Avoiding calvarial defects in a Harrison's class IV thermally injured skull

In deep massive calvarial burns to the head it is difficult to achieve wound closure. Trepanation with subsequent grafting and expectant management while awaiting granulation tissue bed is the current recommended treatment for this clinical problem. The aggressiveness of surgical debridement of dead bone is largely based on clinical appearance of the tissue. In the cases presented here, complete removal of clinically non-viable burned calvarium resulted in calvarial defects that were avoided when some deep calvarium was left in place despite its poor clinical appearance. The clinical challenge of closing calvarial defects in the reconstructive phase of care should not be underestimated. Therefore, avoidance of a defect if possible by allowing some bone to remain during trephination is recommended.