Severe Case of Dissecting Cellulitis of the Scalp; Innovative Technique of Salvaged Full-thickness Skin Grafts: A Case Report

Introduction: Dissecting cellulitis of the scalp (DCS) is an inflammatory disease included in the follicular occlusion tetrad, including hidradenitis suppurativa (HS), acne conglobata, and pilonidal disease. DCS is caused by an obstruction of the pilar infundibulum due to follicular hyperkeratosis, which leads to follicular rupture and inflammation. Due to its wide range of involvement of the scalp, management of DCS is complex. This disease presents with painful purulent nodules of the scalp, and once it becomes tunneled and fibrotic, surgical excision should be considered. This case report follows the surgical excision of DCS using salvaged scalp full-thickness skin graft (FTSG) as an alternate approach for scalp reconstruction following scalpectomy to replace like with like and spare the patient a donor site. This case report highlights the innovative technique of salvaged FTSG in the surgical management of severe cases of DCS.Methods:A 59-year-old male presents with severe DCS, exhibiting chronic inflammatory and infected changes covering 50% of his scalp. He was diagnosed with DCS 10 years ago and has been medically managed by dermatology but now requires extensive surgical intervention. The surgical excision included scalp and posterior neck DCS with reconstruction. During the procedure, all infected tissue was removed, followed by the excision of deep fibrotic tissue, deep dermal tissue, and all hair follicles. Subsequently, the original tissue was utilized as FTSG to cover the scalp defect. A complete closure was achieved. Subsequent wound management included negative pressure wound therapy (NPWT) initially, followed by conservative wound management and dressing changes.Results:Originally, there was about a 20% loss of FTSG, primarily affecting the right lateral region of the scalp. However, through consistent wound management, minor in-clinic debridements, and wound soaks, complete healing occurred. Notably, there has been no recurrence of dissecting cellulitis.Discussion: This case signifies the innovative technique of using salvaged FTSG in the surgical intervention for severe DCS. Due to the rarity and complexity of DCS, there is no consensus on the optical medical management of this disease. Utilizing salvaged FTSG allowed for the use of color and thickness matched scalp skin, improving the durability, cosmetic outcome, and rate of healing.References:Cuellar TA, Roh DS, Sampson CE. Dissecting Cellulitis of the Scalp: A Review and Case Studies of Surgical Reconstruction. Plast Reconstr Surg Glob Open. 2020 Aug 18;8(8):e3015. doi: 10.1097/GOX.0000000000003015. PMID: 32983774; PMCID: PMC7489594. Baneu NS, Bloancă VA, Szilagyi D, Cristodor P, Pesecan A, Bratu TI, Crăiniceanu ZP. Surgical management of dissecting cellulitis of the scalp using free latissimus dorsi flap and meshed split-thickness skin graft: A case report. Medicine (Baltimore). 2021 Jan 29;100(4):e24092. doi: 10.1097/MD.0000000000024092. PMID: 33530203; PMCID: PMC7850723.