Successful Reconstruction of a Large Scalp Wound With Exposed Cranium in an Irradiated Field Secondary to Recurrent Giant Squamous Cell Cancer Utilizing Fish Skin Xenografts

Introduction: Squamous cell carcinoma (SCC) is the second most prevalent malignant skin cancer.  The head and neck is the most common location and generally older patients are affected. In wounds with exposed bone, there are limited reconstructive options. The closure is further complicated if the area received prior radiation therapy due to insufficient blood supply, fibrosis, and attenuated cellular function.  To this end, advanced biologics including fish skin xenografts, are often warranted.Methods:The patient is a 94 year-old white male who presented with a rapidly enlarging (12 by 6 by 4cm) recurrent SCC in March 2024. The patient previously underwent primary radiation therapy in 2022 and salvage radiation therapy in November 2023. He had multiple admissions for transfusions and intravenous antibiotics secondary to hemorrhage and infection due to the mass. The patient and family declined metastatic workup. He underwent palliative wide local excision resulting in a 13 by 7 cm defect with 6 by 5 cm of exposed cranium. Staged bone burring and fish skin xenograft placement was subsequently performed. A nonadherent compressive postoperative dressing was applied.Results:After three additional applications of the fish skin xenograft at weekly or biweekly intervals, the wound bed including the exposed bone was robustly granulated and he underwent successful staged split thickness skin graft reconstruction.Discussion: Fish skin xenografts are FDA approved for treating chronic and acute surgical wounds.  The product is an acellular dermal matrix harvested from Icelandic cod with a porous microstructure like human skin. Characteristics of the xenograft include bacterial resistance, angiogenesis, and inflammatory cytokine mitigation. This case report shows that a fish skin xenograft is suitable for complex wound closure, including exposed cranium in a previously irradiated field.References: