Reconstruction of Extensive Calvarial Exposure After Major Burn Injury in 2 Stages Using a Biodegradable Polyurethane Matrix

John Edward Greenwood, AM, BSc(Hons), MBChB, MD, DHlthSc, FRCS(Eng), FRCS(Plast), FRACS; Marcus James Dermot Wagstaff, BSc(Hons), MBBS, PhD, FRCS(Plast), FRACS; Michael Rooke, BA(Hons), MBBS; Yugesh Caplash, MBBS, MS, MCh, FRACS

Disclosures

ePlasty. 2016;16(e17) 

In This Article

Abstract and Introduction

Abstract

Objectives: To share our experience of an extensive calvarial reconstruction in a severely burn-injured, elderly patient in a 2-stage procedure utilizing a novel biodegradable temporizing matrix (NovoSorb BTM), followed by autograft.

Materials and Methods: A 66-year-old patient with 75% full-thickness burns, including 7% total body surface area head and neck, with calvarial exposure of approximately 350 cm2, complicated by acute renal failure and smoke inhalation injury. Exposed calvarium was burred down to diploe and biodegradable temporizing matrix was applied. Over the next 29 days, the biodegradable temporizing matrix integrated by vascular and tissue ingrowth from the diploe. Delamination and grafting occurred, however, at 43 days postimplantation of biodegradable temporizing matrix due to skin graft donor-site constraints.

Results: Graft take was complete, yielding a robust and aesthetically pleasing early result (26 days post–graft application).

Conclusions: Biodegradable temporizing matrix offers an additional resource for reconstructive surgeons faced with fragile patients and complex wounds.

Introduction

Soft-tissue coverage of calvarial exposure represents a significant surgical challenge. The technique employed is determined by several factors, and an excellent algorithmic approach was published recently.[1] The common causes of calvarial exposure reported include trauma, tumor extirpation (skin cancers or intracranial lesions, with or without secondary radiotherapy), osteoradionecrosis, chronic osteomyelitis, and electrical injury.[2,3] Options open to the reconstructive surgeon for calvarial coverage are relatively broad because the defects caused are usually relatively small,[2,4–8] although larger defects occasionally result.[9] Many approaches are impractical in acutely burn-injured patients, who need to have their wounds controlled quickly but who lack both the physiological reserve to tolerate long procedures and the unburned resources to allow free tissue transfer.

Dermal substitutes have found value and popularity in reconstruction of the exposed calvarium,[4–9] although more commonly in post–cancer treatment. By burring the outer table and placing the product on to the diploe, a potentially contaminated wound bed can be converted to a clean vascularized structure safely and quickly by an experienced surgeon. Exposed calvarium can be physiologically "closed" early on in the patient's treatment, with minimal systemic disruption. This allows treatment efforts to be directed toward optimizing patient comorbidities and recovery, enabling them later to tolerate more insulting secondary reconstructive surgery and allowing previously harvested graft donor sites to heal robustly.

There are limitations with commercially available biological dermal substitutes, particularly with regard to cost[10] and risk of infection.[11,12]

We describe a 66-year-old male patient with 75% total body surface area (TBSA) full-thickness burns, inhalation injury, and acute renal failure, who was colonized with several pathological microbes, both bacterial and fungal. The burns included 7% TBSA full-thickness injury to the head and circumferential neck, sparing only the eyes and midface with calvarial exposure measuring approximately 18 × 19 cm (~350 cm2).

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