Scalping Research Articles

Microsurgical Replantation of Avulsed Scalps

Four cases of extensive scalp avulsion were successfully replanted in this reported series. All patients were female, with the youngest 3 years of age. All replanted scalps survived, with some marginal necrosis due to tissue destruction. Postoperative venous congestion of the involved ear in one patient was managed with anticoagulant therapy. Another patient underwent severe congestion of the whole replanted scalp and was treated with thin skin-graft shaving in the parietal area. In the follow-up period, all patients obtained hair growth in the scalp with light touch sensation.

Secondary Expansion of a Totally Replanted Scalp for Aesthetic Adjustment

Total scalp avulsion is an uncommon and dramatic accident. Replantation is the only way for acceptable aesthetic final results. However, partial loss of tissue can result, and secondary procedures can be required. A total avulsion of a scalp involving the upper part of the right ear and both eyebrows was replanted after a long delay in our department. As a result, loss of a third of the hair-bearing area occurred. Secondary expansion of the replanted scalp achieved complete reconstruction.

Scalping injuries: dos and don'ts

Replantation is the treatment of choice in scalping injuries and should always be considered, even in case of a badly damaged scalp. Specific procedures regarding pre-, intra- and postoperative care are crucial to success in replantation. These include: haemodynamic stabilization of the patient without causing damage to possible donor vessels; cooling, cleaning and further proper care of the avulsed specimen; use of antibiotics and haemodilution to optimize the intra- and post-operative situation. The above is illustrated by a case history of successful replantation of a seriously damaged avulsed scalp.

Single artery replantation of totally avulsed scalp

The treatment of choice for the avulsed scalp is microvascular replantation. After replantation there are numerous arterial anastomoses, with venous congestion. Usually an effort to establish inflow through two arterial anastomoses is made. We elected to anastomose one artery and multiple veins in each of our patients. We present three consecutive successful replantations of total scalp avulsion, using only one arterial anastomosis, and multiple veins. Surprisingly, two of the patients regained their ability to elevate their eyebrows actively.

Reconstruction of avulsed scalp after go-cart injury: M.J. Weinberg, R.M. Zuker, J.L. Mahoney, et al. Can J Surg 35: 637–641, (December), 1992

Reconstruction of avulsed scalp after go-cart injury: M.J. Weinberg, R.M. Zuker, J.L. Mahoney, et al. Can J Surg 35: 637–641, (December), 1992

Total scalp replantation based on one artery and one vein

A successful replantation of a totally avulsed scalp, including both eyebrows, with only one arterial and one venous anastomosis to the superficial temporal vessels is described. Apart from a small partial skin necrosis of the right eyebrow, the entire transplant survived. Subsequently, the patient required only minor additional skin grafting, correction of scars with a skin expander, and reconstruction of the eyebrow with hair micrografts. Replantation of the total scalp based on two or more vessels has previously been recommended and reported elsewhere. In the present case, complete survival of the scalp on only one artery and one vein was demonstrated, indicating that replantation should be considered even if available vessels for anastomosis are minimal.

Experiences in surgical repair of a totally avulsed scalp

A case of total scalp avulsion is described in surgical detail. The neurovascular bundles remained nearly untouched on the surface of the galea aponeurotica. Only one frontal branch of the left temporal artery was found to serve as a nutrient vessel for the whole scalp. Three veins around the scalp circumference supplied the venous drainage. The right-dorsal part of the scalp underwent necrosis, obviously because of internal disruption on the capillary level. This area had to be skin-grafted secondarily. Mechanical aspects in respect of the neuro-vascular situation are discussed theoretically and some advice on the surgical approach is derived from our experience.

Total Scalp Ear, and Eyebrow Avulsion: Aesthetic Adjustment of the Replanted Tissue

A case of successful replantation of a total scalp avulsion, including both ears and one eyebrow, is presented with bilateral anastomoses to the superficial temporal vessels. While over 90 percent of the replant survived, partial loss of occipital and posterior neck skin and the inferior half of the left ear occurred. The patient subsequently required additional procedures, including skin grafting, scar revisions, and staged ear reconstructions. Thus, while microsurgery often provides the only hope for tissue salvage, there is a frequent need for additional revisions and aesthetic adjustment of portions of the replanted tissue.

