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Further support is provided by the levator ani purchase discount cefadroxil online antibiotic iv therapy, which are composed of paired iliococcygeus purchase cheap cefadroxil on line antibiotics for dogs cough, puborectalis generic 250mg cefadroxil overnight delivery virus hunter island walkthrough, and pubococcygeus muscles. These muscles function to maintain a constant level of baseline tone and a closed urogenital hiatus. The puborectalis muscle act as a sling that angles the posterior wall about 45° from the vertical and closes the potential space of the vagina. These levator ani muscles also provide a contraction reflex to increased intra-abdominal pressures, preventing incontinence and prolapse. The anterior sacral nerve roots S2–S4, which innervate these muscles, cross the pelvic floor, and are stretched and compressed during labor, increasing the risk of injury [7,9]. However, rectoceles and enteroceles have been noted to occur in approximately 40% of asymptomatic parous women [10]. Rectoceles may be more prevalent than previously thought and may not be a result of parity [11]. Traumatic obstetric events, which usually occur when the presenting fetal part descends quickly in the second stage of labor, can predispose to rectocele formation. The forces of labor may separate, tear, or distend the pelvic floor, altering the functional and anatomic position of the muscles, nerves, and connective tissues. Low rectoceles are isolated defects in the suprasphincteric portion of the rectovaginal “fascia. A palpable defect at the level of the introitus will be noted on the physical examination. High rectoceles often occur from pathological overstretching of the posterior vaginal wall as the rectovaginal “fascia” does not exist at this level. Rectoceles may occur as a result of pathologic stretching of the pudendal nerves during descent of the fetal head, causing atrophy, and denervation of the pelvic floor muscles. Sultan reported that most damage to the pelvic support occurs in the first vaginal delivery [13,14]. Denervation will probably recover after the postpartum period; however, it has been demonstrated that injury may be cumulative with increasing parity [9]. Increased labor duration and weight of the baby directly influence the perineal damage and denervation of the pelvic floor. This neuropathy can lead to the weakening of pelvic floor muscles and development of a rectocele. They may lead to the weakening of the rectovaginal septum by continuous straining against an obstruction. Some patients may suffer from paradoxical sphincter reaction (anismus), which is the unconscious contraction of the voluntary striated muscles when attempting to defecate. This constant straining with bowel movements has been shown to cause or worsen a preexisting rectocele and to increasingly weaken the rectovaginal septum by denervation injury [15]. Anismus eventually leads to the accumulation of stool in the rectum, which may complicate pelvic outlet obstruction and cause a progressive cycle, worsening the rectocele. This pseudorectocele has its posterior vaginal wall exposed because of the lack of inferior support; this may be corrected by surgical reconstruction of the perineum. Congenital absence allows for deepening of the cul-de-sac and weakening of the rectovaginal septum, leading to the development of a high rectocele and enterocele [10,12]. Clinical Presentation The symptoms associated with a rectocele are summarized in Table 84. A common complaint is constipation, which can occur in 20%–58% of patients with rectoceles [16]. Patients may also complain of incomplete rectal emptying, a sense of rectal pressure, or a vaginal bulge. Vaginal digitation/splinting or perineal support is sometimes necessary to facilitate defecation [5,17–19]. It is also important to note that many women with rectoceles do not have to splint with defecation, and women without rectoceles may require splinting [4]. Constipation and straining may worsen the symptoms and lead to left lower quadrant abdominal pain if impaction occurs. The patient may be in the dorsal lithotomy position (for the gynecologist) or in the left lateral decubitus position (for the colorectal surgeon). The use of the split blade of a Sims or Graves speculum will support the apex and the anterior compartment and can aid in visualization. An exam should also be performed with the patient standing, as a vaginal exam in this position may identify a more prominent rectocele and rectovaginal examination will reveal small bowel herniating into this space when an enterocele is present. Of women with rectoceles, up to 80% are asymptomatic and can only be diagnosed on physical examination [9,20]. This nomenclature has replaced the respective terms cystocele, enterocele, and rectocele as it is often uncertain which specific structures are contributing to prolapse at each segment. Prolapse is measured in centimeters relative to the hymenal ring in relation to the six defined points. Points proximal to the hymen are denoted as negative and points distal as positive. Point Ba corresponds to a point 3 cm proximal to the hymen in the midline of the