out using the tape stripping technique and a flat surface pH electrode. This method was extended to the deeper skin layers (=viable epidermis+dermis; DSL) in vitro. Statistically significant changes in the pH values were detected in the SC between in vivo and in vitro investigations and also between male and female skin in vivo. For the DSL, no gender-dependent differences in pH were observed. While the results achieved for the SC are in accordance with data already published in the literature, the values for the DSL were surprising: An alkaline pH, with a steep increase of about two pH units in the first 100 microm of the DSL and a plateau of this level was thereafter detected. Research was also done to examine the influence of different in vitro test systems on the results of pH measurements across the skin. A permeation model (Franz diffusion cell; FD-C) and a penetration model (Saarbruecken penetration model; SB-M) were compared. Experiments were carried out concerning the incubation time as well as the pH of the acceptor solution in the FD-C. Independent of the test system used, no change in the pH profiles could be observed for the SC, but a strong effect of the acceptor medium and its pH on the pH profiles across the DSL could be demonstrated using the FD-C, which showed itself partly after 30 min in statistically significant differences between incubated and formerly frozen skin. The results after the use of buffer solutions with different pH values, the pH across the DSL seemed to come into line with the one of the buffer solution, which was investigated for acidic as well as alkaline pH values. The results obtained with the flat surface pH electrode were confirmed using two different dyes: the pH-dependent fluorescent dye carboxy-SNARF-1 and the pH indicator bromthymolblue.

The stratum corneum of various donors differs in particular in the composition of the lipoidal phase. Considering the drug amounts penetrating into the stratum corneum a simple methodology to correlate these differences in the stratum corneum composition with the drug amounts detectable within the stratum corneum is desirable. Penetration experiments investigating several incubation times were carried out with three different skin flaps using the Saarbruecken penetration model and the lipophilic model drug flufenamic acid. The drug amounts within the stratum corneum were obtained with the tape-stripping technique, while the drug amounts present in the deeper skin layers were achieved by cryosectioning. The stratum corneum/water-partition coefficient was determined with the same three skin flaps to characterize the lipoidal stratum corneum phase in general, and the differences were attributed to the different amounts of ceramides and sterols. In addition, for the lipophilic drug flufenamic acid, a direct linear correlation was found between the stratum corneum/water-partition coefficients and the drug amounts penetrated into the stratum corneum for all investigated time intervals (correlation coefficients of r(30 min) = 0.998, r(60 min) = 0.998 and r(180 min) = 0.987). In contrast to the stratum corneum/water-partition coefficients, the determination of a corresponding relationship for the stratum corneum and the deeper skin layers failed due to the reason that steady-state conditions could not be achieved for the deeper skin layers during the investigated time intervals. In summary, the stratum corneum/water-partition coefficients offer the possibility to predict drug amounts within the stratum corneum of different donor skin flaps without a time consuming determination of the lipid composition of the stratum corneum., (Copyright 2002 Wiley-Liss Inc. and the American Pharmaceutical Association)

Previously, the interest in in vivo/in vitro correlations in the dermal field of research has increased steadily. Unfortunately, in most cases the skin from different human donors was taken for in vivo and in vitro experiments, which led to problems concerning the interindividual variability of the skin. Therefore, we established a methodology to utilize the same skin for both sets of data. In time dependency, drug amounts in the stratum corneum and the deeper skin layers were determined from eight donors using the same skin area for in vivo and the corresponding in vitro tests. Penetration experiments were carried out with the lipophilic drug flufenamic acid dissolved in wool alcohols ointment as the model formulation, which was administered to the skin under "infinite dose" conditions. At different time points prior to starting the surgery, the drug preparation was applied topically on the edges of the skin area, which was planned for excision using Finn chambers. After anesthetizing the patient and disinfecting the operation area, the incubated skin pieces were cut off first and immediately frozen to limit further drug diffusion. In vitro experiments were performed on the remaining skin flap, using two different test systems, a penetration and a permeation model. At the end of all experiments (in vivo and in vitro) the skin specimens were segmented horizontally and the drug was extracted and quantified. The in vivo and in vitro drug amounts in the stratum corneum and the deeper skin layers, respectively, were compared. The inevitable use of unknown volumes of disinfectant in vivo (medical reasons) might be the reason why a correlation failed for the stratum corneum. Nevertheless, for both in vitro test systems a direct linear correlation was found for the deeper skin layers, which showed slopes of a = 3.2272 +/- 0.3933 (penetration model vs in vivo) and a = 1.7776 +/- 0. 1926 (permeation model vs in vivo). This difference demonstrates the varying influence of the test systems and represents a factor about which in vivo and in vitro data are shifted against each other. As far as the model drug flufenamic acid is concerned, this methodology represents a tool to predict drug penetration into the deeper skin layers in vivo after carrying out corresponding in vitro experiments. Therefore, the potential is given to reduce the number of in vivo experiments, the risk for the volunteers, and the costs for the development of new drug preparations.

