CLINICAL PAPERS
Vacuum-Assisted Closure Therapy to the Brain A Safe Method for Wound Temporization in Composite Scalp and Calvarial Defects Noah Prince, MD,* Spiros Blackburn, MD,† Gregory Murad, MD,† Bruce Mast, MD,* Stamatis Sapountzis, MD,‡ Christiana Shaw, MD,§ John Werning, MD,k and Dhruv Singhal, MD* Background: When composite scalp and calvarial defects with dural or cortical brain exposure are encountered, active infection or indeterminate oncologic margins complicate the timing of scalp reconstruction. The purpose of this study was to evaluate the safety and efficacy of vacuum-assisted closure (VAC) therapy as a temporizing measure in these complex scalp defects with dural or cortical brain exposure and a hostile local wound environment. Methods: From December 2012 to December 2013, all composite scalp and calvarial defects reconstructed by the senior author (D.S.) were reviewed and 10 cases were identified. Five of these cases were temporized with VAC therapy. The medical records of these patients were reviewed. Results: Five patients (mean age, 66.2 years) with composite scalp and calvarial defects were temporized with VAC therapy. The indications for delay included gross wound infection in 4 patients and an indeterminate intraoperative oncologic margin. The average size of the scalp and calvarial defects measured 123 and 49 cm2, respectively. One patient underwent VAC therapy over exposed cortical brain with a dural defect measuring 25 cm2. The average time between the initial operation and definitive reconstruction was 4.8 days. The average daily VAC output was 74 mL. Reconstructive methods included 1 free flap, 2 scalp rotational advancement flaps, and readvancement of 2 prior free flaps. At an average follow-up of 32 weeks, 1 patient developed a subcentimeter postoperative wound breakdown that was treated successfully with an incisional VAC. Conclusions: We found the use of VAC therapy applied directly to the dura or cortical brain as a safe and effective technique for short-term wound temporization in the setting of indeterminate oncologic margins or active infection. Key Words: VAC therapy, scalp reconstruction, calvarial reconstruction, dura, cortical brain (Ann Plast Surg 2014;74: S218–S221)
BACKGROUND Composite scalp and calvarial defects represent unique challenges for the reconstructive surgeon. Concern for exposed dura or cortical brain exposure prompts neurosurgeons and surgical oncologists to request immediate coverage. Moreover, these defects often occur in hostile local tissue environments where the patient's scalp has been previously radiated, is actively infected, or oncologic margins have yet to be confirmed. A method of safely temporizing these complex defects would be a valuable resource to the reconstructive surgeon.
Received August 19, 2014, and accepted for publication, after revision, September 25, 2014. From the *Division of Plastic and Reconstructive Surgery, Department of Surgery, and †Department of Neurosurgery, University of Florida School of Medicine, Gainesville, FL; ‡Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan; §Division of Surgical Oncology, Department of Surgery, and kDepartment of Otolaryngology, University of Florida School of Medicine, Gainesville, FL. Conflicts of interest and sources of funding: none declared. Reprints: Dhruv Singhal, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, PO Box 100138, Gainesville, FL 32610-0138. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7404–S218 DOI: 10.1097/SAP.0000000000000374
S218
www.annalsplasticsurgery.com
Vacuum-assisted closure (VAC) therapy (KCI, San Antonio, Tex) is a proven technique to temporize complex wounds throughout the body. Plastic surgeons frequently use VAC therapy to bridge hostile groin, sternal, and extremity wounds until definitive reconstruction is deemed appropriate.1–3 Similarly, VAC therapy has been used to temporize wounds with unconfirmed oncological margins.4 Literature examining the use of VAC therapy for defects with exposed dura is limited. Two case reports describe the use of VAC therapy applied directly to the dura. One patient became septic and care was withdrawn after 12 days, although healthy granulation tissue was noted postmortem.5 The second patient, after an oncologic excision and a superinfected wound, demonstrated good granulation tissue over the dura after 3 weeks of VAC treatment.6 Another 2 case reports offer differing perspectives of VAC utility when applied to TachoSil (Takeda, Zurich, Switzerland) lining dura. In 1 case, a clean granulation bed formed over 3 weeks7 but the second case was complicated by tissue necrosis necessitating debridement and prolonged VAC therapy before skin grafting could be performed.8 Most recently, a retrospective review demonstrated that VAC therapy applied over dural substitutes promoted granulation tissue formation without further cerebrospinal fluid leak (CSF) leak in 4 patients.5 We hypothesized that VAC therapy would be efficacious in cases of complex scalp and calvarial defects as a temporizing measure when immediate reconstruction would not be optimal due to active infection or malignancy without confirmed negative margins. Moreover, we hypothesized that VAC therapy to exposed dura or even cortical brain with a CSF is safe.
