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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 52  |  Issue : 2  |  Page : 63-65

Closing of postoperative integument, skull bones and dura defects


1 Department of Neurosurgery, Shuang Ho Hospital; Department of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
2 Federal State-Financed Institution Federal Siberian Research Clinical Centre under Federal Medical Biological Agency of Russia, Krasnoyarsk, Russia

Date of Submission21-Aug-2018
Date of Decision01-Oct-2018
Date of Acceptance12-Feb-2019
Date of Web Publication18-Apr-2019

Correspondence Address:
Dr. Evgeny G Sobakar
Federal State-Financed Institution Federal Siberian Research Clinical Centre under Federal Medical Biological Agency of Russia, Kolomenskaya Street, 26, Krasnoyarsk, Krasnoyarsk Region, 660037
Russia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_88_18

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  Abstract 

This article describes skull defect plastic, which is especially relevant, and in particular, cases, is a great challenge for surgeons. The clinical case described covers formation of a defect in the cranial vault bones, complicated by skin integument, skull bones, and the dura matter defects.

Keywords: Cranioplasty, dura matter defects, postoperative integument defects, reconstructive surgery, skull bones defects


How to cite this article:
Lin JW, Sobakar EG, Ivanov OV, Semichev EV. Closing of postoperative integument, skull bones and dura defects. Formos J Surg 2019;52:63-5

How to cite this URL:
Lin JW, Sobakar EG, Ivanov OV, Semichev EV. Closing of postoperative integument, skull bones and dura defects. Formos J Surg [serial online] 2019 [cited 2019 Aug 25];52:63-5. Available from: http://www.e-fjs.org/text.asp?2019/52/2/63/256536


  Introduction Top


Cranioplasty is a reconstructive surgery consisting of repair of skull bones and the dura mater defects, caused by trauma or surgery.[1]

Protakril implants, being the most commonly used materials, have several advantages. They are easy to model and have a relatively low cost. However, they cause a greater risk of complications during the postoperative period. Toxic and allergenic effects of the mixture components may cause local inflammatory reactions. The use of titanium implants is the most preferable due to their high biocompatibility, high mechanical strength, and low specific weight.[2] Titanium has no toxic effect on the tissues while achieving direct contact with the bone. In addition, due to the low risk of development of pyo-inflammatory complications, titanium implants can be used in craniofacial lesions with the paranasal sinuses involvement.[3],[4],[5] Despite the constant development of new techniques and materials to eliminate defects in the skull, the cranioplasty issue remains relevant. Often, simultaneously with cranioplasty, it is necessary to resolve the question of skin integument and the dura matter. The reconstruction of the skin integument is often solved by resection of scar tissue, relocation, and rotation of the skin integument flap and for dealing with extensive scar surfaces, a preliminary extension of the skin integument by subcutaneous implantation of expanders and plastic-free splitting skin integument flap is required. With extensive soft-tissue defects, the method of “walking flap” or “Filatov stalk” was often used. Nevertheless, taking into consideration several complications caused by this technique, its duration, as well as the modern development of microsurgical technologies (prefabrication of flaps, transplantation, and transposition of tissue complexes), the described technique has ceased to apply in clinical practice.[3]


  Case Report Top


The article describes a clinical case of the reconstruction of the skin integument, skull bones, and dura mater postoperative defect in a patient. The patient was admitted to the hospital on an emergency basis. The hemorrhagic stroke in the form of subarachnoid hemorrhage caused by the rupture of the superior mesenteric artery (SMA) saccular aneurysm (Hunt and Hess Grade II, Fisher Grade III) was diagnosed. The patient was conscious, focused, sociable, without any focal signs, but he had moderate cerebral and meningeal symptoms. The patient underwent an emergency craniotomy for SMA aneurysm clipping under a microscope.

In the postoperative period, the patient had a complication. A massive right-hemispheric ischemic stroke developed against the background of the surgical intervention and the postoperative vasospasm, the patient had the symptomatic of the dislocation syndrome, oppression of consciousness to coma I.

