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Objective: Topographic and blood vessel architecture study of the parietal area and distal regional pool of the superficial temporal artery (STA) to assess the possibility of revascularized cranium vault bone autograft formation., Material and Methods: For the topographic and anatomical study, 30 non-fixed corpses (17 male and 13 female) were selected, the average age of which was 59±5 years. In the anamnesis and catamnesis, there were no indications of trauma or other pathology of the head and neck, including vascular. STA was contrasted with a non-radiocontrast dye (brilliant green) with the introduction of the dye into the STA with preliminary ligation of the frontal branch of the STA. The area of blood supply to soft tissue and bone structures was studied. The angioarchitectonics of the parietal region was studied, the feeding vessel of the studied flap was identified., Results: The obtained anatomical landmarks for the collection of CPFP flap make it possible to form a flap with high accuracy and minimize the morbidity of the donor area.

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., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS part of Springer Nature.)

Background: Surgical resection of maxillary tumors can result in defects that can be difficult to reconstruct by conventional means due to the complex functional and anatomic nature of the midface and lack of regional bone flap options in the head and neck. Many reconstructive methods have been used to repair maxillary defects, but the ideal technique for the reconstruction of hemi-maxillectomy defects in growing pediatric patients has yet to be determined., Methods: The authors present a rare pediatric patient with melanotic neuroectodermal tumor of infancy resulting in a hemi-maxillectomy defect after resection that was reconstructed using a pedicled vascularized composite flap consisting of temporalis muscle, pericranium, and parietal bone., Results: The patient achieved successful long-term bony reconstruction of his right maxilla with this flap. Stable skeletal fixation with adequate orbital support was maintained over a >3-year follow-up period., Conclusion: A vascularized composite parietal bone flap is a reliable reconstructive option for reconstruction of large maxillectomy defects providing low donor-site morbidity, adequate globe support, excellent long-term skeletal stability, and malar symmetry in rapidly growing pediatric patients. Successful reconstruction for a rare patient with maxillary melanotic neuroectodermal tumor of infancy requiring hemi-maxillectomy was demonstrated with >3-year follow-up.

Hyaluronic acid (HA) filler injection is widely used for soft-tissue augmentation. Complications associated with HA filling are not uncommon; however, HA-induced alopecia is a rarely reported complication that could result in severe secondary psychological trauma. The etiology, clinical traits, treatment strategies, outcomes, and possible reversibility of HA-induced alopecia have not been characterized. Here, we report a case in which bilateral temple injections of 6.5 mL of HA led to persistent pain over the left scalp for several days. Although the pain was relieved at day 9 after 600 U of hyaluronidase were injected in the left temple, the patient developed localized alopecia at the left temporoparietal region with central skin necrosis at day 15. After topical applications of recombinant bovine basic fibroblast growth factor gel and 2% minoxidil spay, the necrotic skin wound was healed at day 42. Hair regrowth and normal hair density were restored at day 74. Analyses of Doppler ultrasound examinations and histopathology of the skin biopsy suggested that mild ischemia of the left temporoparietal region led to reversible alopecia, while the permanent hair loss in the left parietal area was associated with severe skin ischemia. Therefore, the key to treatment would be to focus on the effective correction of severe ischemia-induced skin necrosis to prevent permanent hair loss. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

In the late 18th and early 19th centuries, Dr. John Howship, a pioneering British surgeon, described the clinical features and pathophysiology of various surgical disorders of the human body. His critical contributions to pediatric neurosurgery came in 1816 when he first described the features of an important childhood condition following head trauma, what he referred to as parietal bone absorption. This condition as depicted by Dr. Howship was soon to be christened by later scholars as traumatic cephalhydrocele, traumatic meningocele, leptomeningeal cyst, meningocele spuria, fibrosing osteitis, cerebrocranial erosion, and growing skull fracture. Nevertheless, the basic features of the condition as observed by Dr. Howship were virtually identical to the characteristics of the above-mentioned disorders. This article describes the life and accomplishments of Dr. Howship and his contributions to the current understanding of growing skull fracture.

It remains unknown whether bone graft vascularity influences calvarial healing. The purposes of this study were (1) to develop a model to study nonvascularized and vascularized calvarial grafts as well as (2) to compare effects of bone graft vascularity on calvarial healing. Bilateral calvarial defects were created in 26 Wistar rats. The defects were left empty within 1 parietal region. On the contralateral side, the defects were partially closed with native parietal bone (control group, n = 6), nonvascularized (N-V, n = 10), or vascularized bone grafts (VAS, n = 10). The vascularized grafts were supplied by perforating dural arterioles. Bone mineralization and healing patterns from serial microcomputed tomographic scans were compared within and across the groups using parametric and nonparametric tests. Differences in bone mineral content across sides were significant between the groups at weeks 6 (P = 0.016) and 12 (P = 0.025). Bone formation was greater within both the control and VAS groups versus the N-V group at weeks 6 and 12 (P < 0.05). Healing patterns differed between the groups (P < 0.05), progressing through islands of new bone formation within the control and VAS groups while limited to defect margins on the N-V graft side. In conclusion, a bilateral calvarial defect model was established to study bone graft vascularity. Bone quantity and healing patterns differed in the presence of the nonvascularized versus vascularized grafts. Although the calvarial defect model is often applied within the plastic surgery literature to study bone substitutes, greater understanding of basic mechanisms influencing calvarial healing is first needed to avoid confounding results.

Background: Although bone repair is often a relatively rapid and efficient process, many bone defects do not heal. Because an adequate blood supply is essential for new bone formation, we hypothesized that augmenting new blood vessel formation by increasing the number of circulating vasculogenic progenitor cells (PCs) with AMD3100 and enhancing their trafficking to the site of injury with recombinant human parathyroid hormone (rhPTH) will improve healing., Methods: Critical-sized 3-mm cranial defects were trephined into the right parietal bone of C57BLKS/J 6 mice (N = 120). The mice were divided into 4 equal groups (n = 30 for each). The first group received daily subcutaneous injections of AMD3100 (5 mg/kg). The second group received daily subcutaneous injections of rhPTH (5 mg/kg). The third group received both AMD3100 and rhPTH. The fourth group received subcutaneous injections of saline. Circulating vasculogenic PC numbers, new blood vessel formation, and bony regeneration were assessed. Progenitor cell adhesion, migration, and tubule formation were assessed in the presence of rhPTH and AMD3100., Results: Flow cytometry demonstrated that combination therapy significantly increased the number of circulating PCs compared with all other groups. In vitro, AMD3100-treated PCs had significantly increased adhesion migration, and tubule formation was assessed in the presence of rhPTH. Combination therapy significantly improved new blood vessel formation in those with cranial defect compared with all other groups. Finally, bony regeneration was significantly increased in the combination therapy group compared with all other groups., Conclusions: The combination of a PC-mobilizing and traffic-enhancing agent improved bony regeneration of calvarial defects in mice.

Objective: This study examined the effect of basic fibroblast growth factor (FGF)-2 with an absorbable collagen sponge on angiogenesis and bone regeneration in rat calvarial critical-sized bone defects using microcomputed tomography., Methods: Forty 7-week-old male Fischer rats were used. The symmetrical critical-sized calvarial bone defects (5 mm diameter) were created. An absorbable collagen sponge with or without FGF-2 (0.1% or 0.3%) was implanted into each bone defect., Results: Blood vessel and bone volumes were significantly higher in the 0.3% FGF-2 group compared with the control and 0.1% FGF-2 groups on day 28. Significantly more osteoblast- and osteoclast-like cells were seen in the 0.3% FGF-2 group., Conclusions: Thus, FGF-2 increased blood vessel and bone formation in rat calvarial critical-sized bone defects.

Objectives: Restoration of an adequate blood supply is essential for the bone healing process and is key to the success of bone augmentation procedures. In this study, we evaluated angiogenesis in rat calvarial flat bone defects using in vivo microfocus computed tomography (micro-CT)., Materials and Methods: Twenty rats were used. The calvarium was exposed and calvarial bone defects of critical (5-mm diameter) and non-critical (2.7-mm diameter) sizes were prepared. Bone regeneration and angiogenesis were evaluated by image analysis using micro-CT and histological examination., Results: Critical- and non-critical-sized calvarial bone defects showed bone regeneration and angiogenesis around the midsagittal suture. Critical-sized calvarial bone defects showed approximately 1.2% reossification of the original surgical defect, whereas the non-critical-sized defects showed approximately 43.3% reossification at day 28. Furthermore, angiogenesis was observed later in the critical-sized calvarial bone defects (about 38.2%), whereas angiogenesis was observed early in the non-critical-sized calvarial bone defects (about 75.5%) at day 28. New blood vessel networks were observed around defects of both sizes., Conclusions: Angiogenesis preceded bone regeneration around critical- and non-critical-sized calvarial bone defects. Angiogenesis led to full bone formation in non-critical-sized defects., (© 2012 John Wiley & Sons A/S.)