PATIENTS AND METHODS With approval from the University of Florida Institutional Review Board, 10 patients with composite scalp and calvarial defects operated on by the senior author (D.S.) at UF Health Shands Hospital from December 2012 to December 2013 were identified. Of those 10 patients, 5 underwent delayed wound closure using VAC therapy applied directly to the dura or cortical brain to allow for wound optimization before reconstruction. The medical records of these patients were reviewed for age, sex, operative indications, history of radiation, evidence of infection, scalp and calvarial defect sizes, presence of dural defects, VAC duration and outputs, method of reconstruction, and complications.
Surgical Technique Gelfoam (Pfizer, New York, NY) or Surgicel (Ethicon, Somerville, NJ) was applied to any exposed cortical brain by the neurosurgical service. A white VAC sponge was then tailored to the calvarial defect and placed directly over the dura. A black VAC sponge was then customized to the scalp defect and the wound edges were lined with Mastisol (Eloquest Healthcare, Ferndale, Mich) and DuoDERM (ConvaTec, Flintshire, UK). For all patients, VAC therapy was set at continuous −50 mm Hg and was continued until flap wound closure was provided as deemed Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015
VAC Therapy to Brain
FIGURE 1. Case 2. A 56-year-old man with a malignant peripheral nerve sheath tumor of the scalp and calvarium. A, Anticipated resection of the left frontoparietal scalp. B, Composite scalp (112 cm2) and calvarial (50 cm2) resection with exposed dura. C, White sponge placement into calvarial defect. D, Black sponge applied over top with DuoDERM applied to the wound edges.
appropriate by control of infection or documentation of oncologically negative margins (Fig. 1).
RESULTS Five patients (mean age, 66.2 years; range, 56–78 years) with composite scalp and calvarial defects were treated with delayed reconstruction using negative pressure wound therapy to temporize the wound. Details for each case are listed in Table 1.
The indications for delay of reconstruction included gross wound infection in 4 patients and an indeterminate intraoperative oncologic margin in 1 patient. The average size of the scalp and calvarial defects measured 123 cm2 (49–216 cm2) and 49 cm2 (16–72 cm2), respectively. One patient demonstrated exposed cortical brain with a dural defect measuring 25 cm2. The average time between the initial operation and definitive reconstruction was 4.8 days (3–7 days). The average daily VAC output was 74 mL
TABLE 1. Demographics and Clinical Data for 5 Patients With Composite Scalp and Calvarial Defects Who Underwent VAC Therapy for Wound Temporization
Case
Age, y/ Sex
Indication
1
66/M Infection/exposed cranioplasty
2
56/M Oncologic
3
78/M Oncologic/ infection
4
75/F
Infection/exposed cranioplasty
5
56/F
Infection/exposed cranioplasty
Initial Pathologic Finding
Hx of Prior Radiation to Scalp
Squamous cell carcinoma of scalp (recurrent) Malignant peripheral nerve sheath tumor of scalp (recurrent) Squamous cell carcinoma of scalp (recurrent)
Evidence of Infection Before VAC
Yes
Anterior scalp
120
56
No
Yes (MSSA)
Yes
Left frontoparietal 112 scalp
50
No
No
Yes
Left frontal scalp 120
16
No
Anterior scalp/ forehead
216
72
Left temporal scalp
49
49
Basal cell carcinoma Yes eroding frontal sinuses Subarachnoid hemorrhage No from ruptured left cerebral artery aneurysm
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Calvarial Evidence of Scalp Defect Defect Dural Defect/ Location Size, cm2 Size, cm2 CSF Leak
Yes (Staphylococcus aureus, Enterobacter, Citrobacter) Yes (Aspergillus) Yes (25 cm2) No
Yes (MRSA, Pseudomonas, Achromobacter)
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015
Prince et al
