Forehead Trauma Outcomes

Share Embed


Descrição do Produto

TECHNICAL STRATEGY

Forehead Trauma Outcomes: Restoration of Brain, Soft Tissues, and Bone Defects: A 3-Step Treatment Cascone Piero, MD,* Gennaro Paolo, MD,* Ramieri Valerio, MD,* and Esposito Vincenzo, MDÞ

Abstract: Head injuries are one of the most common causes of treatment in the emergency and accidents ward. The first causes of head traumatology are still car or motorcycle accidents, followed by personal aggressions. The authors here present a case of forehead trauma outcome after a severe injury in growing age. The interesting aspect is the triple challenge of cerebral, bone, and soft tissue restoration. The main goal was to restore functionality of the brain and to re-establish the integrity of cranial vault. Excision of pathologic cerebral cortex and well-known surgical techniques have been adopted to achieve this result. Moreover, the peculiar technique that led to the good result was to create a barrier between bone layer and soft tissues. The authors present their personal suggestions for the best functional and aesthetic outcome. Key Words: Forehead, trauma, outcomes, gale pericranium sliding flap, skin expansion, calvarial split, cranial vault reconstruction, soft tissues revision, epilepsy, epilepsy surgery (J Craniofac Surg 2009;20: 498Y501)

H

ead injuries are one of the most common causes of treatment in the emergency and accidents ward. The first causes of head traumatology are still car or motorcycle accidents, followed by personal aggressions.1 The outcomes of an eventual trauma deal with the precious content of the skull and the tight relation between the bone, dura mater, and brain. The authors present a case of forehead trauma outcome after a severe injury in growing age. This case, indeed, presents 3 main pathologic issues to be restored. The first was the cerebral involvement, thus being the source of epileptic comitial crisis. The second issue, forehead skin defect, mainly represented an aesthetic complaint of the patient, but nevertheless, it has to be considered as a functional defect also. The third issue dealt with bone restoration being this a risk factor for possible direct trauma on the cerebral mass. The authors present a case and suggest a possible approach for the best result.

From the *Department of Maxillo-facial Surgery, University BLa Sapienza;[ and †Department of Neurosurgery, IRCCS Neuromed, Pozzilli, University of Rome BSapienza,[ Rome, Italy. Received August 22, 2008. Accepted for publication September 29, 2008. Address correspondence and reprint requests to Valerio Ramieri, MD, Via Federico Cesi 21, 00193 Roma, Italia; E-mail: valerioramieri@ gmail.com Copyright * 2009 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31819b9e14

498

CLINICAL REPORT The patient is a 54-year-old man; he reported a frontal trauma with frontal bone fractures and cerebral contusion of the right frontal lobe at the age of 9 years. He underwent emergency neurosurgical treatment with removal of fractured bone impinging on the brain and debridement of the cerebral contusion. As a result, the patient was left with a remarkable forehead depression: the skin covering the depression was very thin and firmly adherent to underlying soft tissue (Fig. 1). From this period, the patient underwent medical treatment for epilepsy, discontinued at the age of 15 years. The patient remained in good general and neurologic conditions until the age of 38 years, when he started to experience generalized epileptic seizures. The seizures occurred at a frequency of 2 to 3 times per week and were resistant to various regimens of multidrug antiepileptic treatment. For these reasons, he underwent evaluation in our Epilepsy Surgery Unit in October 2005. After a presurgical epileptologic evaluation, including detailed cerebral magnetic resonance imaging examination, videoelectroencephalogram recording of seizures, neuropsychologic and psychiatric assessment, the epileptogenic focus was identified in the right frontal pole of the brain, in and around the previously traumatized area. The preoperative workup included a computed tomography (CT) scan with three-dimensional (3D) reconstructions, showing in better details the extension of forehead bone loss (Fig. 2). Removal of epileptogenic brain was proposed to and accepted by the patient. The surgery was planned to treat both the epilepsy and the cosmetic defect. The skin actually overlying the forehead depression was judged to be too thin and poorly vascularized to remain viable after dissection. Thus, in February 2006, the patient underwent surgery so that 2 scalp expanders could be placed to obtain the desired amount of skin to cover the area of injury. The exact volume of the 2 expanders was of 5 mL for the right one and 10 mL for the left one. The expanders have been activated for 2 months until April 2006 (Fig. 3). In May 2006, he underwent a second surgical intervention for removal of the epileptogenic brain and the reconstruction of the bone and skin defect. A bicoronal skin flap was raised. As expected, the skin covering the depression was firmly adherent to the soft tissue and after dissection was unsuitable to repair the subcutaneous tissue. After right frontal craniotomy and opening of the dura mater, the right frontal pole was removed as planned to treat epilepsy. After watertight closure of the dura mater, the calvarial bone of the paramedian frontal segment was raised and split (Fig. 4). Subsequently, the 2 bone fragments have been fixed over the defect area with titanium plates and screws. The very median area of the defect has been strengthened with a titanium mesh forged over the forehead convexity and fixed with titanium screws. The skin was reconstructed, thanks to the extra amount obtained with the expanders. However, the key to success for this particular intervention was the realization of a galea sliding flap to separate the bone layer from soft tissues (Fig. 5).