Avulsion of the Scalp: Which One is the Best Artery for Anastomosis?

We present a patient who underwent successful replacement of a large avulsed scalp with microvascular anastomosis of one artery and three veins. The left occipital artery in the avulsed scalp and a frontal branch of a right superficial temporal artery in the recipient forehead were anastomosed. Three veins in the occipital area in the avulsed scalp were anastomosed via vein grafts to three veins in the frontal area, respectively. For successful replacement, the selection of the vessels depends on each individual case. To give easy anastomosis, a good cosmetic result, and a comfortable postoperative period, it is not always necessary to reconstruct a previously normal anatomical position.

The Versatile Temporoparietal Fascial Flap

The unique properties of the temporoparietal fascial flap (TPFF) offer adaptability in reconstruction of a variety of composite defects. The broad, thin sheet of vascularized tissue may be transferred alone or as a carrier of subjacent bone or overlying skin and scalp. As a pedicled flap, it is ideal for defects of the orbital, malar, mandibular, and mastoid regions. As a free-tissue transfer, the large vessels and lack of bulk find broad utility in reconstruction of the extremities. This flap is our choice for reconstruction of the dorsal hand and non-weight-bearing surfaces of the foot. A viscous gliding surface decreases friction for tendon excursion. The thin contour is aesthetically superior to thicker flaps, allowing unmodified footwear or gloves. The pliable fascia convolutes into surface defects (e.g., bone craters) or drapes over skeletal frameworks (e.g., ear cartilage). The rich capillary network offers nutrition to saucerized bone, cartilage or tendon grafts, and overlying skin grafts. The geometry of the skull lends to fabrication of membranous bone for complex facial puzzles. The donor site is well disguised by hair growth. Twelve cases performed over a 2-year period demonstrate the versatility of this flap. These include complex foot reconstruction, ear and scalp avulsion, shotgun wound of the cheek and orbit, posttraumatic jaw recontouring, chronic osteomyelitis of the hand and foot, and acute resurfacing of dorsal hand with tendon reconstruction.

Lower Extremity Avulsion Injuries

Avulsion injuries are best treated by removal of the avulsed tissue and replacing it as a full-thickness skin graft. Additional meshed split-thickness skin grafts from a separate donor area may be necessary to complete the soft-tissue coverage. Fractures commonly accompany avulsion injuries and require appropriate treatment. The atypical avulsion injury is a special problem that occurs infrequently but results in considerable morbidity. This injury is most commonly seen in individuals run over by heavy vehicles, particularly buses. The shearing forces involved cause extensive undermining of tissues, although the external surface of these areas appears uninvolved. This results in an under-estimation of the true extent of the injury. If not recognized, there may be either delayed full-thickness necrosis of large areas of skin and subcutaneous tissue or the development of sepsis due to deep necrosis of the fat and fascia at the shear plane. If the true extent of injury is initially recognized, a dilemma exists in terms of deciding how much of the normal-appearing tissue to excise. The proper treatment plan for the atypical injury is not yet established with certainty. However, quantitative dermofluorometry has proven to be a valuable means of assessing the viability of extensively undermined areas of skin and subcutaneous tissue. This test is easily performed and can be used for serial study. Viable areas that are undermined and left in place require an early limited debridement of the undersurface to remove necrotic fascia and subcutaneous fat. This may require additional incisions for exposure. Plantar avulsions are another separate category of avulsion injury. Traditionally, the avulsed plantar surface has been sewn back into place, although this frequently resulted in the loss of this specialized tissue. It has become clear that it is possible to revascularize the plantar surface when major avulsion injuries occur. The plantar surface is thus similar to digital amputations and major scalp avulsion injuries in that replantation or revascularization is worthwhile and should be performed whenever possible. Soft-tissue loss around the ankle frequently co-exists with these injuries, and free tissue transfer may be necessary to complete soft-tissue coverage following revascularization.