(14–142 mL). No increased average daily output (46 mL) was noted in the single case of VAC application onto cortical brain with known CSF leak. Reconstructive methods included 1 free radial forearm flap, 2 scalp rotational advancement flaps, and 2 patients underwent readvancement of prior free flaps (Fig. 2). After interval VAC therapy, 1 dural defect was reconstructed with a fascia lata graft and 1 cranial defect was reconstructed with a titanium mesh. No reconstructive complications were noted during any of the patient's hospitalizations. At an average follow-up of 32 weeks (range, 16–42 weeks), 1 patient who underwent readvancement of a prior free flap developed a subcentimeter wound breakdown. The patient was treated with incisional VAC therapy and healed primarily. No patients developed any neurologic sequela or CSF leak throughout the study period.
DISCUSSION In this case series, we examined the use of VAC therapy as a means for wound temporization of complex calvarial defects where immediate reconstruction would not be ideal due to active infection or indeterminate oncologic margins. Patients with grossly infected wounds were able to have finalization of intraoperative cultures and appropriate antibiotic administration before reconstruction. In oncological resections, negative margins were confirmed before closure. Furthermore, exposed cortical brain was successfully temporized with VAC therapy without neurologic sequelae. The VAC provides a safe wound environment, even in the setting of an existent small CSF leak due to a dural defect. This allows maximization of local wound conditions while simultaneously providing the surgeon the time to plan an ideal reconstruction of these complex defects. We offer an algorithm for the management of complex scalp and calvarial defects in Figure 3. When implementing this algorithm, close collaboration with neurosurgery is essential. After VAC application directly to cortical brain, patients were monitored in the neurosurgical ICU as opposed to the step-down unit when the dura remained intact. Although technically challenging to apply the VAC to hairbearing regions of the body, we offset this challenge by performing
VAC Duration, d
VAC Change
6
No
3
No
3
No
5
7
S220
Interim Findings During VAC Therapy
Appropriate antibiotics dosed for intraoperative cultures; overlying flap without ischemic margins Confirmed negative margins
FIGURE 2. Case 2. Two-month follow-up after staged titanium mesh placement and scalp rotation advancement flaps.
a close shave of the scalp with application of Mastisol and DuoDERM to the wound edges.
CONCLUSIONS We found the use of VAC therapy applied directly onto the dura or cortical brain as a safe and effective technique for short-term wound temporization, allowing for confirmation of oncological margins and treatment of infection. In this context, VAC therapy permits
Average Daily VAC Output, mL
Closure/Definitive Procedure
Replacement and repositioning of prior free radial forearm flap; local scalp flaps; incisional VAC Mesh cranioplasty; rotational advancement flaps; STSG Rotational advancement flaps; STSG
Appropriate antibiotics dosed for intraoperative cultures No Appropriate antibiotics dosed Fascia lata dural graft; rotational for intraoperative cultures; overlying advancement of prior anterolateral flap without ischemic margins thigh flap; scalp advancement flaps Yes—day 3 Appropriate antibiotics Free radial forearm flap (bedside) dosed for intraoperative cultures
www.annalsplasticsurgery.com
Complications
Follow-up, wk
37
93
Subcentimeter wound breakdown, treated with incisional VAC None
142
None
25
46
None
42
14
None
40
77
16
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015
VAC Therapy to Brain
FIGURE 3. Algorithm for the management of complex scalp and calvarial defects.
