Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Treatment Options for Exposed Calvarium Due to Trauma and Burns Samuel Golpanian, MD,  Wrood Kassira, MD,  Mutaz B. Habal, MD, FRCSC, y and Seth R. Thaller, MD, DMD  Abstract: Wounds involving the calvarium secondary to trauma or burns are rare. However, they can present with challenging potential clinical sequelae. A wide variety of reconstructive options have evolved over the last century. Technical aspects have progressively improved as well over time. For proper surgical restoration of function and cosmesis reconstructive surgeons must have a detailed understanding of both the scalp and skull anatomy. Several factors such as etiology of the injury, including whether or not calvarial bone defects exists or simply soft tissue loss, as well as size, local tissue environment and patient comorbidities play major roles in appropriate choice for reconstruction. Currently, there is no single treatment option for scalp or calvarial reconstruction after trauma or burns. However, reconstructive alternatives are constantly emer- ging with promising results. Key Words: Burns, calvarium, reconstruction, scalp, skull anatomy, trauma (J Craniofac Surg 2017;28: 318–324) B urns and traumatic injuries involving the scalp and underlying calvarium represent a major clinical challenge for reconstruc- tive surgeons. Throughout medical history, injuries resulting in loss of scalp and damage to the underlying cranium have been reported. Various strategies for treatment have been described. 1,2 In the past, the reconstructive dilemma was centered on the lack of available surgical strategies or replacement materials to cover the exposed bone. Location of this injury presented a significant challenge: lack of adequate quantities of vascularized tissue to cover the underlying exposed and/or burned skull. Skull burns are rare, comprising only 1% to 6% of patients. 3 However, they remain devastating because they may result in severe disfigurement (Fig. 1). Sequela may follow unsuccessful attempts to cover, heal, and reconstruct the exposed injured cranium. Acceptable treatment of calvarial traumatic and burn injuries has gradually evolved. Success is centered upon an increasing under- standing of the involved anatomy. This has been further enhanced by innovative methods sought to restore patients to both preinjury function and health. It is important to acknowledge and discuss the ingenuity of our predecessors’ attempts at treating these challenging wounds. HISTORICAL PERSPECTIVE Any discussion of calvarial burns and traumatic avulsions should include a historical prospective. The following story is referred to in the first edition of the J.M. Converse textbook, Plastic and Recon- structive Surgery. 2 In 1777, at Camp Lady Ambler in Holsten, TN, Dr Patrick Vance treated a victim of the Cherokee Indian conflict who had ‘‘nearly the whole of his head skinned’’ in an Indian attack. 1 The unfortunate patient’s skull was ‘‘quite naked, and began to turn black.’’ 1,2 Dr Vance instructed the military physician stationed at the fort, Dr James Robertson, to burr holes in the patient’s skull as it began to blacken, going only so deep as to see ‘‘a reddish fluid appear.’’ 1 This would allow ‘‘flesh...to rise in these holes’’ which were to be spaced about an inch apart. 1 The surgical instrument of choice was an awl. He was able to penetrate the skull and remove the black scales of dead bone as granulation tissue appeared. These burr holes produced, in time, a good bed of granulation tissue. This stopped the desiccation of the skull and resulted in a slow closed wound (4 years before the defect would completely ‘‘cure up’’). Often successful, this method of coverage became widespread during the conflicts with the American Indians. As quoted, ‘‘This operation became...so common that there were persons in every fort who performed it.’’ 1 The technique was attributed to an unnamed ‘‘French surgeon.’’ Dr Vance’s inspiration for this technique appears to have been Augustin Belloste, a Parisian surgeon born in 1654. He wrote in 1696 about treating scalp avulsion by this method. He also used it to treat combat injuries. 1 This ‘‘most unique procedure’’ was used and reported on by Sneve 4 in 1888 for the treatment of severe cranial burns. Such initial reports formed the basis for the evolution of auto- logous bone grafting, procedures that are now readily available today in the repair of cranial defects. 5 Current processes in bone engineering include using stem cells as a scaffold and a carrier. 6 These enhanced factors contribute to the formation of de novo bone. Other historic landmarks in the treatment of scalp and skull burns follow the course of innovations in the treatment of scalp avulsion injuries. These include various methods of skin grafting, first developed by Netolitsky’s use of full-thickness grafts to cover denuded skull. Development of skin flaps by Gould, Gillies and Kilner, New and Erich, and Cahill and Caulfield furthered available options for reconstructive tools. For a more in-depth account of the historical treatment of scalp loss, see Kazanjian and Webster’s 7 venerable article on treatment of scalp loss. ANATOMICAL PERSPECTIVES Anatomy of the skull and its 2 engulfing fasciae is well described in previous literature. 5,7,8 It is essential to have a clear understanding of the layers of the skull. These represent an important anatomical From the  Division of Plastic Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Miami; and y Tampa Bay Craniofacial Center, Tampa, FL. Received July 1, 2016. Accepted for publication September 13, 2016. Address correspondence and reprint requests to Seth R. Thaller, MD, DMD, FACS, Professor of Surgery, Chief, Division of Plastic Aesthetic and Reconstructive Surgery, DeWitt Daughtry Department of Surgery, Clinical Research Building, 1120 NW 14th Street, 4th Floor, Miami, FL 33136; E-mail: SThaller@med.miami.edu The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003310 ORIGINAL ARTICLE 318 The Journal of Craniofacial Surgery  Volume 28, Number 2, March 2017