Injuries causing major loss of scalp.

Long hair worn by both sexes in a majority of the rural population of Punjab (India) increases the hazard of descalping injuries. Forty-six cases seen over a period of 10 years are reported. Agricultural machinery accounted for 83 percent of these injuries. Males were most commonly involved (63 percent), and 48 percent of the patients were minors. Nearly all cases reported had at least half the scalp avulsed, 56.5 percent being total scalp avulsions, with bare bone exposed in 48 percent of the total. The method of chiseling the outer portion of the exposed bone down to bleeding points and immediately applying a split-thickness skin graft is presented as the procedure of choice for wound closure. This reduced the average hospitalization period by 49 percent as compared with older methods. Follow-up of 67 percent of patients has revealed a surprising instability of the grafted skin, with an ultimate danger of malignant degeneration.

Successful replantation of a totally avulsed scalp following prolonged ischemia

Successful replantation of a totally avulsed scalp following prolonged ischemia

Surgical Treatment of the Totally Avulsed Scalp

Scalp avulsion is associated with significant physical and psychological morbidity. In the past, extended hospitalizations and multiple procedures to achieve coverage were the rule and the chronic morbidity of partial thickness coverage was high. Microvascular surgery now allows an initial chance for successful replantation or a subsequent one-stage reconstruction with well-vascularized tissue with a 90 per cent chance of success. The use of the free latissimus dorsi muscle has been a significant advance in this regard. When progress in immunologic research allows allotransplantation with little morbidity, scalp transplantation may become a useful reconstructive tool.

Application of the halo apparatus in the treatment of the scalp avulsion victim.

Application of the halo apparatus in the treatment of the scalp avulsion victim.

Application of the Halo Apparatus in the Treatment of the Scalp Avulsion Victim

Application of the Halo Apparatus in the Treatment of the Scalp Avulsion Victim

Microsurgical replantation of complete scalp avulsion: a five year follow-up

A 19-year-old woman sustained total scalp avulsion. Replantation of the avulsed scalp by microvascular anastomoses was successfully performed on October 10, 1976. A follow-up evaluation after 5 years is presented.

Scalp Avulsions and Review of Successful Replantation

Microvascular surgery has greatly altered the handling of scalp avulsions. Review of the injury mechanism and of successful replantations has yielded some basic axioms concerning treatment of this tragic injury. Generally, larger avulsions contain vessels that are easily identified and anastomosed, and therefore have a better prognosis. Long periods of ischemia do not appear to threaten graft viability. The superficial temporal artery is the most reliable artery for scalp replantation; accompanying veins can normally be used for venous drainage, though vein grafts are often needed due to vessel disruption at injury. Replantation should be attempted with all scalp avulsions, though the size of the defect and its location will affect the outcome.

Scalp Avulsions and Review of Successful Replantation

Microvascular surgery has greatly altered the handling of scalp avulsions. Review of the injury mechanism and of successful replantations has yielded some basic axioms concerning treatment of this tragic injury. Generally, larger avulsions contain vessels that are easily identified and anastomosed, and therefore have a better prognosis. Long periods of ischemia do not appear to threaten graft viability. The superficial temporal artery is the most reliable artery for scalp replantation; accompanying veins can normally be used for venous drainage, though vein grafts are often needed due to vessel disruption at injury. Replantation should be attempted with all scalp avulsions, though the size of the defect and its location will affect the outcome.

Scalping: the savage and the surgeon.

The treatment of the scalped patient has challenged and fascinated the surgeon for over two millennia. It is an esthetically disastrous mutilation, and the resultant soft tissue defect is a form of trauma calling for the surgeon's most creative efforts. The story of scalping is the story of innovative surgeons, both renowned and obscure, which parallels the development of plastic surgery.