In a comparative study, two different in vitro cutaneous test systems were examined: (1) The Franz diffusion cell (FD-C), a test system to study drug permeation through the skin and to obtain data like steady state flux and lag time as well as permeability and diffusion coefficients. (2) The Saarbruecken penetration model (SB-M), a test system to investigate drug penetration into different skin layers and after varying incubation times to acquire values about the quasi steady state drug amounts in the stratum corneum (SC). Three drug concentrations (0.9, 0.45 and 0.225%) of a lipophilic model drug preparation, flufenamic acid in wool alcohols ointment, were applied on the skin's surface using 'infinite dose' conditions. Trypsin-isolated SC, heat-separated epidermis, full-thickness skin and reconstructed human skin (RHS) served as skin membranes in the FD-C, while the SB-M experiments were only carried out using full-thickness skin. Increasing steady state flux data and m(ss) values (steady state drug amount in the SC) were detectable after the application of rising drug amounts. Concerning the permeability of the used skin membranes in establishing barrier properties, the following rank order was observed: RHS>SC> or =epidermis>full skin. The flux data of the FD-C experiments for isolated SC, separated epidermis and RHS were linearly related with the m(ss) values of the SB-M investigations, allowing a direct comparison of permeation with penetration parameters. Concerning the drug amount in the SC, previous investigations succeeded in the establishment of an in vivo/in vitro correlation. Based on the results presented here, the prediction of drug amounts present in the SC after different incubation times in vivo is now possible after penetration as well as permeation experiments using the lipophilic model drug preparation, flufenamic acid in wool alcohols ointment.

Purpose: Two in vitro test systems used to study drug penetration into human skin--the Franz diffusion cell (FD-C) and the Saarbruecken penetration model (SB-M)--were evaluated, and the results were compared with data gained under analogous in vivo conditions., Methods: Excised human skin was used in all in vitro experiments. Flufenamic acid dissolved in wool alcohols ointment, was chosen as a model drug, and the preparation was applied using 'infinite dose' conditions. To acquire quantitative information about the drug penetration, the skin was segmented into surface parallel sections at the end of each experiment, first by tape stripping the stratum corneum (SC), and second by cutting the deeper skin layers with a cryomicrotome. The flufenamic acid was extracted from each sample and assayed by high performance liquid chromatography (HPLC). For in vivo experiments, only the tape stripping technique was used., Results: a) Drug penetration into the SC: In both in vitro test systems the total drug amounts detected in the SC were found to increase over the different incubation times. Similar conditions were obtained in vivo, but on a lower level. Using Michaelis-Menten kinetics, the m(max) value was calculated for the skin of two donors. The relations of the m(max) values for the FD-C and the SB-M closely correspond (1.26 [donor 1] and 1.29 [donor 2]). A direct linear correlation of the drug amount in the SC and the time data were found for in vivo with both in vitro test systems. b) Drug penetration into the deeper skin layers: The detected drug amounts in the deeper skin layers continuously increased with the incubation time in the SB-M, while in the FD-C, only very small drug amounts were observed after incubation times of 30 and 60 minutes. It was also noticed, that the drug amounts rose steeply at time points 3 and 6 hours. Additional studies showed a remarkable penetration of water into the skin from the basolateral acceptor compartment in the FD-C. This could explain the different drug transport into the deeper skin layers between the two in vitro test systems., Conclusions: Both in vitro models showed comparable results for the drug penetration into the SC and a robust correlation with in vitro data. Different results were obtained for the deeper skin layers. Whether a correlation between in vitro and in vivo data is also possible here has to be investigated by further experiments.

This is a report on thirty six patients with male pattern baldness, surgically treated with one or two parieto-occipital flaps according to Juri. In six patients with isolated occipital baldness, specially designed flaps were used. Since male baldness usually is genetically determined and hairroots of the temporo-occipital scalp remain active throughout life, one can expect that they continue growing within the transposed flaps. There are three indications for parieto-occipital flaps: 1. psychological burden of the patient, 2. genetic background in the family of young patients, and 3. prior punch hair grafts whose roots have atrophied.

The authors report a case of ulnar nerve compression caused by an abductor digiti minimi longus. After resection of the muscle the patient recovered well.

Serial excisions of large defined burn scars often improve the aesthetic appearance as well as reduce subjective complaints such as itching and sensory disturbance. The natural elasticity of undamaged skin allows stepwise excision of areas up to the size of a hand. Ideally, a linear scar the length of the original scar area results. Shrinkage, contour and pigment deficiencies, often seen after skin grafting, are not a problem.