the formation of a protective, optimized wound environment in preparation for scalp and calvarial reconstruction. ACKNOWLEDGMENT Informed consent was received for publication of the figures in this article. REFERENCES 1. Colwell AS, Donaldson MC, Belkin M, et al. Management of early groin vascular bypass graft infections with sartorius and rectus femoris flaps. Ann Plast Surg. 2004;52:49–53. 2. Fleck TM, Fleck M, Moidl R, et al. The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery. Ann Thorac Surg. 2002;74:1596–1600 discussion 1600.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
3. Hardwicke J, Paterson P. A role for vacuum-assisted closure in lower limb trauma: a proposed algorithm. Int J Low Extrem Wounds. 2006;5:101–104. 4. Bartels CG, Voigt C, Blume-Peytavi U, et al. The vacuum sealing technique. A new procedure to cover soft tissue defects after resection of leiomyosarcoma [in German]. Hautarzt. 2001;52:653–657. 5. Powers AK, Neal MT, Argenta LC, et al. Vacuum-assisted closure for complex cranial wounds involving the loss of dura mater. J Neurosurg. 2013;118: 302–308. 6. Marathe US, Sniezek JC. Use of the vacuum-assisted closure device in enhancing closure of a massive skull defect. Laryngoscope. 2004;114:961–964. 7. Subotic U, Kluwe W, Oesch V. Community-associated methicillin-resistant Staphylococcus aureus–infected chronic scalp wound with exposed dura in a 10-year-old boy: vacuum-assisted closure is a feasible option: case report. Neurosurgery. 2011;68:E1481–E1483 discussion E1484. 8. Abbas Khan MA, Chipp E, Hardwicke J, et al. The use of Dermal Regeneration Template (Integra®) for reconstruction of a large full-thickness scalp and calvarial defect with exposed dura. J Plast Reconstr Aesthet Surg. 2010;63: 2168–2171.
www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
S221
Vacuum-Assisted Closure Therapy to the Brain A Safe Method for Wound Temporization in Composite Scalp and Calvarial Defects Noah Prince, MD,* Spiros Blackburn, MD,† Gregory Murad, MD,† Bruce Mast, MD,* Stamatis Sapountzis, MD,‡ Christiana Shaw, MD,§ John Werning, MD,k and Dhruv Singhal, MD* Background: When composite scalp and calvarial defects with dural or cortical brain exposure are encountered, active infection or indeterminate oncologic margins complicate the timing of scalp reconstruction. The purpose of this study was to evaluate the safety and efficacy of vacuum-assisted closure (VAC) therapy as a temporizing measure in these complex scalp defects with dural or cortical brain exposure and a hostile local wound environment. Methods: From December 2012 to December 2013, all composite scalp and calvarial defects reconstructed by the senior author (D.S.) were reviewed and 10 cases were identified. Five of these cases were temporized with VAC therapy. The medical records of these patients were reviewed. Results: Five patients (mean age, 66.2 years) with composite scalp and calvarial defects were temporized with VAC therapy. The indications for delay included gross wound infection in 4 patients and an indeterminate intraoperative oncologic margin. The average size of the scalp and calvarial defects measured 123 and 49 cm2, respectively. One patient underwent VAC therapy over exposed cortical brain with a dural defect measuring 25 cm2. The average time between the initial operation and definitive reconstruction was 4.8 days. The average daily VAC output was 74 mL. Reconstructive methods included 1 free flap, 2 scalp rotational advancement flaps, and readvancement of 2 prior free flaps. At an average follow-up of 32 weeks, 1 patient developed a subcentimeter postoperative wound breakdown that was treated successfully with an incisional VAC. Conclusions: We found the use of VAC therapy applied directly to the dura or cortical brain as a safe and effective technique for short-term wound temporization in the setting of indeterminate oncologic margins or active infection. Key Words: VAC therapy, scalp reconstruction, calvarial reconstruction, dura, cortical brain (Ann Plast Surg 2014;74: S218–S221)
BACKGROUND Composite scalp and calvarial defects represent unique challenges for the reconstructive surgeon. Concern for exposed dura or cortical brain exposure prompts neurosurgeons and surgical oncologists to request immediate coverage. Moreover, these defects often occur in hostile local tissue environments where the patient's scalp has been previously radiated, is actively infected, or oncologic margins have yet to be confirmed. A method of safely temporizing these complex defects would be a valuable resource to the reconstructive surgeon.
