One Case Of Extensive Skull Exposure Burned By High Voltage And Investigation Of Reconstruction Methods

Objective:It is difficult to reconstruct an extensive skull exposure. To investigate the pros and cons of various reconstruction methods, enhance the understanding and provide the basis of making appropriate decision to treat the same disease.Methods:To analyze one case of an extensive skull exposure burned by high voltage electricity and retrospectively study with a review of the literature which is collected from monographs, CNKI and PUBMED databases.The treatments of anti-shock, anti-infection and protection of visceral organs were carried out immediately when the patient was hospitalized. When the condition of the patient was stable, we used the abdominal pedicle flap to treat the wounds of two wrists. The amputation of both two thumbs was carried out for their kraurosis. In order to reduce the intracranial pressure caused by subdural hematoma, we used hemostatic and dehydration drugs. The complications of progressive bleeding and intracranial infection didn’t occur. We use scalp expansion to reconstruct the extensive scalp defect after the loss of right upper limb pedicle flap. The expander with the capacity of500ml was placed in the subgaleal layer of right occiput, the500ml was placed at left tempus, and the70ml was placed at the parietal part. Complications of wound dehiscence, prosthetic exposure and infecton of expander’s cavity occurred during the time of pre-expanding which lasted87days. There was2cm necrosis at the distal part of the flap after reconstructing the defect. Debridement, drawing liquid and compression were carried out to treat high volume fluid which stored in the cavity of connecting with the wound between the flap and necrosis skull.Results:The wounds of both two wrists were repaired well and two thumbs were amputated. Although most part of the scalp defect was healed, the skull exposure with the area of0.5cm×0.5cm was retained.Conclusion:The reconstruction of an extensive scalp defect and skull exposure depends on the condtion of the patient, location, aesthetic needs and so on. We must use the tissue with affluent blood supply to reconstruct the defect timely in order to avoid progressive exposured skull necrosis. It is suggested that local flap and skin traction can be used if the defect diameter is smaller than6cm. We can use crossing flaps over the vertex, the extended trapezius musculocutaneous flap, free greater omentum and free flap to reconstruct the larger scalp defect in one stage timely. Scalp expansion and bi-pedicled separation delay flap can be used for the patients who missed the suitable time of operation.Compared with other methods, expansion can produce additional scalp tissue. It solves the problem that there is no other tissue which can replace the scalp for it’s character of hair grown. On the contrary, patients have to suffer a long pre-expanding period. And complications such as wound dehiscence, prosthetic exposure, cavity infection and so on occur usually for the reasons of poor heal ability of the scalp injured by high voltage electricity and a long time of wound exposure that makes bacteria infect the wound easily. In my opinion, although the advantages of expansion carry more weight than those of other methods, it needs further study on how to avoid complications and reduce the period of expanding.Although the method of reconstruction by upper limb pedicle flap is easy to be designed and performed, the facts of limited current clinical data and the failed operation make us to perform it further in the clinical.