LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 2 | Page : 106-108
Exposed bone with scalp and pericranial loss: Role of multiple calvarial drillings in aiding closure
Dipmalya Chatterjee1, Nabanita Ghosh2, Sachinkumar Maheshbhai Patel3, Prasad Krishnan3
1 Department of Plastic Surgery, Peerless Hospital and B K Roy Research Centre, Kolkata, West Bengal, India
2 Department of Neuroanesthesiology, National Neurosciences Centre Peerless Hospital Campus, Kolkata, West Bengal, India
3 Department of Neurosurgery, National Neurosciences Centre Peerless Hospital Campus, Kolkata, West Bengal, India
|Date of Web Publication||20-Aug-2019|
Department of Neurosurgery, National Neurosciences Centre Peerless Hospital Campus, 2nd Floor 360 Panchasayar Kolkata-700094 West Bengal.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chatterjee D, Ghosh N, Patel SM, Krishnan P. Exposed bone with scalp and pericranial loss: Role of multiple calvarial drillings in aiding closure. J Pediatr Neurosci 2019;14:106-8
A 4-year-old right-handed boy sustained multiple scalp and facial injuries without any intracranial injury following a road traffic accident. The skin with galea and pericranium was found to be partially avulsed off the bone and areas of skin loss were present [Figure 1]A and [Figure 1]B. Initially, a wound debridement was carried out and primary repair was attempted with distal galeal release incisions. After 1 week, a large part of the skin had blackened and could be clearly demarcated from the surrounding viable areas [Figure 1]C. As initially the pericranial loss was noted to be extensive, no attempt was made to advance a flap from the neighboring tissues. Multiple holes were drilled in the outer cortex of the exposed bone [Figure 2]A and saline dressing was continued on alternate days under ketamine anesthesia for the following 3 weeks. Granulation tissue started sprouting out of the holes [Figure 2]B and began covering exposed bone, and when the bed was red and healthy [Figure 2]C, the patient underwent a split skin graft to achieve closure [Figure 2]D.
|Figure 1: Clinical photographs of a child with road traffic accident showing (A) a large irregular area of skin laceration and scalp loss on the left frontoparietal area, (B) other facial soft tissue injuries are seen, and (C) skin necropsies and exposed bone after primary repair failed|
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|Figure 2: Clinical photographs showing (A) multiple holes drilled through the outer cortex, (B) granulations sprouting from the diploic space, (C) the exposed bone is completely covered by granulations and the graft bed is ready, and (D) split skin graft has been carried out|
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Following road traffic accidents, children often present with areas of exposed skull. This is consequent to both the injury itself and also the loose attachment of the deepest layer of the scalp (pericranium) to the underlying bone, which results in its detachment when a shearing force is applied. If the margins of the wound are viable and there is no skin loss, the best option is a primary scalp repair. However, in the presence of devitalized skin or when the patient presents very late with contraction of the margins, the options of closure include the following: release incisions on the galea with undermining of the skin to draw the edges closer, rotation flaps (pedicled flaps), or microvascular free flaps. In our case, the exposed bone appeared to be infected and loss of pericranium was observed. The wound margins were not bleeding and galeal release incisions had already been placed the first time repair was attempted. So we proceeded with making multiple holes in the outer cortex to allow the diploe to granulate.
The oldest reference we could find of this technique was from a study by Mellish in 1904 who mentioned that a Dr. Vance in 1777 instructed a Dr. Robertson to bore the skull of a patient with scalp loss and to blacken the skull till a reddish fluid came out and aided in granulation formation. Skin from the sides grew up on it very slowly over time. Flaherty described the technique in greater detail in 1914 and used a trephine to make holes on the outer table of the skull and proceeded with grafting once granulation tissue had formed. Over time, however, rotation flaps and microvascular free flaps became the gold standard for providing skin cover. Their main advantage was lack of waiting time for the wound to granulate and obviation of the need for repeated dressings. Furlanetti et al. have mentioned that the technique of multiple drilling with subsequent grafting can be used even in total scalp avulsion “when microsurgical replantation fails or is not feasible.” Calderoni et al. likewise stated that the procedure helps granulation tissue to form and in the interim time, scalp expanders can be used at adjacent sites to increase the available tissue for closure. We had made multiple holes with a high-speed cutting burr taking care not to injure the dura. Drilling was stopped when there was bleed from the diploic spaces. Over the next few days, granulation tissue started sprouting out of the holes and joined with their fellows from adjacent holes and created a carpet that covered the skull on which grafting could be carried out. Though classical description is that the holes be made 1cm apart, we preferred to make them closer so that the bone would be covered faster. There are also encouraging reports, that removing outer cortex of the exposed skull over its entirety and going for grafting in the same procedure with or without vacuum-assisted closure drains result in good take of the graft. This method minimizes hospital stay and costs. However, we did not opt for a single stage procedure due to apprehensions of split skin graft failure and fear of osteomyelitis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mellish JE Total avulsion of the scalp. Ann Surg 1904;40:644-9.
Flaherty F Complete avulsion of the scalp: with a report of a case. Ann Surg 1914;59:186-90.
Calderoni DR, Rosim ET, Kharmandayan P Successful calvarial bone salvage using multiple outer table perforation technique on total scalp avulsion injury. Eur J Plastic Surg 2013; 36:49.
Furlanetti LL, de Oliveira RS, Santos MV, Farina JA Jr, Machado HR Multiple cranial burr holes as an alternative treatment for total scalp avulsion. Childs Nerv Syst 2010;26:745-9.
Doumit GD, Schmidek A, Yaremchuk MJ Principles of scalp surgery and surgical management of major defects of scalp. In: Quinones-Hinojosa A, editor. Schmidek and Sweet operative neurosurgical techniques: indications, methods and results. 6th ed. Vol 2. Philadelphia, PA: Elsevier Saunders; 2012. pp. 1598.
Pitkanen JM, Al-Qattan MM, Russel NA Immediate coverage of exposed, denuded cranial bone with split-thickness skin grafts. Ann Plast Surg 2000;45:118-21.
Molnar JA, DeFranzo AJ, Marks MW Single-stage approach to skin grafting the exposed skull. Plast Reconstr Surg 2000;105:174-7.
[Figure 1], [Figure 2]