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Scalp-tissue expansion for a chronic burn wound with exposed calvarium
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e629ee630
CORRESPONDENCE AND COMMUNICATION
Scalp-tissue expansion for a chronic burn wound with exposed calvarium Scalp wounds with calvarial exposure present a complex clinical challenge and require a systematic approach for reconstruction. Local flaps are ideal for small wounds but are rarely adequate for larger defects. Skin grafts can be a useful option, but require removal of the outer table, thus increasing the complexity and risks of the reconstruction. Skin grafts on trabecular bone also break down easily. Free flap tissue transfer is an option, but requires microvascular expertise and a complex, multi-staged reconstructive effort with the potential possibility of donor-site morbidity. Scalp-tissue expansion is a validated, reliable and safe technique for the treatment of alopecia.1e3 The use of this technique to treat scalp wounds with exposed calvarium has been limited. Our search of the English literature yielded only two reports of scalp-tissue expansion for coverage of wounds with exposed calvarium.4,5 These wounds were due to trauma and cancer extirpation. We report the case of a patient who presented with multiple, chronic, scalpburn wounds with exposed calvarium. He was treated successfully with adjacent scalp-tissue expansion and coverage of the scalp defects with hair-bearing skin.
Case report An otherwise healthy 14-year-old male presented to the Boston Shriner’s Hospital with chronic scalp wounds and exposed calvarium 6 months after he sustained an electrical burn injury in Poland (Figure 1, left). On the day of admission, the patient was taken to the operating room where three tissue expanders of 200, 325 and 450 cc capacity (McGhan Medical Corporation, Irvine, CA, USA) were placed via separate incisions under the scalp adjacent to his exposed calvarium (Figure 1, centre). He was given perioperative intravenous antibiotics and discharged from the hospital on the postoperative day 7. His open wounds were managed with local wound care consisting of saline-moist gauze. His expanders were slowly inflated over the next 4.5 months and the wounds were closely monitored. There were no infections or prosthetic-related
complications. After expansion was complete (Figure 1, right), the patient was brought back to the operating room where the expanders were removed and the redundant scalp was used to close the wounds with local flaps (Figure 2). His postoperative course was uncomplicated.
Discussion Tissue expander placement next to an open wound may predispose to infection and may pull on the wound margins, thus enlarging the wound and risking prosthetic exposure. These risks are further compounded in the setting of chronic wounds where the tissues are next to the rigid scar. The unique anatomy of the scalp, however, allows for safe and expeditious expansion despite these risks. The blood supply of the scalp is robust, hence decreasing the chances of infection. The tissue expanders placed under the scalp expand only the tissues directly above them. Perhaps because of the unyielding galea aponeurotica, the scalp about 1e2 cm away from the expander margin is generally undisturbed by tissue expansion. As a result, proximate placement of multiple tissue expanders can be well tolerated despite open wounds. This allows the use of expansion, which is the most favourable reconstructive technique for the scalp, as it provides durable hair-bearing tissue. Mathews and Missotten described early tissue expansion to close a traumatic defect of the scalp and pericranium by inserting a tissue expander under the distant scalp.5 They noted that placement of the expander far from the defect prevented enlargement of the defect during expansion. We did not find this to be necessary. As the wound tissues were tightly adherent to the underlying skull, the wound did not enlarge, but actually contracted (Figure 1, right). Placing incisions next to the defect allowed preservation of the peripheral blood supply to the scalp while permitting controlled undermining away from the wound edges. Kiyono et al.4 used expanded scalp flaps to cover a 7-cm scalp wound with loss of all layers, including periosteum, after cancer extirpation. They placed a tissue expander under the scalp through the defect and sewed marlex mesh to the wound edges. The mesh acted as a high-tensilestrength buttress to prevent wound enlargement and prosthetic exposure during expansion. In our experience, this is unnecessary, as wound contraction and a small rim of unexpanded scalp prevent wound enlargement.
