Case Series/Study

(CS-143) Management of Scalp Avulsion and Exposed Calvarium in the Critically-ill Patient With Resorbable Nanofiber Wound Matrix and Bilayer Collagen Matrix.

Co-Author(s):

Luccie Wo, MD – Resident, Plastic Surgery; Joanne Buitrago, MD – Resident, Plastic Surgery; Taylor Crist, MD – Resident, Plastic Surgery; Wrood Kassira, MD – Attending Physician, Associate Program Director, Plastic Surgery, University of Miami / Jackson Memorial Hospital

Introduction: Scalp avulsion is a devastating injury associated with traumatic injuries to the head. Management typically entails replantation, readvancement, grafting, or closure; however, immediate coverage of the wound may be contraindicated or incur significant morbidity.1 Herein, we present a case of scalp avulsion with exposed calvarium in a patient with significant confounding injuries preventing surgical repair and managed with local wound care.

Methods: We report a case of a 58-year-old-male sustaining multiple injuries from a motorcycle crash, including subdural hemorrhage, spinal fractures with diffuse axonal injury, colonic injuries, liver laceration, and scalp avulsion. On arrival, the patient was critically ill and underwent multiple emergent surgeries and procedures. Intracranial pressure monitors were placed along with an external ventricular drain through the re-approximated scalp. His course was complicated by sepsis, prolonged respiratory failure, and infected scalp hematoma colonized by Acinetobacter, and subsequent necrosis of the scalp flap resulting in a wound with 100cm2 of exposed calvarium.

Results: Management with negative pressure wound therapy (NPWT)⁺ with instillation and dwell (NPWTi-D)⁺ with dilute sodium hypochlorite solution was initially applied to the wound for 14 days. Following this, application of a resorbable nanofiber wound matrix† was placed on the wound with NPWTi-D⁺ therapy continuing, twice weekly, for 30 days. The wound developed significant granulation tissue, with piecemeal areas of exposed calvarium. These exposed areas were trephinated with a pineapple burr, and a bilayer collagen matrix+ was applied, and NPWT⁺ continued for 30 days. At this time, the wound had improved to a vascular bed that was amenable to skin grafting, and subsequently underwent split thickness skin grafting of 58cm2.

Discussion:
Total scalp avulsion is a significant injury that is amplified in the critically ill patient and can become a complex wound that is difficult to manage. When patients cannot tolerate immediate operative intervention, management with local wound care in the interim is a viable alternative. The use of NPWT⁺, synthetic resorbable nanofiber matrix† and bilayer collagen matrix* with trephination of the calvarium is an appropriate alternative to bridge to definitive coverage of a scalp wound.

Trademarked Items: +V.A.C. VERAFLO™ Dressing or V.A.C. VERAFLO CLEANSE CHOICE™ Dressing or V.A.C.® Therapy; V.A.C.® GRANUFOAM™ (KCI, now part of 3M Company, San Antonio, TX)
* Integra® Bilayer Wound Matrix (Integra LifeSciences Corp., Princeton, NJ)
†Restrata Wound Matrix; (Acera Surgical Inc, St Louis, MO)

References: 1. Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp defects: an algorithmic approach. Plast Reconstr Surg. 2005 Sep 15;116(4):54e-72e. doi: 10.1097/01.prs.0000179188.25019.6c. PMID: 16163072.