Hyperbaric oxygen (HBO) therapy is used to treat or prevent tissue necrosis in patients undergoing irradiation. Many such patients require reconstructive surgery, but little is known of the effects of HBO on bone vascularization and regeneration. In this study, copolymer poly(l-lactide-co-1,5-dioxepan-2-one) (poly(LLA-co-DXO)) scaffolds were implanted into critical-sized calvarial defects in Wistar rats. The animals were randomly allotted to hyperbaric or normobaric oxygen groups. The treatment group received five sessions weekly for 90 min at increased atmospheric pressure, for up to 4 weeks. Samples were retrieved at weeks 2 and 8, i.e. after a total of 10 and 20 sessions, respectively. The samples were analyzed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) and histology at week 2, and radiographically and histologically at week 8. At week 2, defects treated with HBO exhibited greater numbers of cells positive for the endothelial marker CD31, up-regulated gene expression of osteogenic markers, and down-regulated expression of pro-inflammatory cytokines. At week 8, radiographic examination revealed that calvarial defects subjected to HBO exhibited a higher percentage of radiopacities than normobaric controls, and histological examination disclosed enhanced bone healing. These results confirmed that HBO treatment was effective in stimulating vascularization and bone formation in rat calvarial defects., (Copyright © 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Enlarged parietal foramina (>5 mm) is an extremely rare developmental defect of the parietal bone, which is distinguished from the normal small parietal foramina, as genes associated with this entity have been identified, suggesting that it is hereditary in nature. We describe a dry skull of a 35-year-old female, with enlarged parietal foramina symmetrically situated bilaterally, oval in shape, measuring 4.5 × 9.3 mm (right) and 4.9 × 9.2 mm (left) in size. The foramina coexisted with multiple Wormian bones in several sites of the skull. On the inner parietal bone surface, the anterior, posterior and lateral foramina's rims carried grooves, which were continuous with the middle meningeal vessels' branches, indicating that a rich vascular network existed around the foramina. These vascular grooves also notched the external table at the margin of the foramina, which suggests a potential communication between the meningeal and the scalp vessels. In addition, this vascular variation should be taken into consideration when performing surgical interventions in the area, because the large vascular supply to the foramina is a possible source of extensive bleeding. Moreover, the interaction of intracranial and extracranial veins and the fact that the blood flows in them in both directions, as they are valveless, could represent a possible pathway for infections to spread in the cranial cavity.

Background: Although bone repair is a relatively efficient process, a significant portion of patients fail to heal their fractures. Because adequate blood supply is essential to osteogenesis, the authors hypothesize that augmenting neovascularization by increasing the number of circulating progenitor cells will improve bony healing., Methods: Bilateral full-thickness defects were created in the parietal bones of C57 wild-type mice. Intraperitoneal AMD3100 (n = 33) or sterile saline (n = 33) was administered daily beginning on postoperative day 3 and continuing through day 18. Circulating progenitor cell number was quantified by fluorescence-activated cell sorting. Bone regeneration was assessed with micro-computed tomography. Immunofluorescent CD31 and osteocalcin staining was performed to assess for vascularity and osteoblast density., Results: AMD3100 treatment increased circulating progenitor cell levels and significantly improved bone regeneration. Calvarial defects of AMD3100-treated mice demonstrated increased vascularity and osteoblast density., Conclusions: Improved bone regeneration in this model was associated with elevated circulating progenitor cell number and subsequently improved neovascularization and osteogenesis. These findings highlight the importance of circulating progenitor cells in bone healing and may provide a novel therapy for bone regeneration.

The superficial temporal artery (STA)-based flaps have been used for different reconstructive purposes. These operations may cause facial nerve injury. The variations of the STA and its relation to temporal branch of the facial nerve (TBFN) were evaluated in this study. Thirteen cadavers with 26 STA and TBFN have been dissected. The bifurcation of STA was found to be 60% above the superior border of the zygomatic arc and 40% below this level. The mean lengths of frontal and temporal branches (FB and TB) of STA were 11.5 and 11.4 cm, respectively. The mean numbers of perforators of FB and TB to deep plane were 1.30 and 1.34, respectively. The mean diameter of STA at the superior border of zygomatic arc was 2.5 mm. The mean diameters of TB and FB at the level of bifurcation were 1.8 mm and 2.0 mm, respectively. The mean number of TBFN at the level of zygomatic arc was 3.70. The mean distance of the first and last branching of TBFN to tragus was found to be 24 mm. The mean number of TBFN at the level of the middle orbita was found to be 2.7. The mean distance of first and last branches of TBFN to the lateral orbital rim was 12 and 24 mm, respectively. The results found in this study may increase the accuracy of flaps based on STA and decrease the risk of facial nerve paralysis during these operations.