posterior segment. In the presence of complete vaginal eversion, the maximum value equals the value of C. Richardson described site-specific defects in the rectovaginal septum that occur in various locations including the superior, inferior, right, left, and midline areas [6]. One study has suggested that locating defects during clinical evaluation of the posterior vaginal wall is often inaccurate when compared to surgical assessment at the time of defect-specific repair [18]. However, the use of imaging 1286 studies does become useful when combined with other ancillary data, especially history and symptomatology for the following patients: (1) symptomatology and physical findings do not correlate, (2) the pelvic anatomy is unusual or altered due to previous pelvic surgery or a congenital defect, and (3) the patient is unable to exert maximal straining during pelvic examination. Imaging results should not be used alone to make treatment decisions as studies have noted that radiographic findings of posterior compartment defects do not necessarily correlate with patient symptomatology [23,24]. Currently, universally accepted radiologic criteria for defining pelvic organ prolapse are lacking [25]. In order to identify a rectocele on imaging, a measurement is made from a reference line to a predefined point. Dynamic Proctography or Defecography The use of contrast media in pelvic fluoroscopy allows the various prolapsed organs to be opacified and seen in real time providing a two-dimensional view of rectal emptying. Traditionally, it has mainly been used in the study of anorectal dysfunction as evacuation proctography, which is also known as defecography. The addition of a cystogram (dynamic cystoproctography) to this modality allows further information to be gained during the assessment especially when the possibility of an enterocele or sigmoidocele exists [28]. The equipment required includes a thick barium paste, a radiolucent toilet, and video equipment.

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There is a correlation between the A-H interval during sinus rhythm and the paced cycle length at which Wenckebach block appears; patients with long A-H intervals tend to develop Wenckebach block at lower-paced rates order 250 mg cefadroxil with visa antibiotic wipes, and vice versa buy 250mg cefadroxil free shipping disturbed infection. In the absence of drugs buy genuine cefadroxil on line 02 antibiotic, this tends to occur in older patients or in young athletic patients with high vagal tone. Although some investigators consider infra-His block abnormal at any paced cycle length,21,25 it can clearly be a normal response at very short cycle lengths. This is a particularly common phenomenon, because if pacing is begun during sinus rhythm, the first or second complex (depending on the coupling interval from the last sinus complex to the first paced complex) acts as a long-short sequence. The long preceding cycle will prolong the His– Purkinje refractoriness; thus, the next impulse will block. The His–Purkinje system may also show accommodation following the initiation of a drive of atrial pacing in an analogous way to the A-V node. Occasionally persistent two-to-one block occurs as a self- perpetuating phenomenon. Repeating the atrial pacing at log cycle lengths with gradual reduction of the paced cycle length will show normal one- to-one conduction up to A-V nodal Wenckebach; thereby demonstrating the P. Prolongation of the H-V interval or infra-His block, however, produced at gradually reduced paced cycle lengths of 400 msec or more are abnormal and probably signify impaired infranodal conduction (see Chapter 5). A: At a paced cycle length of 600 msec, the A-H is 95 msec and the H-V is 50 msec. Shortening the cycle length to 350 msec (B) results in A-V nodal Wenckebach block; that is, progressive A-H prolongation (140, 200, 225 msec) terminating in block of the P wave in the A-V node (no His bundle deflection after the fourth paced beat). The stimulus is delivered, which fails to capture the atrium, which has been previously depolarized by an atrial echo (Ae, arrow) that is due to A-V nodal reentry. The exact proportion of patients demonstrating V-A conduction varies from 40% to 90% and depends on the patient population studied. The incidence of V-A conduction is higher in patients with normal antegrade conduction, although it is well documented that V-A conduction can occur in the presence of complete A-V block if block is localized to the His–Purkinje system. This divergence from the rest of the literature obviously reflected a selected patient population. In 1981, Akhtar74 reviewed his data, which revealed that if retrograde conduction is present, it will be better than antegrade conduction in only one-third of instances. Most of such instances involve patients with either bypass tracts or dual A-V nodal pathways (see Chapters 8 and 10). Our own data have revealed that in 750 patients with intact A-V conduction, antegrade conduction was better (i. These data, which exclude patients with bypass tracts, are comparable to those of Akhtar who only considered patients with intact retrograde conduction. The ability to