Scalp Incisions With Stairstep Pericranial Edges to Minimize Sequalae from Poor Wound Healing in Supratentorial Brain Tumor Surgery

Neurosurgery Practice 4:, 2023

Wound healing problems are especially prevalent in craniotomies for intra-axial brain tumors as patients often require radiation, chemotherapy, and chronic steroids. Although newer techniques such as minimally invasive approaches and routine vancomycin powder use have helped overall complication rates, poor skin healing remains a frustratingly persistent cause of morbidity. Therefore, here we describe the novel technique of elevating and closing a stairstep pericranial edge offset from the skin incision to protect hardware and support wound healing, and we report early outcomes using this technique.

METHODS: Ninety-one consecutive patients underwent supratentorial, intra-axial brain tumor surgery with a single surgeon at a single institution using this technique. Patient demographics, pathology, adjuvant interventions, and other independent risk factors were analyzed.

RESULTS: No wound-related complications requiring readmission, intravenous antibiotics, or reoperation were encountered at a median 3-month follow-up. There were also no surgical site infections, dehiscences, or cerebrospinal fluid leaks. Fifty-one patients (57.3%) had postoperative radiotherapy, 85 patients (93.4%) had perioperative steroids, and 56 patients (61.5%) had postoperative chemotherapy. Six patients (6.5%) were placed on a short course of oral antibiotics perioperatively due to concerns with initial scalp healing (ie, excessive scabbing at follow-up), none of whom progressed to infection or required further intervention. These are the cases where this technique is felt to have been most helpful by potentially preventing worse sequelae. One patient developed a shunt infection during this interval that required removal unrelated to the craniotomy site.

CONCLUSION: Here we outline in detail the principles, design, and execution of incisions and closures with stairstep pericranial edges in supratentorial brain surgery. This technique was designed in consultation with plastic surgeons to provide an intact, vascularized layer of pericranium beneath the healing skin and over the bone graft/hardware to optimize wound healing conditions and prevent morbid sequelae in inevitable cases of poor initial healing. Early results are promising.

KEY WORDS: Cerebrospinal fluid leak, Craniotomy, Resection, Surgical site infection, Surgical technique, Woundhealing