Negative Pressure Therapy for Treatment of Wounds with Exposed Bone and Dura

Abstract

Introduction: Previous dogma has rejected that it is safe to apply a wound vacuum dressing directly onto the brain dura without a barrier. This case presents successful wound healing in a patient with previous failed free flap and skin grafting of her frontotemporal craniotomy wound with wound vacuum dressing application. Case Presentation: The patient is a 76-year-old female with a past medical history of an osseous meningioma who has undergone four prior resections (1994, 2002, 2012, 2021). She underwent her last craniotomy and resection with neurosurgery, leaving a large frontotemporal defect. At that time, a local flap was utilized by extending the resection incision pre- and post-auricular in a “face lift” fashion to gain closure of 95% of the defect. After two months, she returned to the OR due to loss of two areas of the local flap, anteriorly over the left forehead and posteriorly near the rotation point just superior to the ear. There was exposed bone and cranioplasty. A bipedicle fasciocutaneous flap was then created from the left frontal hairline to the midline occipital region with supraorbital and left occipital artery vascular supply. A split-thickness skin graft was applied to the posterior area that was still uncovered. She continued to experience complications with necrosis of areas of the skin flap, which included an additional cranioplasty and attempted local flap coverage, as well as a radial forearm free flap. Flap healing was complicated by pseudomonas infection, which caused partial failure with an area of exposed bone and scarred dura. Management and Outcomes: A black sponge wound vacuum dressing with silver impregnated barrier dressing was applied to the area on the non-wound side of the sponge. Over the course of three months, the patient experienced marked reduction in the size of the wound with progressive closure. Discussion: There has been literature on the benefit of wound vacuum assisted closure in complex wounds and reconstructions in various parts of the body with evidence of reduced surgical site infections and wound necrosis. However, evidence of benefit in scalp reconstruction is largely limiterrd to case series and reports. In these described case reports patients had improved outcomes with fewer dressing changes, and increased success with subsequent skin grafts. Similarly, our patient underwent wound vacuum therapy, after recurrent chronic wound infection with bony defect and recurrent flap failure. She had improved wound healing, resolution of infection and decrease of the defect size. Conclusion: In conclusion, there is a potential bernefit to using wound vacuum assisted therapy in scalp defects that have failed previous reconstruction attempts that merits serious consideration. In this case, it has allowed for better wound healing and has allowed the patient an improved quality of life. Corresponding Author: Yitzchok Greenberg, 2799 W Grand Bvd, Detroit, MD 48202; 313-673-7190