Management of Chronic Scalp Defect with Exposed Dura Mater Post Severe Electrical Burn: Case Report
by Fatima Alameri*, Maurice Mimoun
Department of plastic and reconstruction surgery / Burn unit, Saint Louis Hospital, Paris, 75010, France.
*Corresponding author: Fatima Alameri, Department of Plastic and Reconstruction Surgery / Burn Unit, Saint Louis Hospital, Paris,75010, France.
Received Date: 27 March 2024
Accepted Date: 01 April 2024
Published Date: 04 April 2024
Citation: Alameri F, Mimoun M (2024) Management of Chronic Scalp Defect with Exposed Dura Mater Post Severe Electrical Burn: Case report. Plast Surg Mod Tech 8: 170. https://doi.org/10.29011/2577-1701.100070
Abstract
Multiple managements were introduced to treat skull defect due to high voltage electrical burns. The main objective of this article is to highlight the acute management in treating skull defect aiming to ensure healthy tissues and eliminate the risk of infection before proceeding into further indicated management.We report a case of a 28-year-old male, previously healthy with a history of high- voltage electrical burns due to a home incident in Algeria in 2019. Admitted two years later at Saint Louis Hospital Burn Unit with a skull defect and amputated big and second toes of the left foot. He was treated initially in a local hospital in Algeria, underwent two rotational flaps with multiples burr holes were made over the outer table of parietal region. He had multiple surgical debridement with serial dressing for one year. At the time of admission, the patient was complaining of uncovered scalp defect located over the parietal region with exposure of the external table and purulent discharge. Debridement and skin graft was performed as acute coverage, two months post-operation the defect was completely covered, satisfying healthy tissues were identified. Skin graft can be considered as one of the optimal managements for treating a scalp defect if there is any suspicion of underlying infection and collection or vascular issues before proceeding to preform further coverage as free flap.
Keywords: Electrical, Burn, High Voltage, Scalp, Defect, Skin Graft.
Introduction
Electric burn injuries typically manifest as localized wounds with extensive damage to deep tissues. These injuries are particularly severe at entry and exit points. Although uncommon, electrical burns on the scalp can occur. The heat generated during these incidents may result in necrosis affecting one or both calvarial tables. Effectively managing these injuries requires thorough surgical debridement of the devitalized tissues [1].
A lot of controversy exists in the decision making with regards of the timing of the operation, choice of the flap and the role of debridement. Proper management of those cases prevents further complication and improves cosmetic disfigurement.
Scalp deficiencies can arise from diverse etiological factors, including tumor removal, burns, injuries, or congenital abnormalities, giving rise to notable surgical and aesthetic challenges [2]. Multiple managements were introduced to treat skull defect due to high voltage electrical burns. Most of the fullthickness burn injuries, including those affecting the head and neck regions, can be successfully addressed using split-thickness skin grafts. However, in cases where defects involve exposed or implicated underlying bone, flap reconstruction becomes a necessary requirement [3].
Case Presentation
A 28-year-old Algerian male suffering from an extensive scalp electrical burn, came to France seeking to improve the appearance of the skull defect following an electrical burn occurred at home in 2019. He was admitted to Saint Louis Hospital Burn Unit in Paris on March 2021. Patient has no prior medical history, and no documented drug usage or any familial background of genetic disorders. Additionally, the individual is a non-smoker. He suffered from depression and low self-esteem related to his appearance at admission, requiring regular follow-up by our psychologist and psychiatric team. Financial support was provided by the national French insurance authorities, and the patient was accompanied by his relative in France.
Initially, treated in Algeria in May 2019 by a plastic surgery team with two rotation flaps that covered 40% of scalp defect and skin grafting over the donner zones. He underwent multiple surgical debridement followed by serial dressing and amputation of the first and second toes with skin grafting due to the development of necrosis. Neurosurgeons addressed the residual scalp defect by employing a burr hole in the outer cortex. This procedure facilitated the formation of granulation tissue on the scalp, establishing a foundation for subsequent skin grafting.
Diagnosis and Treatment
On clinical examination, the patient was alert, oriented with neurologic deficit manifesting as multiple abnormal upper limbs movements treated with Gabapentin.
The scalp defect was located over the parietal region (10x11cm) in size, with exposed calvarium. Multiple drill holes were seen with purulent discharge without exposed of dura mater (Fig 1).
Figure 1
A Head CT scan was preformed that demonstrated a discontinuation of the internal table in the central part of the parietal region with underlying collection between the external table and the dura mater, as well as a remarkable space which leads into separation of the outer table from the internal table (Fig 2).
Figure 2
Our plan included: first, the removal of the outer table, and second, covering it with a split-thickness skin graft to eliminate any underlying cause leading to purulent discharges.
During the first operation, the skull bone was raised by using Obwegeser Rugine over the right parietal region. During the elevation of the skull bones in right parietal region, we noticed after removing the outer table that the bone aspect of the inner table was in a good condition, we continued to separate the bone over the left parietal region and good granulation tissues were found as well between the outer and the inner tables. After complete removal of the skull bone, an exposure of dura mater was found around (6x9 cm) (Fig 3, 4, 5).