Received August 19, 2014, and accepted for publication, after revision, September 25, 2014. From the *Division of Plastic and Reconstructive Surgery, Department of Surgery, and †Department of Neurosurgery, University of Florida School of Medicine, Gainesville, FL; ‡Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan; §Division of Surgical Oncology, Department of Surgery, and kDepartment of Otolaryngology, University of Florida School of Medicine, Gainesville, FL. Conflicts of interest and sources of funding: none declared. Reprints: Dhruv Singhal, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, PO Box 100138, Gainesville, FL 32610-0138. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7404–S218 DOI: 10.1097/SAP.0000000000000374
S218
www.annalsplasticsurgery.com
Vacuum-assisted closure (VAC) therapy (KCI, San Antonio, Tex) is a proven technique to temporize complex wounds throughout the body. Plastic surgeons frequently use VAC therapy to bridge hostile groin, sternal, and extremity wounds until definitive reconstruction is deemed appropriate.1–3 Similarly, VAC therapy has been used to temporize wounds with unconfirmed oncological margins.4 Literature examining the use of VAC therapy for defects with exposed dura is limited. Two case reports describe the use of VAC therapy applied directly to the dura. One patient became septic and care was withdrawn after 12 days, although healthy granulation tissue was noted postmortem.5 The second patient, after an oncologic excision and a superinfected wound, demonstrated good granulation tissue over the dura after 3 weeks of VAC treatment.6 Another 2 case reports offer differing perspectives of VAC utility when applied to TachoSil (Takeda, Zurich, Switzerland) lining dura. In 1 case, a clean granulation bed formed over 3 weeks7 but the second case was complicated by tissue necrosis necessitating debridement and prolonged VAC therapy before skin grafting could be performed.8 Most recently, a retrospective review demonstrated that VAC therapy applied over dural substitutes promoted granulation tissue formation without further cerebrospinal fluid leak (CSF) leak in 4 patients.5 We hypothesized that VAC therapy would be efficacious in cases of complex scalp and calvarial defects as a temporizing measure when immediate reconstruction would not be optimal due to active infection or malignancy without confirmed negative margins. Moreover, we hypothesized that VAC therapy to exposed dura or even cortical brain with a CSF is safe.
PATIENTS AND METHODS With approval from the University of Florida Institutional Review Board, 10 patients with composite scalp and calvarial defects operated on by the senior author (D.S.) at UF Health Shands Hospital from December 2012 to December 2013 were identified. Of those 10 patients, 5 underwent delayed wound closure using VAC therapy applied directly to the dura or cortical brain to allow for wound optimization before reconstruction. The medical records of these patients were reviewed for age, sex, operative indications, history of radiation, evidence of infection, scalp and calvarial defect sizes, presence of dural defects, VAC duration and outputs, method of reconstruction, and complications.
Surgical Technique Gelfoam (Pfizer, New York, NY) or Surgicel (Ethicon, Somerville, NJ) was applied to any exposed cortical brain by the neurosurgical service. A white VAC sponge was then tailored to the calvarial defect and placed directly over the dura. A black VAC sponge was then customized to the scalp defect and the wound edges were lined with Mastisol (Eloquest Healthcare, Ferndale, Mich) and DuoDERM (ConvaTec, Flintshire, UK). For all patients, VAC therapy was set at continuous −50 mm Hg and was continued until flap wound closure was provided as deemed Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015
VAC Therapy to Brain
FIGURE 1. Case 2. A 56-year-old man with a malignant peripheral nerve sheath tumor of the scalp and calvarium. A, Anticipated resection of the left frontoparietal scalp. B, Composite scalp (112 cm2) and calvarial (50 cm2) resection with exposed dura. C, White sponge placement into calvarial defect. D, Black sponge applied over top with DuoDERM applied to the wound edges.
appropriate by control of infection or documentation of oncologically negative margins (Fig. 1).