Object: There are few systematic investigations of the dissected surgical anatomy of the diploic venous system (DVS) in the neuroanatomical literature. The authors describe the DVS relative to different common neurosurgical approaches. Knowledge of this system can help avoid potential sources of unacceptable bleeding and may impact healing of the cranium., Methods: Using a high-speed drill with a 2-mm bit, the authors removed the outer layer of the compact bone in the skull to expose the DVS in 12 formalin-fixed cadaver heads. Pterional, supraorbital, and modified orbitozygomatic craniotomies were performed to delineate the relationship of the DVS., Results: The draining point of the frontal diploic vein (FDV) was located near the supraorbital notch. The draining point of the anterior temporal diploic vein (ATDV) was located in all pterional areas; the draining point of the posterior temporal diploic vein (PTDV) was located in all asterional areas. The PTDV was the dominant diploic vessel in all sides. The FDV and ATDV could be damaged during supraorbital, modified orbitozygomatic, and pterional craniotomies. The anterior DVS connected with the sphenoparietal and superior sagittal sinus (SSS). The posterior DVS connected with the transverse and sigmoid sinuses and was the dominant diploic vessel in all 24 sides. Of all the major diploic vessels, the location and pattern of distribution of the FDV were the most constant. The parietal bone contained the most diploic vessels. No diploic veins were found in the area delimited by the temporal squama., Conclusions: The pterional, orbitozygomatic, and supraorbital approaches place the FDV and ATDV at risk. The major anterior diploic system connects the SSS with the sphenoparietal sinus. The posterior diploic system connects the SSS with the transverse and sigmoid sinuses.

The morphogenesis and evolution of the cranium are the result of structural interactions among its components, leading to covariance between traits. Soft and hard tissues exert a reciprocal physical and physiological influence, leading to the final phenotype in terms of both ontogeny and evolution. The middle meningeal vessels, interfacing the brain and the braincase, provide an opportunity to study this network, even in extinct human species. Between and within-species variations of the vascular patterns may be mechanically influenced by the cranial morphology (structural hypothesis) or else by actual physiological responses and adaptations, mostly related to oxygen supply and/or thermoregulation (functional hypothesis). In this analysis, we tested the relationship between neurocranial shape and the general morphology of the traces of the middle meningeal vessels in a modern human population, by using landmark-based geometrical models. Although there are some neurocranial differences between groups with different vascular patterns, they are very small or not statistically significant. Only the depth of the imprints may be more influenced by the endocranial morphology. Even if the neurocranial differences among extinct hominids are definitely larger than those within the modern species, the present analysis suggests that it is unlikely that the differences in vascular patterns among the human species are related only to the effects of different neurocranial geometry. This is rather relevant when the marked development of the meningeal network in Homo sapiens is taken into account, compared with the patterns described for nonmodern human species.

Introduction: Intradiploic cavernous hemangioma of the skull is seen rarely. Intradiploic cavernous hemangiomas arise from the intrinsic vasculature of the bone and generally picks up at the fourth and fifth decades., Discussion and Conclusion: In this report, we present a 16-year-old child who was admitted with a swelling lesion in the right parietal bone and diagnosed as cavernous hemangioma after total extirpation.

Here we describe an 8-year old male child with homozygous sickle cell disease who presented with left parietal skull bone infarction and, during his stay in hospital, developed a right femoral deep vein thrombosis (DVT), both uncommon complications of the disease. He initially presented with severe headache and generalised tenderness of the calvarium, which did not respond to simple analgesics. Scalp swelling in and around the left frontal (including left orbit) and parietal regions developed 24 h after presentation. The differential diagnosis included incipient stroke, acute sickle bone crisis and osteomyelitis, with a possible complication of epidural haematoma, or orbital compression syndrome. An initial exchange blood transfusion did not lead to appreciable reduction in opiate requirements. Significant symptomatic relief was attained only after a second exchange transfusion. The DVT developed at the site of catheterisation (right femoral vein), and this was treated with maximal doses of enoxaparin followed by warfarin. The child is now well and off anti-coagulants. In this article we present a review of the literature and discuss possible mechanisms of these complications in our patient.

Orbital wall infarction and subperiosteal haematomas are unusual manifestations of sickling disorders. Here we report an 11-year-old girl with sickle cell anaemia having multiple skull infarctions including the orbital bony structures associated with subperiosteal haematomas. The diagnosis was made by MRI, which showed bone marrow changes and associated haemorrhagic collections. The patient was successfully managed without surgical intervention.