conduct retrogradely during ventricular pacing is directly related to the presence and speed of antegrade conduction. Patients with prolonged P-R intervals are much less likely to demonstrate retrograde conduction. Thus, A-V nodal conduction appears to be the major determinant of retrograde conduction during ventricular pacing. As with atrial pacing, ventricular pacing is begun at a cycle length just below the sinus cycle length. The paced cycle length is gradually reduced until a cycle length of 300 msec is reached. Further shortening of the ventricular-paced cycle length may also be used, particularly in studies assessing rapid retrograde conduction in patients with supraventricular arrhythmias (see Chapter 8) or during stimulation studies to initiate ventricular arrhythmias (see Chapter 11). During ventricular pacing, a retrograde His deflection can be seen in the His bundle electrogram in the majority of cases. We have used the Bard Electrophysiology Josephson quadripolar catheter for obtaining distal and proximal His deflections (Chapter 1). Using this catheter, we observed a retrograde His potential in 86 of 100 consecutive patients in whom we attempted to record it. Ventricular pacing at the base of the heart opposite the A-V junction (Para-Hisian pacing) facilitates recording a retrograde His deflection, particularly when the His bundle recording is made with a narrow bipolar signal (i. Retrograde His deflections are much less often seen in the presence of ipsilateral bundle branch block. In all instances, V-H (or stimulus-H) interval exceeds the anterograde H-V by the time it takes for the stimulated impulse to reach the ipsilateral bundle branch. This response occurred because the effective refractory period of the His–Purkinje system was 350 msec, which is longer than the paced cycle length. The normal response to ventricular pacing is a gradual prolongation of V-A conduction as the ventricular-paced cycle length is decreased. Retrograde (V-A) Wenckebach-type block and higher degrees of V-A block appear at shorter cycle lengths (Fig. Although Wenckebach-type block usually signifies retrograde delay in the A-V node, it is only when a retrograde His deflection is present that retrograde V-A Wenckebach and higher degrees of block can be documented to be localized to the A-V node (Fig. This extra beat is termed a ventricular echo and is not infrequent during retrograde Wenckebach cycles. Ventricular echoes of this type are due to reentry secondary to a longitudinally dissociated A-V node and require a critical degree of V-A conduction delay for their appearance. Patients with a dual A-V nodal pathway manifesting this type of retrograde Wenckebach and reentry are generally not prone to develop clinical supraventricular tachycardia that is due to A-V nodal reentry (see Chapter 8). Because a retrograde His bundle deflection may not always be observed in patients during ventricular pacing, in the presence of V-A block, localization of the site of block in such patients must be inferred from the effects of the ventricular-paced beat on conduction of spontaneous or P. Thus, one localizes the site of delay by analyzing the level of concealed retrograde conduction. If the A-H interval of the spontaneous or induced atrial depolarization is independent of the time relationship of ventricular-paced beats, then by inference, the site of retrograde block is infranodal in the His–Purkinje system. On the other hand, variations in the A-H intervals that depend on the coupling interval of the atrial complex to the ventricular-paced beat, or failure of the atrial impulse to depolarize the His bundle, suggest retrograde penetration and block within the A-V node (Fig. Another method of evaluating the site of retrograde block in the absence of a recorded retrograde His potential is to note the effects of drugs, such as atropine or isoproterenol, which affect only A-V nodal conduction, on V-A conduction. Improvement of conduction following administration of these drugs suggests that the site of block is in the A-V node. On the bottom, ventricular pacing at the same cycle length is associated with the V-H interval of 70 msec. B: During sinus rhythm at a cycle length of 550 msec, the right bundle branch block is present with an H-V interval of 80 msec. The presence of a retrograde His deflection allowed the site of block to be localized to the A-V node. After the third paced ventricular complex, pacing is terminated (open arrow) and a return beat appears that has the same configuration as the subsequent sinus beat. In contrast to the development of the V-A Wenckebach, if one can record a retrograde His deflection, it is possible to demonstrate that V-H conduction remains relatively intact at rapid rates despite the development of retrograde block within the A-V node (Fig. Refractory Periods The refractoriness of a cardiac tissue can be defined by the response of that tissue to the introduction of premature stimuli. In clinical electrophysiology, refractoriness is generally expressed in terms of three measurements: relative, effective, and functional. The definitions differ slightly from comparable terms used in cellular electrophysiology.