RESULTS Five patients (mean age, 66.2 years; range, 56–78 years) with composite scalp and calvarial defects were treated with delayed reconstruction using negative pressure wound therapy to temporize the wound. Details for each case are listed in Table 1.
The indications for delay of reconstruction included gross wound infection in 4 patients and an indeterminate intraoperative oncologic margin in 1 patient. The average size of the scalp and calvarial defects measured 123 cm2 (49–216 cm2) and 49 cm2 (16–72 cm2), respectively. One patient demonstrated exposed cortical brain with a dural defect measuring 25 cm2. The average time between the initial operation and definitive reconstruction was 4.8 days (3–7 days). The average daily VAC output was 74 mL
TABLE 1. Demographics and Clinical Data for 5 Patients With Composite Scalp and Calvarial Defects Who Underwent VAC Therapy for Wound Temporization
Case
Age, y/ Sex
Indication
1
66/M Infection/exposed cranioplasty
2
56/M Oncologic
3
78/M Oncologic/ infection
4
75/F
Infection/exposed cranioplasty
5
56/F
Infection/exposed cranioplasty
Initial Pathologic Finding
Hx of Prior Radiation to Scalp
Squamous cell carcinoma of scalp (recurrent) Malignant peripheral nerve sheath tumor of scalp (recurrent) Squamous cell carcinoma of scalp (recurrent)
Evidence of Infection Before VAC
Yes
Anterior scalp
120
56
No
Yes (MSSA)
Yes
Left frontoparietal 112 scalp
50
No
No
Yes
Left frontal scalp 120
16
No
Anterior scalp/ forehead
216
72
Left temporal scalp
49
49
Basal cell carcinoma Yes eroding frontal sinuses Subarachnoid hemorrhage No from ruptured left cerebral artery aneurysm
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Calvarial Evidence of Scalp Defect Defect Dural Defect/ Location Size, cm2 Size, cm2 CSF Leak
Yes (Staphylococcus aureus, Enterobacter, Citrobacter) Yes (Aspergillus) Yes (25 cm2) No
Yes (MRSA, Pseudomonas, Achromobacter)
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
S219
Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015
Prince et al
(14–142 mL). No increased average daily output (46 mL) was noted in the single case of VAC application onto cortical brain with known CSF leak. Reconstructive methods included 1 free radial forearm flap, 2 scalp rotational advancement flaps, and 2 patients underwent readvancement of prior free flaps (Fig. 2). After interval VAC therapy, 1 dural defect was reconstructed with a fascia lata graft and 1 cranial defect was reconstructed with a titanium mesh. No reconstructive complications were noted during any of the patient's hospitalizations. At an average follow-up of 32 weeks (range, 16–42 weeks), 1 patient who underwent readvancement of a prior free flap developed a subcentimeter wound breakdown. The patient was treated with incisional VAC therapy and healed primarily. No patients developed any neurologic sequela or CSF leak throughout the study period.
