12 Successful treatment of avulsion scalp injury with V.A.C.® system and INTEGRA® dermal regeneration template

Of all emergency pediatric conditions, dog bites account for 0.3-1.5%. Particularly at-risk group is children under 10 years of age. Lately, dog bites have been increasingly recognized as a medical and public health issue, as they leave functional, aesthetic and psychosocial consequences. We show the case of a one-year-old boy who was referred from a general hospital to our Clinic for extensive scalp injury by a neighbor’s dog. In the general hospital, the wound was flushed and the child was administered ceftriaxone. In addition to the one-year-old boy, in saline, a piece of skin of the scalp was sent. Upon arrival, the child was vaccinated (tetanus-diphtheria toxoids/tetanus immune globulin). The craniogram showed no signs of fracture. At the operating table, we verified a 22 cm long forehead and scalp injury that extended from the left eyebrow to the middle of the scalp. A swab was taken. Immediately, thinking about the final aesthetic appearance, we decided to primary close the forehead region first. On the part of the scalp that we were unable to primarily close, we reimplanted a piece of boy’s scalp measuring 9 cm x 5 cm. The edges of the wound were sutured with Monosyn® 4/0 sutures. 2 drains were placed. Despite regular dressings and monitoring with appropriate antibiotic therapy (the following pathogens were isolated in the swab; Enterobacter aerogenes, Pasteurella multocida, Citrobacter freundii – all resistant to penicillin, ampicillin, amoxicillin-clavulanic acid) the reimplanted part of the scalp was not accepted. On the eighth day, a necrectomy of the devitalized tissue was performed. The wound edges were refreshed, treated with Microdacyn®, and a V.A.C.® system (-125mmHg) was set up. He worked continuously for 2 days before Integra® was set up. Integra® was fenestrated before placement. After setting Integra® 2 times we changed the V.A.C.® system. With the acceptance of Integra®, on the 14th day a silicone layer was removed and split-thickness skin graft (STSG) was transplanted from the left upper leg. On the STSG Bactrigas® was placed with the V.A.C.® system. By monitoring and replacing the V.A.C.® system, STSG was accepted. One month after the injury, the boy was released from the hospital. After 3 months the local status is satisfactory. We plan to hair transplantation in the future.