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Eventually generic cefadroxil 250mg otc antibiotic quiz pharmacology, the bladder may become progressively overdistended purchase cefadroxil uk antibiotics for uti most common, impairing contractility and leading to incomplete emptying [212] cheap 250 mg cefadroxil overnight delivery virus united states. Subsequently, symptoms associated with traditional “diabetic cystopathy” may include urinary hesitancy, slowing of the urine stream, and decreasing urinary frequency [211,213]. These symptoms may progress to include a sensation of incomplete emptying or even urinary dribbling from overflow incontinence [211,214]. When questioned, up to 50% of unselected diabetes mellitus patients have subjective evidence of traditional diabetic cystopathy. The urodynamic evaluation, however, suggests alterations in lower urinary tract function in only 27%–85% of these patients [214,215]. Urodynamic studies frequently reveal impaired bladder sensation, increased cystometric bladder capacity, decreased detrusor contractility, an impaired urine flow, and an elevated postvoid residual urine volume [91]. Kaplan and Te reported on another group of patients with diabetes referred because of voiding symptoms. In addition, poor diabetic control will contribute to urgency and frequency as a result of decreased warning time from impaired sensation and polyuria from the elevated glucose. Upper tract changes depend upon the duration and severity of the disease process as well as the effect on intravesical pressure. The effect of diabetes-induced lower urinary tract dysfunction on the upper urinary tract is difficult to determine because of the other effects of diabetes on renal function [1]. When managing patients with diabetic cystopathy, preservation of renal function is paramount. A direct effect of diabetes on renal microvasculature, combined with upper tract obstructive changes resulting from diabetic cystopathy, put the diabetic kidneys at great risk. A timed voiding schedule is effective in those with impaired contractility, while intermittent catheterization is reserved for those who experience greater difficulty with emptying. A high index of suspicion should be maintained where the severity of symptoms is disproportionately high or in rapid onset of symptoms. A brief neurological examination at the time of presentation of new patients —or during urodynamic—should be considered as a standard for good practice. Management of voiding dysfunction in patients with neurological comorbidities requires consideration of functional disabilities and other medications. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the international continence society. High incidence of occult neurogenic bladder dysfunction in neurologically intact patients with thoracolumbar spinal injuries. Mice lacking M2 and M3 muscarinic acetylcholine receptors are devoid of cholinergic smooth muscle contractions but still viable. Notes on the arrangement and function of the cell groups in the sacral region of the spinal cord. Neural control of the urinary bladder: Possible relationship between peptidergic inhibitory mechanisms and detrusor instability. Combination treatment with mirabegron and solifenacin in patients with overactive bladder: Efficacy and safety results from a randomized, double blind, dose-ranging, phase 2 study (symphony). Botulinum toxin A (Botox) intradetrusor injections in adults with neurogenic detrusor overactivity/neurogenic overactive bladder: A systematic literature review. Long-term durability of percutaneous tibial nerve stimulation for the treatment of overactive bladder. Clinical outcomes of sacral neuromodulation in patients with neurologic conditions. Percutaneous tibial nerve stimulation for refractory lower urinary tract symptoms in patients with neurogenic bladder conditions. Urodynamic patterns after acute spinal cord injury: Association with bladder trabeculation in male patients. Cystometrographic patterns in predicting bladder function after spinal cord injury. Detrusor–external sphincter dyssynergia in men with multiple sclerosis: An ominous urologic condition. The urologic status of the Vietnam War paraplegic: A 15-year prospective follow-up. Urodynamic evaluation after abdominal–perineal resection and lumbar intervertebral disc herniation. Botulinum toxin urethral sphincter injection to restore bladder emptying in men and women with voiding dysfunction. A review of the current terminology, definitions, epidemiology, aetiology, and diagnosis. Atypical syndromes caudal to the injury site in patients following spinal cord injury. Comparison of urodynamics between ischemic and hemorrhagic stroke patients; can we suggest the category of urinary dysfunction in patients with cerebrovascular accident according to type of stroke? Acute cerebrovascular accident and lower urinary tract dysfunction: A prospective correlation of the site of brain injury with urodynamic finds. Clean, intermittent self-catheterization in the treatment of urinary tract disease. Hydroureteronephrosis after spinal cord injury: