Outcomes of Dermal Regeneration Templates in Irradiated and Nonirradiated Scalp Defects.

OBJECTIVES: Dermal regeneration templates (DRTs) are frequently used to treat scalp defects. The aim was to compare the time course of healing for DRTs in scalp defects with and without preoperative radiation. METHODS: The authors conducted a retrospective cohort study of DRT-based scalp reconstruction at 2 academic medical centers between 2013 and 2022. Information was collected on demographic variables, comorbidities, medication use, history of radiation, and DRT outcomes. The primary outcome was DRT loss, defined as exposed calvarium or DRT detachment based on postoperative follow-up documentation. Kaplan-Meier survival analysis and multivariable Cox proportional-hazard regressions were used to compare DRT loss in irradiated and nonirradiated defects. Multivariable logistic regressions were used to compare 30-day postoperative complications (infection, hematoma, or seroma) in irradiated and nonirradiated defects. RESULTS: In total, 158 cases were included. Twenty-eight (18%) patients had a preoperative history of radiation to the scalp. The mean follow-up time after DRT placement was 2.6 months (SD: 4.5 mo). The estimated probability of DRT survival at 2 months was 91% (95% CI: 83%-100%) in nonirradiated patients and 65% (95% CI: 48%-88%) in irradiated patients. In the 55 patients with a bony wound base, preoperative head radiation was associated with a higher likelihood of DRT loss (hazard ratio: 11). Half the irradiated defects experienced uncomplicated total wound closure using Integra Wound Matrix Dressing with or without second-stage reconstruction. CONCLUSIONS: Dermal regeneration template can offer durable coverage in nonirradiated scalp defects. Although DRT loss is more likely in irradiated scalp defects, successful DRT-based reconstruction is possible in select cases.

Humicola Trauma-related Invasive Fungal Infection in an Immunocompetent Patient.

The majority of invasive fungal infections arise in immunocompromised patients; however, there exist many clinical interventions and physiologic phenomena in the setting of traumatic injury that induce immunosuppressant states. Enhanced clinical suspicion and early detection of invasive fungal infections has played an increasingly pertinent role in clinical management of patients admitted for traumatic injury, given its substantial morbidity and mortality rates. In this case report, we discuss a case of trauma-related invasive fungal infection by a rare humicola pathogen in a previously immunocompetent patient. We present this case in hopes of instilling a high index of clinical suspicion for trauma-related invasive fungal infections. We also discuss the role of negative pressure wound therapy and aggressive surgical management, including debridement and various levels of amputation to optimize patient outcomes. Clinical management of trauma-related IFI has adopted increasingly aggressive approaches with respect to its formidable morbidity and mortality rates. Multidisciplinary discussions and patient-centered care are essential when making surgical decisions that impact quality of life such as amputation level.

Weighing In on the Controversy: Preoperative Imaging in Unicoronal Craniosynostosis Leads to Strategic Changes in Surgical Care.

BACKGROUND: Clinical findings in children with unilateral coronal craniosynostosis are characteristic, and therefore clinicians have questioned the need for confirmatory imaging. Preoperative computed tomographic imaging is a powerful tool for diagnosing associated anomalies that can alter treatment management and surgical planning. The authors' aim was to determine whether and how routine preoperative imaging affected treatment management in unilateral coronal craniosynostosis patients within their institution. METHODS: A retrospective, single-center review of all patients who underwent cranial vault remodeling for unilateral coronal craniosynostosis between 2006 and 2014 was performed. Patient data included demographics, age at computed tomographic scan, age at surgery, results of the radiographic evaluation, and modification of treatment following radiologic examination. RESULTS: Of 194 patients diagnosed with single-suture craniosynostosis, 29 were diagnosed with unilateral coronal craniosynostosis. Additional radiographic anomalies were found in 19 unilateral coronal craniosynostosis patients (65.5 percent). These included severe deviation of the anterior superior sagittal sinus [n = 12 (41.4 percent)], Chiari I malformation [n = 1 (3.4 percent)], and benign external hydrocephalus [n = 2 (6.9 percent)]. The radiographic anomalies resulted in a change in management for 48.3 percent of patients. Specifically, alteration in frontal craniotomy design occurred in 12 patients (41.4 percent), and two patients (6.9 percent) required further radiographic studies. CONCLUSIONS: Although clinical findings in children with unilateral coronal craniosynostosis are prototypical, preoperative computed tomographic imaging is still of great consequence and continues to play an important role in surgical management. Preoperative imaging enabled surgeons to alter surgical management and avoid inadvertent complications such as damage to a deviated superior sagittal sinus. Imaging findings of Chiari malformation and hydrocephalus also permitted judicious follow-up. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Therapeutic, IV.