Objective: The early effect of platelet-rich plasma (PRP) on bone regeneration in combination with dense biphasic hydroxyl apatite (HA)/beta-tricalcium phosphate (TCP) particles (ratio 60%/40%) was evaluated in rat cranial defects with a diameter of 6.2 mm. We hypothesize that PRP exerts its beneficial effect on bone regeneration within the first and second week after application in a bone defect combined with an osteoconductive material., Materials and Methods: Forty-five rats were used in the study, in which always one cranial defect was created. The defects were filled with HA/beta-TCP particles and HA/beta-TCP particles combined with PRP gel. Some defects were also left unfilled as control. One and two weeks after surgery specimens were retrieved for light microscopy [hematoxylin-eosin, trichrome staining (Masson modification Goldner) and basic fuchsin-methylene blue] and micro-CT analysis to evaluate bone formation and neovascularization. One-way analysis of variance was performed on the raw data obtained from micro-CT analyses., Results: The histological evaluation showed no effect of PRP on bone formation and neovascularization for both implantation times. In the first week, the defect closure was evaluated subjectively to be between 10% and 50% in all samples, whereas no difference among the groups appeared to occur. After 2 weeks, complete bridging of the original bone defect was observed for most of the empty defects, as well as for the defects that contained HA/beta-TCP particles. The trichrome staining revealed no difference in the number of blood vessels between the PRP and non-PRP groups for both implantation times. The osteoconductive nature of dense HA/beta-TCP particles was confirmed, as the bone formation was guided by their outer surfaces and resulted in a larger amount of newly formed bone in comparison with the empty defects. The quantitative micro-CT analysis demonstrated a statistically significant difference in new bone formation between the empty defects and defects filled with particles after 1 week of implantation, but there was no difference between the non-PRP and PRP groups. In at the second week, no difference in bone formation among all groups was observed, whereas even the non-filled control defects were almost completely closed., Conclusions: A 6.2 mm cranial defect is not a critical-sized defect in rats. Rat PRP had no effect on the early stages of bone healing in addition to an osteoconductive material. Dense HA/beta-TCP particles showed a beneficial effect on bone formation already after 1 and 2 weeks of implantation in non-critical-sized cranial defects in rats.

The retroauricular region provides adequate tissue of excellent color and texture match for the reconstruction of small- and medium-sized facial defects. In this study, parietal branch of the superficial temporal artery (STA) was used as the pedicle for the retroauricular island flap. Anastomoses between the parietal branch of STA, occipital artery, and contralateral STA were observed to deliver adequate nutritional blood supply to the flap. Total upper eyelid defect in 1 case, malar defect in 1 case, and forehead defects of various sizes in 4 cases were included in our study. Sizes of the flaps varied from 4 x 4.5 cm to 6 x 8 cm (mean 4.7 x 6.6 cm). All cases had venous congestion for 2-4 days (mean 3.4 days). Only 1 case experienced a superficial dermal necrosis of 1 x 3 cm in size in the distal part of the flap. Esthetic and functional results were satisfactory during the 1- to 14-month (mean 7) follow-up period. This flap is thought to be advantageous for the repair of defects and traumas of the forehead and upper eyelid as the pedicle does not develop torsion and dissection is easy.

The authors report on the case of a 28-year-old woman presenting with an intraosseous arteriovenous fistula (AVF) located in the left parietal bone. The fistula was formed by direct arteriovenous shunts connecting branches of the left middle meningeal and superficial temporal arteries with a parietal diploic vein. Drainage occurred through both the external and internal jugular venous systems. Therapy consisted of combined surgical and endovascular approaches. The results of a pathological examination of the resected AVF showed mild enlargement of the diploic space. The angiographic appearance, pathological anatomy, and treatment of this rare lesion are discussed, as is a possible relationship between diploic AVFs and the development of aneurysm bone cysts.

Objectives: Cranial vault is widely used in experimental models on membranous bone healing in general, guided bone augmentation (GBA) studies being one example. To our knowledge, however, few studies on the characteristics of the untreated calvaria regarding bone density, vessel topography, and their intra/interindividual variations and associations are available. The aims of this investigation were to (1) map the large vessel topography of the skull vault, (2) describe the parietal bones of the adult rabbit histologically and morphometrically, and (3) histologically compare untreated parietal bone with parietal bone that had been treated with a GBA device., Material and Methods: Ten adult untreated rabbits were microangiographed. General anesthesia was induced and the mediastinum was opened. Heparin and lidocaine were injected in the aorta followed by perfusion with India ink. After death, en bloc biopsies of the skull vault including the overlying soft tissues and dura mater were taken. The specimens were cleared with the Spalteholtz technique, microscopically examined, and digitally imaged. Thereafter, circular biopsies were harvested to obtain decalcified sections. In addition, sections from 14 GBA-treated rabbit skulls (of the same race, sex and age as the untreated animals) served as reference specimens for comparison. Histomorphometric examinations were carried out., Results: In the cleared specimens, all parietal bones were found to be supplied by one major branch of the meningeal artery. From each of these, separate branches supplied the dura wherein a fine vessel network covered the bone. No major vessels were found in the supracalvarial soft tissue. Numerous fine vessels were found within the periosteum and dura entering the cortical plates. The decalcified sections of the parietal bones revealed an outer and inner cortical plate enveloping a diploic space containing bone trabeculae, marrow tissue and larger sinusoids. Hollow connections were frequently found in both the outer and inner cortical plates in both the untreated and the GBA-treated specimens. These connections contained marrow tissue that extended to the periosteum and the dura. The morphometric measurements revealed similar proportions of cortical, trabecular, and marrow areas in the right and left untreated bones. The area of the outer cortical plate was significantly larger than the area of the inner cortical plate. Bone density was similar in the right and left untreated and GBA-treated specimens, as was the frequency and width of hollow connections through the cortical bone plates., Conclusions: The symmetry between the left and right parietal bones concerning the large vessel topography and the histomorphometric parameters assessed was high. Hollow connections in the cortical plates were frequently found. The bilateral use of the parietal bones is suggested to be reliable in experimental GBA models regarding the blood supply and bone quality.