Effects of lower urinary tract dysfunction on upper tract anatomy. The incidence and etiology of overactive bladder in patients after cerebrovascular accident. Urinary incontinence after unilateral hemispheric stroke: A neurologic epidemiologic perspective. Urinary symptoms and natural history of urinary incontinence after first 828 ever stroke—A longitudinal population-based study. Detrusor contractility and overactive bladder in patients with cerebrovascular accident. Neurologic aspects of detrusor–sphincter dyssynergia, with reference to the guarding reflex. Assessment of voiding dysfunction in Parkinson’s disease by the international prostate symptom score. Cerebral vascular accident, Parkinson’s disease and other supra spinal neurologic disorders. Urodynamic and neurophysiological evaluation of Parkinson’s disease and multiple system atrophy. Voiding dysfunction and Parkinson’s disease: Urodynamic abnormalities and urinary symptoms. Video-urodynamic and sphincter motor unit potential analyses in Parkinson’s disease and multiple system atrophy. Urinary dysfunction and orthostatic hypotension in multiple system atrophy: Which is the more common and earlier manifestation? How to recognize patients with parkinsonism who should not have urological surgery. The natural history of voiding dysfunction in patients with idiopathic Parkinson’s disease.

An assessment is explain this to the patient so that when the fluid and fullness made of the amount of transverse forehead rhytids and a rela- recur following the procedure order cheap cefadroxil online bacterial infection symptoms, the patient understands that tive assessment of the strength of frontalis muscle contrac- this is not a failure of the procedure 250 mg cefadroxil otc antimicrobial list. The soft tissues have tion to gauge the amount of thinning that may be required of fallen off of the malar eminence in both the primary and sec- the frontalis muscle order cefadroxil 250 mg online infection while pregnant. This ptosis of the soft tissues to the and their configuration from corrugator superciliaris contrac- fixed line of the nasolabial crease leads to an increase in the tion is noted as is the number and depth of creases from the size of the nasolabial fold and a deepening of the nasolabial procerus muscle. It also results in a skeletonization of the malar area sor superciliaris by having the patient close their eyes tightly and when combined with the soft tissue ptosis in the region against upward resistance on the medial brow. Many secondary configuration rather than the heart-shaped configuration of face-lift patients have previously had blepharoplasty proce- youth. The amount of excessive sagging skin is the face restores the softness over the malar areas and noted after the eyebrow has been restored to its appropriate decreases the thickness of the nasolabial folds [9 ]. Undermining over the orbicularis oculis muscle to the area of Typically the authors have not performed aggressive blepha- the lateral canthus and the lateral aspect of the lower eyelid roplasty procedures at the time of brow, face, and neck lift- will result in a significant improvement in the appearance of ing. In addition, an assessment must be made large skin resection may result in an inadequate brow lift for regarding the depressor portion of the orbicularis oculis mus- fear of creating lagophthalmos with the brow lift. This portion has been termed as the “depressor orbicularis Reoperative Surgery of the Face 963 oculis lateralis” by the authors. The neck is examined for large digastric muscles that will oppose any lifting of the lateral brow and will result in may create prominence in the submandibular area as well as failure of lifting of the lateral brow with the brow lift proce- interfering with an aesthetic cervicomental angle and sub- dure. The presence of jowls and tight mandibular having the patient smile and apply traction to the lateral brow. The presence of platysmal bands is noted If the muscle action is strong, it can be divided to weaken the and an assessment is made as to whether the bands are tight depressor action [10, 11]. The position tions between the orbicularis oculis and skin (smile creases) of the cricoid cartilage and thyroid cartilage are noted. The are released, 60 % or more of the lower eyelid excessive skin neck is also inspected for any irregularities that may be pres- is reduced by the shift of the face-lift flaps. The release of the muscle/skin connec- sensation is assessed to make sure that the great auricular tions also facilitates the change in direction of the nasojugal nerve is intact. The angle of the dangle of the ear lobule from groove from the diagonal direction of older age to the horizon- the axis of the ear is noted. This should normally be 10–15° tal direction of youth as seen in their earlier photographs. This is especially important in the secondary patient failure to have placed the ear into the appropriate position to document the status of the facial nerve preoperatively. To correct oral commissures are then evaluated to see if there is a dour (fish this