Traumatic Scalp Defects: Case Studies And Treatment Approaches
Overview
The management of traumatic scalp defects presenting with exposed calvaria devoid of pericranium is a formidable clinical challenge. This case series details the successful treatment of such cases through a combination of low-temperature plasma (LTP) and negative pressure wound therapy (NPWT). In a retrospective single-surgeon case series involving three patients, cortical calvarial bone removal followed LTP treatment, which was applied weekly or bi-weekly to the diploic space of the calvaria using BioPlasmaJet BPJ1, followed by NPWT with continuous pressure. The results showed that this combined approach yielded well-developed granulation tissue within an average of 4 weeks, facilitating successful skin grafting without complications, infection, or calvarial issues, marking it as a secure and efficacious modality for managing challenging traumatic scalp defects.
Introduction
Management of traumatic scalp defects featuring exposed calvaria devoid of pericranium poses a formidable clinical challenge, often necessitating multiple interventions to achieve optimal healing and functional as well as esthetic outcomes. The early reconstruction or appropriate wound dressing in such cases is paramount to prevent desiccation, sequestration, and sepsis of the exposed calvarial bone. In scenarios where reconstruction with local or free flaps is unfeasible, skin grafting serves as a rapid, straightforward, and reliable method for addressing medium-to-large scalp defects, especially when cosmesis is not a primary concern. However, challenges arise with skin graft adherence and survival on exposed calvaria without pericranial coverage. Adjunctive therapies such as milling or drilling the outer cortex of the calvaria, cortical craniectomy to expose the diploic space, and negative-pressure wound therapy (NPWT) have been explored to enhance granulation tissue formation. NPWT, a well-established approach, leverages negative pressure to foster wound healing by removing excess fluids, improving blood flow, reducing bacterial colonization, and promoting granulation tissue formation. Nonetheless, the application of NPWT can be associated with patient discomfort due to pain.
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Low-temperature plasma therapy (LTP) emerges as a novel treatment modality that promotes wound healing through the induction of angiogenesis, stimulation of cell proliferation and migration via intracellular signaling pathways, as well as the reduction of inflammation and antimicrobial effects via lipid peroxidation. This case series details the application of a combination of NPWT and LTP following cortical craniectomies with the intent of promoting granulation tissue formation, preventing local infection, and potentially reducing the duration of NPWT in three patients.
Case 1
A 37-year-old male patient with a 6 cm wide by 18 cm long scalp defect resulting from a lightning burn was referred from a regional hospital. The patient had previously undergone debridement, drilling of the outer cortex of the calvaria, and NPWT. Exposed calvaria with minimal granulation tissue necessitated initial cortical craniectomy and subsequent LTP therapy, followed by NPWT. After four weeks of treatment, significant granulation tissue formation allowed for successful reconstruction with a split-thickness skin graft, although the patient reported moderate pain during the NPWT period.
Case 2
A 17-year-old female patient presented with an 8 cm by 10 cm scalp defect resulting from a motorcycle accident. Prior to referral, she had undergone wound debridement and suturing. Exposed frontal bone with limited granulation tissue prompted cortical craniectomy, LTP therapy, and NPWT. A second cortical craniectomy was performed after four weeks to address areas with insufficient granulation tissue. Six weeks of treatment led to significant granulation tissue formation, suitable for split-thickness skin grafting. However, the patient experienced severe pain during the NPWT treatment period.
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Case 3
A 35-year-old male patient with a 4 cm by 12 cm scalp defect due to a motorcycle accident was referred from a regional hospital. Granulation tissue covered a substantial portion of the exposed parietal bone. Following cortical craniectomy and LTP therapy in the diploic space, the old granulation tissue underwent NPWT. Two weeks of treatment yielded substantial granulation tissue formation, facilitating reconstruction with a split-thickness skin graft. The patient reported mild pain during the NPWT treatment period, which was controlled with non-opioid medication.
These cases highlight the potential benefits of combining LTP and NPWT as an innovative approach to manage traumatic scalp defects characterized by exposed calvaria denuded of pericranium, emphasizing the promotion of granulation tissue formation and the prevention of local infections while addressing the associated discomfort during NPWT application.