The Journal of Craniofacial Surgery

& Volume 20, Number 2, March 2009

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 20, Number 2, March 2009

Forehead Trauma Outcome/3-Step Challenge

FIGURE 1. View of the patient before the treatment. The forehead depression is remarkable.

The postoperative course was uneventful. The surgical wound healed without problems. Postoperative 3D CT scan 6 months after surgery showed a satisfactory bone covering of the surgical site (Fig. 6). Also, cosmetic results were very good (Fig. 7). At the last follow-up, 2 years after surgery, the patient is completely seizure-free.

DISCUSSION The interesting aspect of this case is the complexity of trauma outcomes. The patient, indeed, presented 3 main pathologic issues to be restored. The first was the cerebral involvement, thus being the source of epileptic seizures. The second issue, forehead skin defect, mainly represented an aesthetic complaint of the

patient, but nevertheless, it has to be considered as a functional defect also. The third issue dealt with bone restoration being this a risk factor for possible direct trauma on the cerebral mass. The first problem was the restoration of a physiologic cerebral cortex function. Indeed, the patient presented epileptic seizures as the consequence of the trauma. In posttraumatic epilepsy, excision of the pathologic cortex after a deep and accurate study performed with magnetic resonance imaging and videoelectroencephalogram is widely accepted.2 The second problem was the complete absence of bone protection in the injured area, thus exposing the patient to further risk of cerebral involvement and possible infections. It must be underlined indeed the closeness of cerebral mass to the surface in this particular case because of the soft and hard tissue defect. To achieve a complete bone restoration, we planned the calvarial split of the frontal bone. This technique

FIGURE 2. CT scan 3D reconstruction and coronal view. * 2009 Mutaz B. Habal, MD

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

499

Piero et al

The Journal of Craniofacial Surgery

& Volume 20, Number 2, March 2009

FIGURE 5. Intraoperative view of the galea pericranium flap.

FIGURE 3. The patient with activated tissue expanders in the temporoparietal region.

has been extensively described in literature.3,4 Usually, to restore these particular defects, alloplastic bone grafts or rigid internal fixation devices are adopted.5,6 In our case, we preferred the autologous bone graft because it is our opinion that the transplanted bone undergoes remodeling, so far that after 6 months from surgery, it is hardly possible to recognize the transplanted area even with radiographs and CT scan imaging. The last pathologic issue, soft tissue defect, was treated with soft tissue expanders, and subsequently, a skin plastic has been realized to obtain the best aesthetic result possible. The use of skin expanders as a surgical option to recover wide defects has been extensively described in literature.7 Although nowadays it is considered as a safe procedure, it presents a small incidence of complications.8,9 There are many advantages in using this technique. First, it is relatively simple to perform and gives very good results in soft tissue gaining.10 Particularly in the presented patient, we had the necessity to cover the brain that, until the moment of surgery, was in direct contact of a very thin layer of

