The surgical closure of exposed skull

The closure of scalp defects is still surrounded by many uncertainties. Free skin graft has proved most successful. Thiersch graft, split skin graft and full thickness skin graft have their indication for use. Thiersch skin graft is used as a temporary dressing, in order to achieve aseptic wound conditions, but cannot be looked upon as a lasting solution cosmetically and functionally. Split skin is used only for the closure of smaller defects. Full thickness skin grafts are most suitable, because they offer a lasting coverage, which meets to all demands. If the outer table of the skull is exposed, multiple bur holes could be placed immediately in cases of fresh injuries, and these facilitate the growth of granulation tissues which nourish the outer table adequately, so that it remains viable. Exposure of the outer table of the skull for a long time leads to necrosis of the superficial layer. It must therefore be removed down to the diploe with a chisel, or brought to early sequestration by means of numerous perforations made with a bur. Skin should not, however, be placed on the exposed diploe immediately, but it should be allowed to granulate, so as to produce a layer of fibrous tissue beneath the grafted full thickness skin. Thus a direct adhesion to the bony underlayer is prevented, and the skin remains movable. The danger of pressure ulcer is also prevented. The figures show the surgical procedure.