1. Introduction

a. Scrape Away Granulation Tissue

b. Clean Skin Edges

c. Drill Exposed Bone to Reduce Bacterial Biofilm and to Deepen Resection Margin

d. Measure Wound Dimensions

2. Surgical Approach and Wound Preparation

a. Suture the Integra Graft and Ensure it is in Full Contact with the Underlying Bone

3. Application of Integra Bilayer Wound Matrix

4. Secure Matrix with Bolster

Reconstruction of full-thickness scalp defects often poses various challenges depending on the complexity and characteristics of the wound as well as independent patient health factors. Despite a range of reconstructive options ranging from primary closure, adjacent tissue transfer, and autografts to free flap reconstruction, there is no universally adopted decision algorithm.

Integra, an acellular matrix composed of crosslinked bovine collagen and glycosaminoglycan covered by a silicone membrane, is widely used for scalp reconstruction and has been shown to produce excellent functional and cosmetic results.

The featured case involves staged scalp reconstruction utilizing the Integra bilayer matrix wound dressing for an elderly immunocompromised patient presenting with two adjacent full-thickness scalp defects resulting in exposed calvarial bone over the vertex. The discussion centers on determining the most optimal scalp reconstructive option and exploring the treatment algorithm used at our institution. Furthermore, application of Integra for calvarial bone coverage will be discussed.

<h4>CHAPTER 1</h4>

<p>So I'm Dr. Thomas Lee
from Virginia Commonwealth University.
I work in the Department of Otolaryngology.
The case we're seeing today is a type of case
that is relatively common.
This is an elderly patient
who has multiple skin cancer
involving the vertex of his skin.
This patient presented with
basal cell carcinoma of the scalp,
and he had undergone two separate lesions
under Mohs surgery.
And the resulting defect on one of them
left 4x3-cm skin defect down to bare bone,
and the other was superficial,
but not involving the bone itself,
but just down to the pericranium.
So the decision was made to reconstruct this area.
The top priority in this case
is to ensure that the bone itself is covered.
And in this situation, we looked at different options
because patient has multiple other skin lesions
surrounding this area.
Instead of using local tissue advancement option,
we decide to place an Integra matrix
and come back and do a staged skin grafting.
The surgical step today is once patient's asleep,
we will look at the wound.
The wound with the bone exposed -
we are gonna remove any remaining granulation tissue
and also drill down the surface of the bone
so that we get rid of any concern for bacteria left behind.
And also to just give us deeper margin
along the deep aspect of this area,
even though it's been cleared with Mohs surgery.
Once we completed that,
we then proceed with applying the Integra wound matrix,
cutting it to appropriate size,
and secure it with a bolster,
and the dressing will stay on for about a month.
And in a separate surgery about a month from now,
we'll come back and place a skin graft.</p>

<h4>CHAPTER 2</h4>

<p>That's good there.
And then let's go ahead and scrape out
this granulation tissue.
That's probably - yeah, that's just...
Okay.
Okay.
Gotta freshen up those skin edges here.
You have a 15 blade?</p>

<p>Some of the skin's rolling in here.
Let's cut this out.
That's good.
Do you have pickups?
Then this skin here.
Let's cut it down.
Okay, let's go ahead and drill this down.
Better freshen up all this.</p>

<p>Here's a - needle down.
In this case, we're drilling it
to get rid of any overlying bacteria from exposure.
Also to get slightly additional margin,
even though the deep margin was cleared
from Mohs surgery.
But we want the bone to bleed so that it'll integrate into -
help integrate the Integra matrix.
The other reconstructive option here
is to do local tissue advancement,
but in this case, we want to avoid that
because he has other surrounding scalp area
that has potential for other malignancies.
Additional skin cancer sites, so it's better to not
use that to reconstruct this area.
Oh yeah - do we have the Integra in the room?
Bilayer? Yeah.
How big is it?
What is that, how many is that?
2x2 inch.
Okay, let me see.
You have a ruler, please?
Do we have like Baci or something as well?</p>

