Complete scalp avulsion with absent periosteum poses a significant reconstructive challenge. If scalp replantation is unfeasible, alternative treatment options are often challenging for both patient and surgeon. Moreover, results obtained with conventional soft tissue coverage procedures are often aesthetically unfavorable.

Development of synthetic biologic products has increased our range of reconstructive options; however, indications for usage have generally been limited to restricted clinical situations.

We describe several guidelines in the use of a synthetic collagen and chondroitin coated silicone membrane (Integra, Integra Lifesciences Corporation, Plainsboro, New Jersey) when reconstructing large traumatic scalp wounds associated with periosteal loss. The success in this particular clinical case illustrates these fundamental principles.

An eight year old girl was mauled by two pit bulls. The resultant total scalp loss included exposed calvarial bone denuded of periosteum extending from the middle forehead to the posterior occiput and bilaterally just superior to the auricles. After performing serial debridements, miniplate fixation of the Integra, and negative pressure therapy, we obtained vascularized granulation tissue over 5 millimeters in depth overlying the previously exposed bone. Subsequent split thickness skin grafting was successful and resulted in a stable, well-contoured reconstruction.

The use of Integra in treating wounds with bare bone has been previously described in small settings. Extrapolating those results to successfully manage exposed calvarium with wholly devitalized periosteum requires close adherence to well-established surgical principles including adequate debridement, maintenance of an appropriate wound healing environment, and stable fixation of the biologic coverage.

While this technique carries several disadvantages, including a delayed inpatient course required for multiple stages of reconstruction, limited patient mobility due to attachment of negative pressure devices, and permanent alopecia, they are outweighed by its technical ease of application, the immediate coverage of exposed bone, uniform soft tissue cover, and low patient morbidity. Furthermore, failure of attempted Integra reconstruction does not preclude subsequent autologous tissue reconstruction.

With this technique, surgeons and patients have a less intensive yet technically sound treatment choice without eliminating more established options for reconstruction. Clinical success with the careful application of synthetic biologic materials demonstrates the widening treatment choices surgeons now have in treating some of our most challenging and devastating injuries.