Discussion
Managing traumatic scalp defects characterized by exposed calvariae devoid of the pericranium presents a complex clinical challenge, particularly when previous partial treatments have been employed. The decision-making process regarding scalp reconstruction involves a multitude of factors, including the defect’s location, size, etiology, tissue quality, wound environment, exposed structures, and potential distortion of the hairline. An essential consideration in reconstructive planning is whether the affected area is hair-bearing or non-hair-bearing, as it significantly impacts the esthetic outcome.
Skin grafting can be problematic in situations where the denuded bone lacks a suitable vascular bed, necessitating the formation of granulation tissue on the exposed bone surface. The time required for granulation tissue to form is estimated to be three times the diameter of the wound in centimeters. Skin grafting is a quick, straightforward, and reliable method for reconstructing medium-to-large scalp defects when esthetics are not a primary concern.
For full-thickness scalp defects with a denuded pericranium, local flaps are often preferred, even though they may lead to relatively slower granulation tissue growth. Additional procedures such as cortical craniectomy, milling, or drilling of the outer cortical calvaria can be performed to expose the diploic space, which offers a well-vascularized environment facilitating granulation tissue formation and serving as a healing bed for secondary skin grafting. The thickness of the calvaria varies based on factors like skull region, race, age, weight, and sex of the patient and should be taken into account when performing these procedures, with a preferable time window within 6-8 weeks.
Negative-pressure wound therapy (NPWT) is a well-documented approach that promotes tissue granulation, reduces wound volume by debriding devitalized tissue, enhances blood flow and tissue perfusion, reduces bacterial colonization, and removes excess serous fluid. However, it often leads to patient-reported pain and discomfort, necessitating the consideration of pain management strategies.
Low-temperature plasma therapy (LTP) presents a nonthermal, noninvasive treatment approach using positive and negative ion gases to stimulate tissue healing through ion-catalyzed peroxidation. This innovative approach, as exemplified by the BioPlasmaJet BPJ1 system, has been shown to induce angiogenesis, promote cell proliferation, reduce inflammation, and exhibit antimicrobial effects, making it a potential option for wound care in cases of non-healing wounds. Notably, LTP is associated with reduced patient discomfort.
Case 1 involved a patient with a substantial vertical scalp defect caused by a lightning burn, necessitating skin grafting due to the unsuitability of large local or rotational flaps and the high risk of flap necrosis. It was crucial to perform cortical craniectomy with care to avoid trauma to the inner cortex of the calvarial bone.
In Case 2, the patient had a large frontal scalp defect, with both hair-bearing and non-hair-bearing areas, making reconstructive decisions challenging. The use of skin grafting was chosen over local flaps or free tissue transfer due to concerns about esthetic outcomes and donor site issues. Milling the outer cortex of the calvaria required caution, particularly in younger female patients, to prevent excessive thinning of the frontal bone. Delaying skin grafting until granulation tissue formation resulted in an inconspicuous depression and discoloration of the forehead scalp, masking the mislocated hairline.
Case 3 featured a parietal scalp defect suitable for skin grafting. LTP therapy was applied twice a week to expedite granulation tissue formation, based on the experience of faster healing in chronic wound management. This approach was expected to facilitate quicker granulation tissue formation compared to previous cases.
Conclusion
The combination of negative-pressure wound therapy (NPWT) and low-temperature plasma therapy (LTP) emerges as a safe and effective treatment modality for managing scalp defects characterized by exposed calvaria devoid of the pericranium, typically resulting from trauma and burns. This innovative approach offers synergistic effects that enhance granulation tissue formation while reducing the duration of negative pressure therapy, all without introducing complications. LTP can be safely applied to such scalp defects, presenting a novel method for scalp reconstruction that prioritizes long-term durability, contour preservation, acceptable cosmesis, and minimal donor-site morbidity. However, further extensive studies are necessary to validate the effectiveness of this approach within larger patient populations, ensuring its widespread clinical applicability and benefits.
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