Description
C.W. was a 39-year-old white woman, mother of 5, with a history of depression who presented with an enlarging full-thickness right paramedial scalp wound (Figure 1). Over the past year, the patient was noted by multiple family members to be compulsively picking her scalp until she finally presented by the urging of her mother with exposed calvarium. Social history was pertinent for mothering 5 children along with multiple pets at home including cats and a bearded dragon. Psychiatry, neurosurgery, and plastic and reconstructive surgery (PRS) were consulted. Her depression had been worsening, but she had not sought out any additional treatment. Psychiatry diagnosed her with body-focused repetitive behavior (BFRB) disorder, starting her with fluoxetine and cognitive behavioral therapy (CBT). Neurosurgery denied indication to intervene, as the calvarium was intact and there were no neurological deficits. PRS then performed a 2-stage reconstruction of the 6 × 8-cm defect. Stage 1 included debridement, bone burring and placement of a dermal matrix template, and negative pressure wound therapy (NPWT) (Figure 2). Stage 2 took place 5 weeks later with placement of a meshed split-thickness skin graft (Figure 3). Reconstruction was successful, and the patient is doing well amidst ongoing psychiatric challenges (Figure 4).
Figure 1.
Preoperative photograph. Patient lying supine; right 6 x 4-cm paramedian oval defect.
Figure 2.
Surgical photograph. Taken after neurosurgery assessment, plastic and reconstructive surgery debridement, and Integra placement and securement.
Figure 3.
Surgical photograph. Five weeks post-Integra placement. (a) Integra silicone outer layer removed with evidence of graft vascular integrity. (b) After placement of meshed split-thickness skin graft.
Figure 4.
Postoperative photograph. (a) Three-week follow-up from split-thickness skin graft placement. (b) Three-month follow-up.