Surgical treatment of scalp ulcers

Received on: 12/04/2011
Approved on: 23/08/201

This study was carried out at the Hospital
Josina Machel, in Luanda, Angola through an
agreement of international technical cooper-
ation with the Universidade Estadual de
Campinas (Unicamp)– Campinas (SP), Brazil.

Conflicts of interests: none
Financial support: None

Abstract

The scalp has a key role in maintaining the integrity of the osseous structure that protects the central nervous system. Its restoration, especially keeping the aesthetic appearance and shape following lesions, is challenging. The present study describes the case of a child with extensive slough and bone exposure in the scalp following a necrotising cellulitis-type infection, which was treated with debridement, microperforation of the calvaria, and application of a gauze bandage with vaseline. Granulation tissue formed after 10 days. A partial skin graft was later carried out with satisfactory results.

Keywords: BACTERIAL INFECTIONS, SCALP, RECONSTRUCTION

INTRODUCTION

The outer protective covering structure of the brain is constituted of different and clearly distinct anatomical structures that can be classified as either soft parts (the scalp and its respec- tive layers) or osseous tissue (calvaria). The soft parts are sub- classified into five different anatomical layers: skin, subcutaneous layer, galea, soft areolar tissue and pericranium. 1 Scalp ulcera- tions can be classified as either partial or total according to their thickness and anatomical compromising.

The clinical history of scalp lesions can be acute or delayed. In full-thickness scalp lesions (i.e., the lesion goes through all scalp layers to expose the calvaria), the osseous struc- ture should be covered with vascularized tissue and the affected site should be properly closed in order to avoid areas of alope- cia. In addition to furunculoid or cavitary myiasis, abscesses and necrotizing cellulite (as seen in the present case), other causes of scalp ulcers are traumatic injuries such as dog bites, burns, and neoplasias. 2

CASE REPORT

A 17-month old patient was admitted to the emergency room of the Hospital Josina Machel (Luanda, Angola) with a neglected furuncle in the frontal region. Treatment had been attempted at home. The boil developed necrotic tissue and full- thickness ulcerated lesions on the scalp (Figure 1). The lesion measured 15 cm and 8 cm at its largest and smallest diameters, respectively, with irregular borders and purulent secretion. The external surface of the calvaria was visible The debridement and cleansing with 0.9% saline solution were carried out, and a dressing with 1% silver sulfadiazine was applied and left in place for two days. The patient was then referred to the surgical cen- ter, where microperforations of the external osseous surface of the calvaria were carried out (Figure 2) and a dressing with petrolatum was applied and removed on the seventh day. On the tenth day, after the lesion was 95% granulated (Figure 3), a partial skin graft was carried out (Figure 4), resulting in the sat- isfactory integration of the graft (Figure 5).

DISCUSSION

In extensive lesions of the scalp, when there is a loss of per- icranium 1 and infection, or when the patient is debilitated, the technique of creating multiple perforations in the external sur- face of the calvaria is the most suitable. This is especially true in children, since their diploë contains a large amount of richly vascularized spongy osseous tissue, which allows the formation of granulation tissue in a few days, on which a thin skin graft can be applied. 3

References

1 . Alpert Bs, Buncke HJ, Mathes SJ. Surgical treatmentebof the totally avulsed scalp. Clin Plast Surg. 1982;9(2):145-59.

2 . Argenta L, Watanabe M, Grabb W. The use of tissue expansin in head and neck reconstrucion. Ann Plastic Surg. 1983;11(1):31-7.

3 . Temple CL, Ross DC. Scalp and forehead reconstrution. Division of Plastic Surgery,Clin Plast Surg. 2005;32(3):377-90.