The urgent decompression surgery with extended cranial vault resection in the right frontotemporal part with the reconstruction of the dura mater was performed. Following surgical site infection, repeated surgical inspections, and necrectomy of the wound edges resulted in an extensive defect of the skin and cranial vault bones as well as in the dura mater defect in the right frontotemporal part [Figure 1].
Figure 1: Photo was taken after treatment for purulent process and cleaning the wound

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To close the defect of the surgical wound, it was decided to resect the open area of the skull bone and to perform the autoplasty with free split-thickness graft taken from the hip. At the first stage, the resection of nonviable bone was performed [Figure 2] and [Figure 3].
Figure 2: Photo was taken after the removal of the open bone area, resection of scar-deformed skin integument edges, and imposing suggestive stitches

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Figure 3: Photo was taken 10 days after surgery after the stitches were removed

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At the second stage, autodermoplasty was performed with a free split flap thickness of 0.4 cm from the front surface of the right thigh [Figure 4] and [Figure 5].
Figure 4: Photo was taken during autodermoplasty

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Figure 5: Photo was taken 10 days after autodermoplasty

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On the pictures presented above, autografts have successfully healed, both on the dura mater and on the free brain tissue. The absence of liquorrhea is explained by the fusion of the skin integument along the defect edges and by the limitation of the subarachnoid space.

The patient was discharged for further rehabilitation treatment after his condition stabilized.


  Discussion Top


The plastic of the dura mater is performed by using autotransplantation (periosteum and aponeurotic flaps), allografts and xenografts (synthetic membranes).[6]

For surgery performed on the brain and bones of the skull in everyday clinical practice, the most common complications are bleeding with the formation of hematomas, surgical wound infection, necrosis of the skin integument edges of the wound, osteomyelitis, and sepsis. Each of these complications can occur either relatively typically or follow untypical scenario.[7]

Hence, extensive defects of the skin integument and bones of the skull are formed after local infectious processes and necrectomy. The absence of a skin integument barrier in turn forms an open wound with the exposure of both the bones of the skull, the dura matter, and brain tissue. It is difficult to decide how to close the extensive skin integument defects in the absence of the underlying bone flap and the dura matter. In this case, the open wound becomes an additional source of infection and the ongoing liquorrhea. The skull defect can be freely replaced with an artificial graft, but the extensive defect of the skin integument is not so easy to close due to the rigidity and low mobility of the skin epicranial aponeurosis.[1],[8]


  Conclusion Top


The best way to close combined defects of the skull bones and the soft tissue is to use allograft (mesh nikelid-titan plates) and to perform the autodermoplasty with split flaps as well as to apply modern techniques of balloon dilatatie, prefabrication of flaps with their subsequent transposition or transplantation.[2],[3],[9] When curating patients with a severe form of disease in neurosurgical departments, it is necessary to take into account the fact that time does not play in favor of the patient. It is necessary to make a clear, balanced decision, not delayed in time, as well as to assess the severity of patient who will not be able to tolerate complex reconstructive surgeries simultaneously, so it is necessary to stabilize the patient and perform the first stage which is the “simplest” reconstructive surgery to close a large defect. For this stage, the most suitable is autodermoplasty with split flaps. Later, after the patient's condition is stabilized and infectious processes are stopped, it is recommended to carry out a number of reconstructive surgeries to close defects of the skull bones and soft tissues.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Blokhin NN, Trapeznikov NN, Aliev DA. Plastic surgery for malignant skin tumors. Moscow, Russia: Meditsina; 1979. p. 207.  Back to cited text no. 1
    
2.
Lebedev VV, Krylov VV. Emergency neurosurgery. Doctor's guide. Moscow: Medicine; 2000. p. 568.  Back to cited text no. 2
    
3.
Semichev EV, Malinovskaya IS, Senichev DN. Vascular track of the axial flap and the recipient bed in the early stages after flap coverage of wound. Bulletin of Siberian Medicine 2008;7:52-8.  Back to cited text no. 3
    
4.
Lin SJ, Hanasono MM, Skoracki RJ. Scalp and Calvarial Reconstruction. Semin Plast Surg 2008:281.  Back to cited text no. 4
    
5.
Sweeny L, Eby B, Magnuson JS, Carroll WR, Rosenthal EL. Reconstruction of scalp defects with the radial forearm free flap. Head Neck Oncol 2012;4:21.  Back to cited text no. 5
    
6.
Nerobeev AI. Plasty of extensive defects of head and neck tissues with complex flaps with axial vascular pattern. Moscow: Abstract of a Thesis; 1982. p. 272.  Back to cited text no. 6
    
7.
Kapustina OG. Diagnosis and optimization for treatment skin tumors in outpatient practice of a dermatologist. Moscow: Dissertation; 2009. p. 312.  Back to cited text no. 7
    
8.
Elistratov OB. Experience of usage various reparative materials to close defects of the bones of the cranial vault. Available from: www.gkb3.ru/document.php?id=591. [Last accessed on 2018 Jun 04].  Back to cited text no. 8
    
9.
Matyakin EG. Reconstructive plastic surgery for head and neck tumors. Head and neck tumors. Moscow: European School of Oncologists; 1993. p. 158.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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