deformity, it requires an additional 4–5 mm of excessive mouth) and downturned appearance of the mouth. Patients with long old appearing earlobes with a to perioral rejuvenation rather than using excisional approaches deep crease may benefit from a wedge excision of the ear- such as those advocated by Weston et al. Trimming the caudal margin of the earlobe is best for The presence of fine vertical lines (smoker’s lines) is also long old appearing earlobes without a deep crease [15 ]. The author’s treatment of choice for these lines is length of the earlobe is important if the face-lift makes the dermabrasion at the completion of the face-lift procedure. Dermabrasion usually results in improvement of the dark pigmentation of the lips and better color blending than other techniques. Phenol peels microscopically show aging of the 3 Vectors of Aging skin with disruption of the elastic fibers and collagen. Laser produces a smooth burned appearance that does not hold up The vectors of the aging face are an inferior lateral and ante- with continued sunlight exposure. These soft tissue biopsy of upper lip skin to show a great amount of collagen changes are responsible for the characteristic appearance of build up, which contributes to the smooth appearance. This is the aging face with enlargement of the nasolabial creases and equivalent to having a filler injected. The soft tissues seem to fall off of oral dermabrasion is needed, the lower lip and chin are done the malar eminence and the boxiness and angularity of the at a second stage some time later. The secondary face-lift, however, has little laxity dermabrasion results in difficulty for the patient to open their in the anterior-posterior direction and most of the skin laxity mouth in the perioperative period. However, this direction of the patient’s lips is made and if they are quite thin, the lips skin laxity makes it difficult to correct some deformities that may be augmented with fat grafting or fascial grafts. An example of this problem is seen in the case of the pixie The laxity of the skin is noted as above. Frequently these scars deformity, about 5–15 mm of skin must be advanced are actually placed into the submental crease and they must posteriorly in order to transpose the earlobe posteriorly. The most infe- that same patient has fullness in the preauricular area coupled rior level of the skin fold is noted because the extent of the with the pixie ear, an additional 1 cm of skin may be required skin incision in the occipital area is perpendicular to this to make a concavity anterior to the tragus, which makes the crease. Sundine to the timing of the surgery informing the patient of what can 4 Problems Seen After Primary be achieved and what cannot be achieved with the secondary Face-Lifting surgery. If understanding is limited, the limitations and pos- sibilities should be written in a letter to the patient. Perhaps one of the most important points that can be made for face-lifting, which has been presented at teaching courses for many years by Dr. Connell, is that performing a good primary face-lift procedure is the key to setting up a second- ary face-lift. Conversely, a poorly planned and executed pri- mary face-lift will make it difficult and nearly impossible to obtain a quality result from the secondary face-lift. There are many problems seen in evaluating patients for secondary face-lifting that may need to be addressed. Starting at the temporal area, there may be a widened scar extending vertically from the root of the helix cephalad into the tempo- ral hair. A widened scar indicates that there was too much skin (hair-bearing skin) excised and this may also result in distortion of the hairline in the temporal area. This may also result in widening of the distance between the lateral canthus and the temporal hairline (Fig. Displacement of temporal hair by non-hair–bearing preauricular skin will result in a loss of hair, which looks like a widened scar in the temporal area and may also lead to loss or distortion of the sideburn area (Fig. Further inferiorly, the scar tragus out onto the cheek and after the skin resection, two should follow the margin of the tragus and should not be different colors of skin are juxtaposed next to each other placed anterior to the tragus. In the postauricular area, the incision should be made close to the ear-postauricular skin junction. If the incision is onto the con- cha, a webbing will develop where the incision transitions to the occipital skin (Fig. Skin removal in the neck should be mainly in a posterior direction perpendicular to the neck folds. For eliminating hair shifts, which prevent wearing short hairstyles and wearing the hair upward, the incisions in the occipital area should follow the hairline except at the most posterior aspect where the dog-ear is transposed into the occipital hair. The incision described in articles and text- books extending from the postauricular incision into the occipital hair will often transpose non-hair–bearing skin into the occipital hair and create an unusual triangular area of alo- pecia (Fig.