Partial-Thickness Skull Wounds Treated Without Free Tissue Transfer in an Outpatient Setting

Partial-thickness skull wounds after cancer or trauma are often treated with free tissue transfer. This technique may lead to secondary donor site morbidity and prolonged hospitalization. Other techniques for skin grafting these defects include negative pressure wound therapy and, again, associated prolonged inpatient hospitalization. We present a small case series of post-traumatic and cancer patients with partial-thickness skull wounds (exposed outer cortex and no periosteum), with wounds greater than 60 square centimeter, that were completely healed in less than six weeks in an outpatient setting.

Post-traumatic or oncologic resection was performed in the operating room with a bone burr to prepare the skull. Acellular matrix powder was applied in a slurry of hydrogel, covered with aceullar dermal matrix sheets, and affixed with a self-contained dressing consisting of petroleum fine mesh gauze, dry coarse mesh gauze, and oil emulsion dressing under stapled tension. Patients returned one week later to an office setting for reapplicaton of acellular matrix powder in the hydrogel slurry if indicated. Split-thickness skin grafting was performed again in an outpatient setting when adequate granulation tissue was clincially evident. A similar bolster dressing was used as graft fixation and the patient discharged on the day of skin grafting. Graft adherence was assessed at weekly postoperative intervals.

Healing was complete within six weeks of the original resection in 66% of the cases and would have been possible had oncologic treatment not delayed the grafting. Free tissue transfer is often though to be necessary in patients undergoing radiation treatment because of the vascularity associated with the reconstruction. Oncologic patients treated with our method tolerated postoperative radiation therapy when indicated. We have adopted this technique in lieu of free tissue transfer as a cost-effective outpatient method for treating this complex patient cohort.