gms | German Medical Science

Introduction: Large skin defects over the forehead and scalp that are down to bone are often significant reconstructive challenges. Lack of local tissue elasticity precludes closure with simple flaps while multi-stage tissue expansion or free tissue transfer may be limited by patient co-morbidity and age. Grafting on to bare bone must be preceeded by procedures to stimulate granulation tissue, usually by drilling of the outer table. Wound healing is a long-term, multiple dressing changes are necessary and the cosmetic result is usually not optimal [1], [2], [3], [4].

To achieve faster healing of large wounds of the forehead and the scalp we use, in appropriate cases, the vacuum-assisted wound therapy. This thechnic is well established in the managment of complex or chronic wounds of the trunk. However, its use prior to scalp grafting has not been well described. The aim of this presentation is to describe our experience of using this technique and its clinical application.

Case report: A large scalp BCC on a 83-year-old male patient required excision down to bone for clearance. The V.A.C. system (V.A.C.-System KCI Medial Ltd, Oxfordshire, UK) was applied to the resulting defect with a diameter of 11 cm. To protect the surrounding skin from damage DuoDERM (ConvaTec, Flintshire, UK) was applied. The wound was coffered with TELFA (Medline Industries, Illinois, USA) and the vacuum dressing was applied. The drain is fixed with the adapter and the system was put under suction (125 mmHg). The sponge system was changed weekly.

Results: After 3 weeks of vacuum-assisted dressing as an outpatient the entire wound was filled with a vital granulation tissue. The defect diameter had additionally reduced by about 40%. A closure with a full-thickness skin graft from the groin was performed. The V.A.C.-system was applied as well at the end of surgery and removed one week postoperatively. No wound healing problems occured. 7 weeks after removal of the BCC the wound was closed and the scalp was covered with vital skin and the aesthetic result was very satisfactory.

Discussion: The vacuum assisted wound therapy promotes the need for good wound healing conditions: wound toilet, reduction of wound edema, improvement of blood circulation, enhancement of wound contraction, accelerated granulation phase, reduction of bacterial colonization and a moist wound environment. Thus, the stimulation of granulation tissue formation in an ideal moist wound environment is seen even in bad vascularized areas such as tendons, bones and even metal implants [1], [2].

Dressing changes are well tolerated by the patients as well as walking around with the mobile V.A.C.-machine. In the patients treated so far we saw a rapid and efficient wound healing with a thus increased quality of life of the patients.

Conclusion: The V.A.C system for the treatment of larger defects in the head area is, in our experience, easy to use and well tolerated by the patient. Wound healing was expedited with minimal morbidity. This technique should be added to the surgical armamentarium of all surgeons working in this area.