<p>Two. That's a five.
Okay.
This one doesn't really need it.
If I was gonna - 
if there was anything left, I was gonna use that.
It's a 2x3,
and then this is 4  by -
4x3.5.
Yeah, can you open the 2x2 bilayer?
Is that what you have over there?
Yeah.
Is it bilayer?
It's double?
Yeah, that's good.
So open it? Yep.
So we'll put down this one first.
This area, again, there's stuff on it, which is good.
This if you just let it be, it'll heal in all the way.
This is not gonna heal at all.
See you got other things that
may potentially be premalignant.</p>

<h4>CHAPTER 3</h4>

<p>Okay.
Yep.
Thank you.
Is this one premeshed?
[No.]
Do you have the scissors?
How about some sutures?
You have any chromic stuff?
I have 3-0 on an SH.
And let's save these.
I don't know if it's gonna be very useful,
but we'll put a suture right here.
Let's pack it.
Hold on one second, there's something going on.</p>

<p>Hey Kevin, these are pickup-outs.
Another pickup, please.
One more.
Suture scissors. I got it.
You got it?
Yep.
Put one right here.
Yep.
Let's save those.
I might reuse it.
All right, let's go do this one right here.
Yep.
Right there.
And this guy we'll use.
Okay, one more suture.
I'm gonna start sewing this one, Brooks.
I'll put one in there.
Do you have one more chromic?
Otherwise, I'll use...
You wanna sew this one in, Brooks? Sure.
Then, let me see the Xeroforms.
Do you have Baci?
Yep.
Do you want me to bring this whole little table over there?
Do you have Baci?
Like a lot of it? Okie dokie.
Yeah, nice.
Perfect.
Get a deep bite, yep.
This is gonna be our dressing-making table.
Yay!
I'm super pumped.
And maybe be one at this corner. Okay.
Just to tack it down.
You got the Xeroform?
Yeah, and lemme see the Baci next.
Our dressing-making table.
I like it.
Very fancy.
I will make several more fluffs.
Scissors.
All right.
We have silks, right?
Might need two packs.
I'm not sure if you have...
Might need one more pack than that.</p>

<h4>CHAPTER 4</h4>

<p>Let's do...
You got one more of these, the Xeroforms?
Yep.
Can I get one more of the Xeroform things?
We can use that for that one.
All right, so when I suture this in,
I like to secure it to the skin edge.
This Integra material.
So just secure it through this, this, and then the skin.
We'll leave this long.
There's a needle down.
Okay, we'll just take that in a second.
Let me get more silks.
Gonna get one through there.
Kind of - let's go ahead and secure that.
Let's stop here or here?
This one here.
Let's just get this in this little tight space here.
So just go right through the skin edge.
And the point of this bolster is to push it down
so it doesn't lift off as it's healing.
More, please.
Picking all this up, please.
Okay, let's do the fluff.
You got some mosquitoes?
Two's probably good.
Then we'll do that, and then we'll do that one next.
I'm gonna tie this.
Kevin, go ahead.
Lemme see the mosquito.
Okay.
Nice.
Okay, good.
We haven't done any local yet, are we gonna?
No.
No local? No local.
And just leave it long for now.
Okay, now let's go to this one to this one.
Then just tie this to this.
We'll need more silks,
and then I'll take...
I have one more loaded up back here.
We need another pack.
Okay.
Scissors first and then - silks, please.
Use six, I would say.
Get it from all sides.
Can I have another silk?
Do you have a pickups?
Yeah, more pickups.
Secure it to the edge.
Can I get another silk?
I can use this.
Here's a brown.
That's fine.
I'll use this, no worries.
Two more, maybe.
One, two.
There's needle back.
Needle back.
Gracias.
One - last one, yep.
All right, the fluffs, please.
Got a mosquito?
Please?
Suture scissors.
Okay.
We are done.
All right, thank you guys.</p>


Watch this full-length, narrated surgical video of the application of an Integra bilayer wound matrix for a full-thickness scalp defect with exposed calvarium along the vertex in an elderly immunocompromised patient.

VCU Medical Center