skin. The challenge was to recreate a skin layer similar as much as possible to the forehead region. The uniqueness of the proposed treatment is the 3-step restoring of all issues adopting surgical techniques that have never been combined in such a protocol. Moreover, we can firmly assess that the key to obtain the best result possible is the complete healing of every graft layer. It is our opinion indeed that, if the cutaneous scar is positioned above the bone graft, this may be responsible for bone resorption and failure of the intervention. For this reason, we raised a galea sliding flap from the parietal area with a 6-cm base. The flap was then placed over the calvarial bone split graft to separate it from the soft tissue layer.

CONCLUSIONS Forehead trauma outcomes usually deal with incorrect bone repositioning and fixation, thus leading to deformities and aesthetic problems. In this particular patient, all of the 3 main issues of cranial integrity were compromised. First, the brain was damaged, this being the cause of epileptic seizures. The bone layer presented a remarkable defect and soft tissues layer. Our main goal was restore functionality of the brain and to re-establish the integrity of cranial vault. We adopted well-known surgical techniques to achieve our goal. Moreover, the peculiar technique that led to the

FIGURE 4. Intraoperative view of the bone defect before and after the restoration.

500

* 2009 Mutaz B. Habal, MD

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 20, Number 2, March 2009

Forehead Trauma Outcome/3-Step Challenge

FIGURE 6. CT scan 3D reconstruction: postoperative control.

FIGURE 7. The patient at the end of the treatment.

good result was to create a barrier between bone layer and soft tissues. For this reason, we raised a parietal galea sliding flap to cover the bone graft and separate it from the restored soft tissues layer. With this precaution, we granted the best result possible, both dealing with functionality and a very good aesthetic result.

REFERENCES 1. Servadei F, Verdicchi A, Soldano F, et al. Descriptive epidemiology of head injury in Romagna and Trentino: comparison between two geographically different regions. Neuroepidemiology 2002;21:6 2. Kuzniecky R, Devinsky O. Surgery insight: surgical management of epilepsy. Nat Clin Pract Neurol 2007;3:673Y681 3. Tessier P, Kawamoto H, Posnick J, et al. Taking calvarial grafts-tools and techniques: VI. The splitting of a parietal bone Bflap.[ Plast Reconstr Surg 2005;116:74SY88S 4. Tessier P, Kawamoto H, Posnick J, et al. Taking calvarial grafts, either

5.

6.

7. 8. 9. 10.

split in situ or splitting of the parietal bone flap ex vivoVtools and techniques: V. A 9650-case experience in craniofacial and maxillofacial surgery. Plast Reconstr Surg 2005;116:54SY71S Eguchi T, Harii K, Sugawara Y. Repair of a large Bcoup de saber[ with soft-tissue expansion and artificial bone graft. Ann Plast Surg 1999;42:207Y210 Wiltfang J, Kessler P, Buchfelder M, et al. Reconstruction of skull bone defects using the hydroxyapatite cement with calvarial split transplants. J Oral Maxillofac Surg 2004;62:29Y35 Numann CG. The expansion of an area of skin by progressive distension of a subcutaneous balloon. Plast Reconstr Surg 1957;19:124Y130. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg 74:482Y90, 1984 Austad ED. Contraindications and complications in tissue expansion. Facial Plast Surg 1988;5:379Y382 Chao JJ, Longaker MT, Zide BM. Expanding horizons in head and neck expansion. Oper Tech Plast Reconstr Surg 1998;5:2Y11

* 2009 Mutaz B. Habal, MD

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

501

Lihat lebih banyak...

Comentários

Copyright © 2017 DADOSPDF Inc.