The authors report an unusual case of an extensive spontaneous subgaleal hematoma caused by a bilateral arteriovenous shunting lesion involving the diploic veins. The enlarged diploic canals and the existence of bilateral diploic arteriovenous shunts with no history of fracture or trauma indicate that these fistulas developed spontaneously over a long period of time. Angiographic findings in these unusual arteriovenous shunting lesions and their endovascular management are briefly illustrated. A case of a bilateral diploic fistula has not been reported before and it may contribute to the understanding of the diversity of dural arteriovenous shunting lesions.

Bone wax was used to stop bleeding of the diploic vessels after harvesting cranial bone for reconstruction of an orbital floor defect. After five months a fistula in the overlying skin of the donor site appeared and was eventually surgically explored. Remnants of bone wax and surrounding inflammatory tissue were removed and the fistula was excised. Histological examination revealed a foreign body granuloma. The use of bone wax and possible alternative local haemostatic agents and their complications are discussed.

Purpose: The aim of this study was to investigate the influence of particle size of autogenous bone grafts on the early stages of bone regeneration., Materials and Methods: Bicortical skull bone defects were prepared in 15 rabbits (4 in each rabbit). Two defects were filled at random with either small (0.5 to 2 mm3) or large (10 mm3) autogenous bone particles. In addition, 1 defect was left unfilled (control defect). All defects were covered bicortically by expanded polytetrafluoroethylene membranes. The animals were divided randomly into 3 groups and sacrificed after 1, 2, and 4 weeks, respectively. Histologic and stereologic evaluations were performed after the sections were blinded., Results: No significant differences in total vessel surface area could be identified among the 3 groups. The total volume of newly formed bone in defects with small particles was larger and more mature compared to defects with large particles after 2 and 4 weeks. Furthermore, the resorption of small particles was more pronounced after 4 weeks, documenting a higher level of bone substitution compared to large particles., Discussion: The early stages of bone regeneration were influenced by the particle site of autogenous bone grafts., Conclusion: The present study indicated that particles of 0.5 to 2 mm3 in size should be preferred to particles of 10 mm3 in size for bone grafting.

Objective: The present study investigates the potential relationship between craniosynostosis and any changes in endocranial vasculature. The hypothesis that crania from rabbits with familial, nonsyndromic coronal suture synostosis and crania from rabbits with experimental immobilization of the coronal suture are associated with altered form of the middle meningeal vessels and dural venous sinuses is tested., Design: Silicone rubber endocasts from 14 adult New Zealand white rabbits (Oryctolagus cuniculus) with familial nonsyndromic coronal suture synostosis (five with bilateral coronal suture synostosis and nine with unilateral coronal suture synostosis) were made to assess middle meningeal vessel and dural venous sinus form. For comparative purposes, endocasts were made from 25 rabbits with normal, patent coronal sutures and 10 rabbits with experimental immobilization of the coronal suture. Impressions of the dural venous sinuses were assessed for depth and width. The area of the confluens of sinuses was also assessed. Impressions of the middle meningeal vessels were assessed for depth, width, and degree of convolution. For width of the dural venous sinuses and area of the confluens of sinuses, comparisons among groups were made with a one-way analysis of variance (ANOVA). For depth of the dural venous sinuses and impressions of the middle meningeal vessels, comparisons among groups were made using a Kruskal-Wallis one-way ANOVA., Results: Crania with familial coronal suture synostosis had significantly (p <.05) reduced posterior dural venous sinus dimensions when compared with both crania from rabbits with experimental immobilization of the coronal suture and rabbits with normal coronal sutures. Crania with both coronal suture synostosis and experimental immobilization had significant increases in dimensions of the middle meningeal vessels relative to normal crania. In addition, casts from rabbits with unicoronal suture synostosis showed marked asymmetry in the dural venous sinuses., Conclusions: These results support the hypothesis that craniosynostosis is associated with alterations in endocranial vasculature. These changes are most likely a secondary response to synostosis rather than a causal factor and may reflect increased intracranial pressure, decreased intracranial volume, and local accumulations and reductions of cerebrospinal fluid in the posterior region of the skull and immediately deep to the coronal suture.

