Autologous omental harvest for microvascular free flap reconstruction of a severe traumatic scalp degloving injury: a case report

• Published in: Canadian Journal of Surgery Vol. 64; p. S42
• Main Authors: MacLean, Alyssa, Ladak, Adil, Snelgrove, Ryan, Wang, Haili, Power, Hollie, Bradley, Nori
• Format: Journal Article
• Language: English
• Published: Ottawa CMA Impact, Inc 01-10-2021
• Subjects: Case reports; Injuries; Laparoscopy; Neurosurgery; Plastic surgery; Skin & tissue grafts; Trauma
• ISSN: 0008-428X; 1488-2310

Background: Traumatic scalp degloving injuries are associated with substantial morbidity and profound psychosocial impacts. Injury management is complicated by extensive surface area of exposed calvarium and limited availability of local vascularized tissue for coverage. Reconstructive options include advancement of local periosteal, muscle or fascial flaps, regional pedicled flaps or free tissue transfer flaps. Vascularized omental free flaps have been described with good results, but rarely outside the plastic surgery literature. Methods: We present a case of severe traumatic scalp degloving and describe the multidisciplinary operative management approach. Following wound bed preparation, autologous omentum was harvested laparoscopically and used as a vascularized free flap to support a splitthickness skin graft and successfully cover a near-total scalp avulsion injury. Results: A 29-year-old female presented to our level 1 trauma centre following blunt head trauma from agricultural equipment. During advanced trauma life support assessment, secondary survey revealed near total scalp degloving encompassing the forehead and circumferential scalp to the superior nuchal line. The avulsed scalp was fragmented, precluding reimplantation. The patient underwent multiple operative debridements. Wound management consisted of salinesoaked dressings, then negative pressure wound therapy once the wound base was clean. Despite elevation of local periosteal and temporalis muscle advancement flaps, incomplete calvarial coverage rendered primary skin graft reconstruction impossible. Plastic and general surgery teams collaborated to plan for autologous omentum as a vascularized free tissue transfer flap. In a combined procedure, the plastic surgeons prepared the skull and left superficial temporal vessels for free flap transfer, while the general surgeons performed laparoscopic omentectomy with preservation of right gastroepiploic artery and vein. The omentum was removed via laparoscopic retrieval bag and primed with heparinized saline, and a microvascular anastomosis of gastroepiploic to superficial temporal vessels was completed. Indocyanine green confirmed perfusion, and nonilluminating segments were resected. The omental flap was inset along the defect. A split-thickness skin graft was harvested from the patient's thigh, meshed and secured over the omental flap. Neurosurgery applied a halo device to offload the posterior flap/graft for optimal healing. Graft take was excellent with complete coverage and an aesthetic scalp contour. Conclusion: We report a case using laparoscopic retrieval of autologous omentum for successful microvascular free tissue transfer flap reconstruction in a severe traumatic scalp degloving injury. Collaboration between plastic, general and neurosurgery colleagues facilitated this reconstructive technique and yielded excellent functional and cosmetic results for the patient. Omental free flap is an uncommon but useful approach and should be considered part of the management algorithm for traumatic scalp degloving injuries.