PMC10185356_01
(a) The patient on arrival. On some parts of his head, skin was severed, and the brain tissue out-slipped through the open skull fracture.
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(b), (c), (d) Head computed tomography (CT) showed widely open skull fracture, brain contusion, and acute subdural hematoma.
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On some parts of his head, skin was cut off, and the brain tissue out-slipped through an open skull fracture (Fig. 1a). Computed tomography (CT) of the head showed a widely open skull fracture, brain contusion, and acute subdural hematoma (Fig. 1b-d).
(a) Dural defect was reconstructed using the deep fascia of the thigh.
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(b) Skin defect was reconstructed using an artificial dermis.
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We then performed dural plasty using fascia and fibrin glue (Fig. 2a). Plastic surgeons closed the skin defect with an artificial dermis (Terdermis, Olympus Terumo Biomaterials Corp., Tokyo, Japan) (Fig. 2b).
(a) The severed skin edges, fasciae, and substitution of the dura mater were necrotic.
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(b) After debridement, vacuum-assisted closure (VAC) therapy was performed to promote wound healing.
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(c) After lumber drainage for hydrocephalus, sinking skin flap syndrome (SSFS) was observed (arrow).
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(d) The dural defect was filled with the deep fascia of the thigh.
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(e) The gastro-omental artery and vein were anastomosed to the superficial temporal artery and vein under a microscope, and an omental flap was then created to close the skin defect.
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(f) Titanium mesh was wrapped with the omental flap, and extradural dead space was also filled with excessive omental flap.
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(g) The surface of omental flap was covered with dermal graft from the thigh.
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However, the severed skin edges, fasciae, and the substitution of the dura mater were deemed necrotic (Fig. 3a). On day 22, plastic surgeons performed debridement and vacuum-assisted closure (VAC) therapy to promote wound healing (Fig. 3b). Lumbar drainage was performed on day 24; however, sinking skin flap syndrome (SSFS) was observed on day 25 (Fig. 3c). Thereafter, plastic surgeons filled the dural defect with the contralateral deep fascia of the thigh (Fig. 3d). Then, the plastic surgeons anastomosed the gastro-omental artery and vein to the superficial temporal artery and vein under a microscope and created an omental flap to close the skin defect (Fig. 3e). The titanium mesh was wrapped with an omental flap, and the extradural dead space was filled with sufficient omental flap (Fig. 3f). The surface of the omental flap was then covered with a dermal graft from the thigh (Fig. 3g).
(a) The head computed tomography (CT) after ventriculoperitoneal (VP) shunt. Note that the extradural dead space was filled with the omental flap (arrow).
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(b) Perfect wound healing was obtained 5 months after the reconstructive surgery.
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We performed ventriculoperitoneal shunting on day 64 (Fig. 4a). However, severe consciousness disturbance remained due to primary brain damage (Fig. 4b).