Orbital and intracranial complications of dental cellulitis are exceptional. The authors report such a case with orbital cellulitis and frontal abscess that dictated orbital exenteration with resection of the eyelids. Before realization of an implant supported epithesis, the orbit was filled with a prefabricated vascularized fascio-osseous parietal bone flap. This allowed placement of two extra-oral fixtures (Nobel biocare) in an antero-posterior axis. In some cases, preimplant orbital bone graft appears to be the only solution when implant placement in the orbital rim is impossible or contra-indicated. Indications, advantages and disadvantages of this technique will be discussed.

A giant-cell tumour involving the cranial vault was diagnosed in a 37-year-old man who presented with a large swelling at the vertex. The role of imaging in the diagnosis and treatment of this tumour is described. On CT and MRI the appearances were nonspecific and the diagnosis was established by histological examination after removal of the tumour. A preoperative angiogram showed a tumour blush and before surgery, embolisation was performed via the percutaneous and transarterial routes.

Cephalhematomas are subperiosteal blood collections occurring in newborns secondary to trauma at birth. They develop within a few days and are subsequently resorbed. Infection of a cephalhematoma is unusual and caused most often by colonization of the hematoma during bacteremia or by direct inoculation secondary to trauma. Less than 10 patients with primary infection of the hematoma, in the absence of a positive blood culture, complicated by osteomyelitis have been described. We report a newborn with a primarily infected cephalhematoma complicated by parietal bone osteomyelitis.

The aim of this study was to examine the osteogenic potential of demineralized bone matrix prepared from intramembranous bone (DBMIM) and to examine its effects on the healing of endochondral autogenous bone grafts. Twenty-four defects in 24 New Zealand white rabbits were used as experimental groups. Twelve defects were grafted with endochondral bone, and the other 12 defects were grafted with endochondral bone with DBMIM (EC-DBMIM). One rabbit from each group was sacrificed on days 1, 2, 3, 4, 5, 6, and 7 postgrafting, and the remaining 5 rabbits from each group were sacrificed on day 14 postgrafting. Another 8 defects in 4 rabbits were used as control groups: 4 defects were left empty (passive control), and 4 defects were grafted with rabbit skin collagen (positive control). They were all sacrificed at 14 days after grafting. Serial sections were made across the whole defect. Quantitative analysis was performed on 100 sections of the 14-day experimental groups by image analysis. Four hundred fourteen percent more new bone was formed in defects grafted with composite EC-DBMIM than in those grafted with endochondral bone alone (P < 0.0001). No bone was formed in either passive or positive controls. Histologic examination of the bone grafts revealed intermediate-stage cartilage, and immunohistochemical examination revealed earlier vascularization in the composite EC-DBMIM groups. In conclusion, DBMIM has extremely high osteoinductive properties and greatly enhances the integration of endochondral bone with defects of intramembranous bone in origin.

Background: Little is known about the organization of microcirculation in flat bones in comparison with long bones. This study, therefore, helps us to determine the design of this vascular system in flat bones in relation to their structure and function., Methods: The organization of microvasculature in parietal, scapula, and ileum bones of 15 young sexually mature rats, aged 6-7 weeks, was studied by light and scanning electron microscopy (SEM) from vascular corrosion cast (vcc), a resin-cast obtained material., Results: Our observations show that the pattern of the microcirculation in flat bones is different in the thick and thin parts of such bones. Where the bone is thinner than 0.4 mm, only periosteal and dural network exist. Larger vessels which do not form a real network connect the two tables of the bones in these regions. In thicker areas, the organization of the microvasculature is similar to that in long bones, with distinct periosteal, cortical and bone marrow networks. Moreover, in different bones, outer networks show slightly different characteristics according to the different adjacent structures (dura mater, muscles etc.). Different types of vessels were recognized by comparing their different diameter, course and endothelial imprints., Conclusions: The microvascular patterns of the flat bones are strongly influenced by the bone thickness. The different microvascular systems can interact both with the bone modelling and remodeling and with the variable metabolic needs, modifying the microvascular pattern and the blood flow. This is even more important in view of the reciprocal influence of the different networks within the same bone.

The purpose of the current study was to determine the timely ingrowth of blood vessels associated with demineralized bone matrix (DMB) induced osteogenesis. Critical-size (10 x 5mm), full thickness bony defects in rabbit parietal bone were implanted with DBM. Histological and ultrastructural changes were examined 1, 2, 3, 4, 5, 6, 7 and 14 days later. Neovascularization was assessed by immunohistochemical staining for factor VIII antigen (marker for vascular endothelium) and also confirmed by staining using pan-endothelial antibody (CD31) (a marker for endothelium). Immunohistochemical evaluation revealed a positive staining for CD31 and Factor VIII expressed by endothelial cells by day 3 post grafting. By day 4, small blood vessels were first seen budding from host bed towards the grafted DBM. Ultrastructural identification of cells in the early stages of healing revealed the presence of macrophages. The monocyte-derived macrophage appears to play a central role in the repair process using DBM. Results of this study demonstrated a rapid vascularization during the DBM induced osteogenesis. This rapid vascularization is vital to the healing and bone induction ability of the DBM.

