Scalp Reconstruction

A Review of the Literature and a Unique Case of Total Craniectomy in an Adult With Osteomyelitis of the Skull

John P. Tutela, MD; Jonathan C. Banta, BS; Travis G. Boyd, MD; Sean S. Kelishadi, MD; Saeed Chowdhry, MD; Jarrod A. Little, MD


ePlasty. 2014;14 

In This Article


Our patient, VS, is a 54-year-old white woman who sustained a scalp wound while moving a refrigerator at work. She developed a hematoma that was observed and subsequently became infected. Her medical history was insignificant except an extensive tobacco use. She underwent an incision and drainage; however, her scalp infection was recalcitrant to treatment and required multiple debridements. Eight months after her initial injury, she was found unresponsive by her family at home and was brought to an outside hospital. Computed tomographic (CT) scan of her head demonstrated a right parietal lobe subdural empyema causing a left midline shift and a moth eaten appearance of the calvarium. Her white blood cell count was 28,000. She underwent a right frontoparietal craniotomy. On her first postoperative day, she was taken back to the operating room (OR) for a decompressive craniectomy of the right frontotemporal parietal bone for increasing intracranial pressure.

The patient's initial culture of the drained subdural empyema grew Streptococcus intermedius and the patient was started on ceftriaxone. Upon stabilization on hospital day 7, she was transferred to our institution for further management. Her CT scan on her admission to our institution confirmed full-thickness destruction of her cranial vault (Fig 1). On presentation, she was verbally nonresponsive, would withdraw from pain, and displayed left-sided weakness. Upon examination, there was an 8 × 8 cm2 area of chronically infected scalp (Fig 2). Her white blood cell count was 23,000 and her alkaline phosphatase was 389.

Figure 1.

Computed tomographic image demonstrating full-thickness osteomyelitis of the cranium.

Figure 2.

Preoperative photograph showing an 8 × 8 cm2 area of a chronically infected scalp wound. A halo was secured around the patient's head to suspend it without pressure in the postoperative period.

The patient was taken to the OR, in conjunction with the neurosurgical team. A halo was placed to keep her head suspended without pressure on her bed postoperatively. Scalp flaps were raised revealing full-thickness destruction of the cranium (Fig 3). Debridement of the infected cranium resulted in a skull defect approximately 50 cm in circumference (Fig 4). A dural defect was noted at the site of the original craniectomy site and was covered with Duragen (Integra LifeSciences Corporation, Plainsboro, New Jersey). Culture from bone specimen grew Pseudomonas aeruginosa, and her antibiotic was changed to cefepime. Wet to moist dressings with one-eighth strength daikins solution were then placed under the scalp flaps and the flaps were approximated. Dressings were changed every 8 hours.

Figure 3.

Intraoperative photographs showing full-thickness osteomyelitis of the cranium as well as the "moth-eaten" appearance of the underlying bone after the bone flap was lifted.

Figure 4.

Sagittal computed tomography of patient's head showing the extent of skull debridement required for treatment.

On postoperative day 7, she was taken back to the OR for further debridement and for drainage of a frontal lobe abscess. Following debridement of devitalized dura, bovine pericardium (Edwards Lifesciences Corporation, Irving, California) was used as a sling to support the brain parenchyma. At this time, cultures from the wound grew Candida albicans, but the abscess failed to show any growth. Amphotericin B was added to her antimicrobial regimen.

On postoperative day 27, when the wound cultures showed no growth from qualitative cultures, the patient was taken to the OR for wound coverage with a free omental flap (Fig 5). A free latissimus dorsi flap was also high on our list of potential donor flaps for its size and durability, however, because our patient lacked proper cranial support of her brain to allow for lateral decubitis or prone positioning we felt it was best to keep her in the supine position. Omental harvest allowed for this approach. Acellular dermal matrix (Alloderm, Lifecell Corporation, Bridgewater, New Jersey) was secured to the granulating bed overlying the dura and under the remaining scalp flaps with the intention of adding durability to the soft tissue reconstruction. The omental flap was harvested, anastomosed to the patient's right superficial temporal artery, and laid over the newly placed acellular dermal matrix. A split-thickness skin graft was used for final coverage over the omental flap once the viability of the flap was verified (Fig 6).

Figure 5.

Intraoperative photographs showcasing free omental flap harvest and subsequent coverage.

Figure 6.

Postoperative photograph of the patient's scalp showing the skin graft overlying the defect.