Indication

Patient with prior bifrontal craniotomy through partial bicoronal incision and mesh cranioplasty after meningioma resection. Presented 11 years after surgery with mid-incision dehiscence and exposed mesh. 

Local anesthetic

None is used. In particular, epinephrine is avoided to maintain good blood flow to the incision. 

Draping

Shave a wide strip around prior incision. Clearly mark beginning and end of incision and mark dots along scar. 

Positioning

Supine, arm opposite anesthesia tucked, head on a horseshoe. Moderate head extension, no rotation. Back of bed up and some reverse Trendelenberg. 

Prep

For Gardner, use a chlorhexidine scrub brush to brush the remaining hair away from the incision. This is used whether or not the patient is "grungy" and functions mainly to brush the hair away from the incision. 

Chlorhexidine unless there is exposed dura in which case use Betadine. Have an assistant stand beside the patient's chest, reach behind the neck, and lift the patient's head off the horseshoe. 

Prep the entire head liberally. The back of the head is being held off the non-sterile horseshoe by the assistant. In sterile fashion, place a 3/4 non-permeable sterile drape beneath the head before asking the assistant to allow the patient's freshly-prepped head to rest on the sterile drape. 

Place a single blue towel over the face with the top border at the brow ridge and the lateral borders covering the patient's ears. Staple the blue towel to the horseshoe. 

Remark the incision then place Ioban over the head. Cut the clear sticky part out of a crani drape then place over the head. 

Exposure

Open the entire prior incision and elevate the scalp away from the mesh. Remove the screws holding the mesh in place. Use a broad periosteal dissector to dissect the underlying dura and granulation tissue away from the underside of the mesh before gently removing the mesh. 

Gently debride any loose granulation tissue. Do not take cultures unless there is obvious purulence or infected tissue. 

Closure

Dissect in the subperiosteal plane posteriorly only. Do not dissect anteriorly any more than was required to remove the mesh. This is to avoid injury to the frontalis branches. 

After dissecting a few centimeters posteriorly, use the Bovie set to 30/30 blend (blend option 1) with a non-protected paddle tip to score the galea to the fat in a single linear coronally-oriented incision. I.e. from right to left. Releasing the galea in this way allows the scalp to be pulled anteriorly and allows the incision to close in a tension-free manner. 

Using 3-0 Maxon suture, place a series of interrupted temporary retention stitches to reapproximate the incision. The retention sutures are interrupted vertical mattress, but Russavage makes a slight modification to the stitch. Go far-far then near-near as you normally would for a vertical mattress. Pull the length of the suture through the tissue until only a small length of the free end remains visible. This is the point where the difference is. Rather than tie the knot here, pass the tip of the needle driver through the loop, grab the short free end of the suture, and pull it through the loop. Pull it tight then tie the suture as you would normally. 

The primary virtue of this modification is in allowing easier removal of the stitch at a later date. Admittedly, this is less relevant in this circumstance given that these retention sutures will be removed before the end of the case. When tightening these retention sutures, Russavage is feeling for the amount of tension across the incision, which informs his decision on whether primary closure in this way will be adequate or a different approach will be necessary (i.e. Z-plasty or rotational flap with skin grafting). The goal should be to have the skin edges overlap with redundant tissue without tension. The redundant tissue is then trimmed with a pair of Metzenbaum scissors to expose fresh, healthy, bleeding skin edges. 

The galea is then closed with interrupted 3-0 Maxon suture with buried knots followed by a running "baseball" 3-0 Caprosyn suture. The Caprosyn suture is rapidly absorbed within 3 weeks. This minimizes the risk of persistent retained suture fragments by the time of eventual cranioplasty which could be a nidus for developing a stitch abscess.