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.11.089
e630
Correspondence and communication
Figure 1 Preoperative view of open scalp wound with exposed calvarium after burn (left). Note that the right mastoid scalp and upper neck have also been burned with resultant distortion of the mastoid hairline. Two weeks after the placement of three tissue expanders via incisions placed next to the wounds (centre). Location of each tissue expander is noted by an asterisk. Four-and-ahalf month postoperative view (right), just prior to removal of tissue expanders and wound closure. Note that the larger central wound has partially closed.
Figure 2 Postoperative views of the occipital scalp (left) and the right mastoid hairline (right) taken 1.5 years after the reconstruction. The hair has been parted to show the minimal extent of remaining alopecia.
Reconstruction of chronic scalp wounds with exposed calvarium can be challenging. We describe the expansion of local scalp tissue to cover a chronic scalp-burn wound with exposed calvarium. Durable, well-vascularised, hairbearing coverage was provided with minimal morbidity in two stages. As presented in this report, the scalp is a privileged site for tissue expansion.
Conflict of interest statement None.
References 1. MacLennan SE, Corcoran JF, Neale HW. Tissue expansion in head and neck burn reconstruction. Clin Plast Surg 2000;27:121.
2. Manders EK, Graham 3rd WP, Schenden MJ, et al. Skin expansion to eliminate large scalp defects. Ann Plast Surg 1984;12:305. 3. Donelan MB. Discussion of: complications of controlled tissue expansion in the pediatric population. Plast Reconstr Surg 1988; 82:846. 4. Kiyono M, Matsuo K, Fujiwara T, et al. Repair of scalp defects using a tissue expander and Marlex mesh. Plast Reconstr Surg 1992;89:349. 5. Matthews RN, Missotten FE. Early tissue expansion to close a traumatic defect of scalp and pericranium. Br J Plast Surg 1986;39:417.
Emily Ridgway Harvard Plastic Surgery Training Program, Boston, MA, USA Amir Taghinia Matthias Donelan Shriner’s Hospital, Boston, MA, USA
CORRESPONDENCE AND COMMUNICATION
Scalp-tissue expansion for a chronic burn wound with exposed calvarium Scalp wounds with calvarial exposure present a complex clinical challenge and require a systematic approach for reconstruction. Local flaps are ideal for small wounds but are rarely adequate for larger defects. Skin grafts can be a useful option, but require removal of the outer table, thus increasing the complexity and risks of the reconstruction. Skin grafts on trabecular bone also break down easily. Free flap tissue transfer is an option, but requires microvascular expertise and a complex, multi-staged reconstructive effort with the potential possibility of donor-site morbidity. Scalp-tissue expansion is a validated, reliable and safe technique for the treatment of alopecia.1e3 The use of this technique to treat scalp wounds with exposed calvarium has been limited. Our search of the English literature yielded only two reports of scalp-tissue expansion for coverage of wounds with exposed calvarium.4,5 These wounds were due to trauma and cancer extirpation. We report the case of a patient who presented with multiple, chronic, scalpburn wounds with exposed calvarium. He was treated successfully with adjacent scalp-tissue expansion and coverage of the scalp defects with hair-bearing skin.
Case report An otherwise healthy 14-year-old male presented to the Boston Shriner’s Hospital with chronic scalp wounds and exposed calvarium 6 months after he sustained an electrical burn injury in Poland (Figure 1, left). On the day of admission, the patient was taken to the operating room where three tissue expanders of 200, 325 and 450 cc capacity (McGhan Medical Corporation, Irvine, CA, USA) were placed via separate incisions under the scalp adjacent to his exposed calvarium (Figure 1, centre). He was given perioperative intravenous antibiotics and discharged from the hospital on the postoperative day 7. His open wounds were managed with local wound care consisting of saline-moist gauze. His expanders were slowly inflated over the next 4.5 months and the wounds were closely monitored. There were no infections or prosthetic-related
complications. After expansion was complete (Figure 1, right), the patient was brought back to the operating room where the expanders were removed and the redundant scalp was used to close the wounds with local flaps (Figure 2). His postoperative course was uncomplicated.