Eleven patients underwent mandibular reconstruction with pedicled temporal muscle flaps combined with vascularised or free full thickness calvarial bone grafts. Six were primary and five secondary reconstructions. The indications were squamous cell carcinoma (n = 6), radio-osteonecrosis (n = 4), and gunshot wound (n = 1). Five patients also had endosseus implants, either simultaneously or delayed. The only major complications were necrosis of the whole calvarial bone (n = 1) and permanent facial nerve palsy (n = 1). The advantages of using full thickness calvarial bone are that it is thick enough to take an endosseous implant, morbidity is low, there is virtually no postoperative pain, the scar is invisible, and there is only one donor area for both hard and soft tissue. Transplantation of full thickness calvarial bone and temporal muscle is a viable alternative to an osseomyocutaneous microvascularised free flap for reconstruction of the mandible when the neck has been previously operated on or irradiated, and anastomosis may be critical.

The clinical and radiographic results of 9 consecutive vascularized full-thickness cranial bone grafts to the midface are examined for a period of 3 to 8 years. Satisfactory contour was maintained throughout the follow-up in 5 patients with severe congenital facial deformities. Axial computerized tomography revealed complete survival of a trilaminar bone graft in each case. The complications were limited to a small area of alopecia in the midportion of one temporal scar. This relatively tedious harvest of bone is indicated for severe congenital malar and maxillary midface hypoplasia beginning at 4 years of age.

The authors have performed 13 cases of vascularized cranial bone grafts for reconstruction of maxillofacial defects since 1986. Two types of flaps were used: the parietal osteofascial flap pedicled to the parieto-temporal fascia based on the superficial temporal artery and the temporalis osteomuscular flap pedicled to the temporalis muscle based on the deep temporal artery. Zygomatico-orbital complex, maxilla and mandible were reconstructed and hemifacial microsomia was also treated. The results of vascularized cranial bone grafts pedicled to fascia were as good as those of grafts pedicled to muscle. There were no major complications. Two types of vascularized cranial bone grafts seem to be useful in reconstruction of maxillofacial defects with avascular recipient beds because of their good blood supply. The parietal osteofascial flap has additional advantages including easy rotation of the flap to the defect, particularly a mandibular defect, and versatile use of fascia without bulkiness for reconstruction of soft tissue defects. This flap can be designed as a full- or partial-thickness cranial bone graft with good vascularity. In this paper, our technique for mandibular and maxillary reconstruction using the parietal osteofascial flap is introduced, and the results compared with our temporalis osteomuscular flap technique are reported.

The ultimate objective, when treating a mandibular defect, is to restore completely the function and cosmetic appearance of the face. The reconstruction must include bone from a similar source, good in quality and shape and living, to resist infection and the continuous stress that takes place in the mandible during mastication. Our technique for mandibular reconstruction using bone from the calvarium, of full thickness to receive implants and living because it is pedicled on the galea (from the superficial temporal artery) is reported. Our criteria for reconstruction, and the analysis of all the cases reconstructed with the technique mentioned above, is presented. Emphasis is placed on the good shape of this bone flap, its vascularization studies (compared with those in other techniques) and the high rate of success in both cosmetic and functional results.

A 47-year-old male was concerned with a large AVM involved extensively in the parietal region and the posterior fossa. Radiological examinations showed multiple radiolucencies in the parietal and occipital bone and torturous vascular nets (nidus) in those bones on the angiograms. Nidus was found also in the dura mater in the posterior fossa. Therefore, this case seemed to be an extremely rare case of calvarial AVM in the parietal region with the mixed calvarial dural AVM in the posterior fossa. His symptoms were bruit, transient hemiparesis and Gerstmann's syndrome in addition to the symptoms due to raised intracranial pressure. Favorable results of therapies could be attained by extensive exfoliation of dura mater from the cranial bone and incision of proximal dura mater in the sinus.

The structure of the veins forming the frontal, occiputal, mastoidal and sinciputal veins--emissaries was studied on 48 human cadavers by using various methods of silver-staining and a delicate anatomic sectioning and examination of the impregnated material with a binocular magnifying glass. The architectonics of these veins showed the drainage of the venous blood from the soft tissues of the cranial vault and its periosteum to proceed predominantly under normal condtions into the sinuses of the dura mater.

The anatomy of the superficial temporal artery was investigated in radiographic and cadaveric studies. The superficial temporal artery divides into an anterior and posterior branch, and the diameters of these vessels are similar. The anatomy of these two vessels is described, and implications for their use in reconstructive flaps are suggested.