DISCUSSION In this case series, we examined the use of VAC therapy as a means for wound temporization of complex calvarial defects where immediate reconstruction would not be ideal due to active infection or indeterminate oncologic margins. Patients with grossly infected wounds were able to have finalization of intraoperative cultures and appropriate antibiotic administration before reconstruction. In oncological resections, negative margins were confirmed before closure. Furthermore, exposed cortical brain was successfully temporized with VAC therapy without neurologic sequelae. The VAC provides a safe wound environment, even in the setting of an existent small CSF leak due to a dural defect. This allows maximization of local wound conditions while simultaneously providing the surgeon the time to plan an ideal reconstruction of these complex defects. We offer an algorithm for the management of complex scalp and calvarial defects in Figure 3. When implementing this algorithm, close collaboration with neurosurgery is essential. After VAC application directly to cortical brain, patients were monitored in the neurosurgical ICU as opposed to the step-down unit when the dura remained intact. Although technically challenging to apply the VAC to hairbearing regions of the body, we offset this challenge by performing
VAC Duration, d
VAC Change
6
No
3
No
3
No
5
7
S220
Interim Findings During VAC Therapy
Appropriate antibiotics dosed for intraoperative cultures; overlying flap without ischemic margins Confirmed negative margins
FIGURE 2. Case 2. Two-month follow-up after staged titanium mesh placement and scalp rotation advancement flaps.
a close shave of the scalp with application of Mastisol and DuoDERM to the wound edges.
CONCLUSIONS We found the use of VAC therapy applied directly onto the dura or cortical brain as a safe and effective technique for short-term wound temporization, allowing for confirmation of oncological margins and treatment of infection. In this context, VAC therapy permits
Average Daily VAC Output, mL
Closure/Definitive Procedure
Replacement and repositioning of prior free radial forearm flap; local scalp flaps; incisional VAC Mesh cranioplasty; rotational advancement flaps; STSG Rotational advancement flaps; STSG
Appropriate antibiotics dosed for intraoperative cultures No Appropriate antibiotics dosed Fascia lata dural graft; rotational for intraoperative cultures; overlying advancement of prior anterolateral flap without ischemic margins thigh flap; scalp advancement flaps Yes—day 3 Appropriate antibiotics Free radial forearm flap (bedside) dosed for intraoperative cultures
www.annalsplasticsurgery.com
Complications
Follow-up, wk
37
93
Subcentimeter wound breakdown, treated with incisional VAC None
142
None
25
46
None
42
14
None
40
77
16
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015
VAC Therapy to Brain
FIGURE 3. Algorithm for the management of complex scalp and calvarial defects.
the formation of a protective, optimized wound environment in preparation for scalp and calvarial reconstruction. ACKNOWLEDGMENT Informed consent was received for publication of the figures in this article. REFERENCES 1. Colwell AS, Donaldson MC, Belkin M, et al. Management of early groin vascular bypass graft infections with sartorius and rectus femoris flaps. Ann Plast Surg. 2004;52:49–53. 2. Fleck TM, Fleck M, Moidl R, et al. The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery. Ann Thorac Surg. 2002;74:1596–1600 discussion 1600.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
3. Hardwicke J, Paterson P. A role for vacuum-assisted closure in lower limb trauma: a proposed algorithm. Int J Low Extrem Wounds. 2006;5:101–104. 4. Bartels CG, Voigt C, Blume-Peytavi U, et al. The vacuum sealing technique. A new procedure to cover soft tissue defects after resection of leiomyosarcoma [in German]. Hautarzt. 2001;52:653–657. 5. Powers AK, Neal MT, Argenta LC, et al. Vacuum-assisted closure for complex cranial wounds involving the loss of dura mater. J Neurosurg. 2013;118: 302–308. 6. Marathe US, Sniezek JC. Use of the vacuum-assisted closure device in enhancing closure of a massive skull defect. Laryngoscope. 2004;114:961–964. 7. Subotic U, Kluwe W, Oesch V. Community-associated methicillin-resistant Staphylococcus aureus–infected chronic scalp wound with exposed dura in a 10-year-old boy: vacuum-assisted closure is a feasible option: case report. Neurosurgery. 2011;68:E1481–E1483 discussion E1484. 8. Abbas Khan MA, Chipp E, Hardwicke J, et al. The use of Dermal Regeneration Template (Integra®) for reconstruction of a large full-thickness scalp and calvarial defect with exposed dura. J Plast Reconstr Aesthet Surg. 2010;63: 2168–2171.
www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
S221