Discussion Tissue expander placement next to an open wound may predispose to infection and may pull on the wound margins, thus enlarging the wound and risking prosthetic exposure. These risks are further compounded in the setting of chronic wounds where the tissues are next to the rigid scar. The unique anatomy of the scalp, however, allows for safe and expeditious expansion despite these risks. The blood supply of the scalp is robust, hence decreasing the chances of infection. The tissue expanders placed under the scalp expand only the tissues directly above them. Perhaps because of the unyielding galea aponeurotica, the scalp about 1e2 cm away from the expander margin is generally undisturbed by tissue expansion. As a result, proximate placement of multiple tissue expanders can be well tolerated despite open wounds. This allows the use of expansion, which is the most favourable reconstructive technique for the scalp, as it provides durable hair-bearing tissue. Mathews and Missotten described early tissue expansion to close a traumatic defect of the scalp and pericranium by inserting a tissue expander under the distant scalp.5 They noted that placement of the expander far from the defect prevented enlargement of the defect during expansion. We did not find this to be necessary. As the wound tissues were tightly adherent to the underlying skull, the wound did not enlarge, but actually contracted (Figure 1, right). Placing incisions next to the defect allowed preservation of the peripheral blood supply to the scalp while permitting controlled undermining away from the wound edges. Kiyono et al.4 used expanded scalp flaps to cover a 7-cm scalp wound with loss of all layers, including periosteum, after cancer extirpation. They placed a tissue expander under the scalp through the defect and sewed marlex mesh to the wound edges. The mesh acted as a high-tensilestrength buttress to prevent wound enlargement and prosthetic exposure during expansion. In our experience, this is unnecessary, as wound contraction and a small rim of unexpanded scalp prevent wound enlargement.
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.11.089
e630
Correspondence and communication
Figure 1 Preoperative view of open scalp wound with exposed calvarium after burn (left). Note that the right mastoid scalp and upper neck have also been burned with resultant distortion of the mastoid hairline. Two weeks after the placement of three tissue expanders via incisions placed next to the wounds (centre). Location of each tissue expander is noted by an asterisk. Four-and-ahalf month postoperative view (right), just prior to removal of tissue expanders and wound closure. Note that the larger central wound has partially closed.
Figure 2 Postoperative views of the occipital scalp (left) and the right mastoid hairline (right) taken 1.5 years after the reconstruction. The hair has been parted to show the minimal extent of remaining alopecia.
Reconstruction of chronic scalp wounds with exposed calvarium can be challenging. We describe the expansion of local scalp tissue to cover a chronic scalp-burn wound with exposed calvarium. Durable, well-vascularised, hairbearing coverage was provided with minimal morbidity in two stages. As presented in this report, the scalp is a privileged site for tissue expansion.
Conflict of interest statement None.
References 1. MacLennan SE, Corcoran JF, Neale HW. Tissue expansion in head and neck burn reconstruction. Clin Plast Surg 2000;27:121.
2. Manders EK, Graham 3rd WP, Schenden MJ, et al. Skin expansion to eliminate large scalp defects. Ann Plast Surg 1984;12:305. 3. Donelan MB. Discussion of: complications of controlled tissue expansion in the pediatric population. Plast Reconstr Surg 1988; 82:846. 4. Kiyono M, Matsuo K, Fujiwara T, et al. Repair of scalp defects using a tissue expander and Marlex mesh. Plast Reconstr Surg 1992;89:349. 5. Matthews RN, Missotten FE. Early tissue expansion to close a traumatic defect of scalp and pericranium. Br J Plast Surg 1986;39:417.
Emily Ridgway Harvard Plastic Surgery Training Program, Boston, MA, USA Amir Taghinia Matthias Donelan Shriner’s Hospital, Boston, MA, USA