Case of  the Fortnight
Replantation of  Total Avulsion of  Scalp

A eleven year old female child's hair was caught in a gaint wheel, when she went to play at a local temple car festival on 6-6-2002.  The whole scalp was avulsed with bare bone exposed in most of the vault of the skull.  CT Scan of skull did not reveal any injury to the brain.
 

Total scalp avulsion - side view
Bare bone seen from top
Inner view of the Avulsed Scalp
Avulsed Scalp with both eyebrows and long hair as seen before and after shaving

The avulsed scalp was brought properly stored along with the child.  Shaving of scalp hair requires patience and care.  The long hair is first trimmed and then shaved after making it wet.  The commonest problem is the cut hair getting adherant to the inner aspect of the scalp.  We have devised a simple technique of  shaving  the avulsed scalp.  After thoroughly washing the scalp to remove all dirt,  it is placed on the side of a cylindrical plastic container.  The inner surface of the scalp sticks to the container snugly.  Shaving is started from one edge to the other and carried out from top to bottom.  The Scalp is not removed from the container until all hair is shaved.  Then the surrounding area is cleaned of all the shaved hair.   In this way, no loose hair comes in contact with the inner surface.  This saves considerable time in preparing the scalp for replantation.  (Ref. Hari Venkataramani., S. Raja Sabapathy. A Simple method of shaving avulsed scalp before replantation.  Plast. Reconstr. Surg. 107:1,286. given below)
 

Method of Shaving of Avulsed Scalp (Not the present case report)
Plast. Reconstr. Surg. 107:1, 286.

The patient arrived 5hrs after the accident.  The part was properly preserved. (click for how to bring an amputated part), 2 hours after the accident.  The part was examined under the microscope.   Both superficial temporal vessels, 3 veins on the forehead and two veins on the occipital area were identified and tagged with 8-0 ethilon.  3-0 prolene stitches were taken at the skin edges where the vessels were found.  This is particularly useful and saves precious time while identifiying the vessels once the scalp is fixed on to the skull. The scalp was attached to the head by tagging 3-0 prolene sutures in between the sites where the vessels were identified.

Both the superficial temporal arteries and veins and two veins on the forehead were anastomosed with 10-0 ethilon under the microscope.  Though the forehead scalp veins measured 0.5 mm in diameter, they functioned well. The whole scalp circulation picked up once  the clamps were released.  Two units of blood were given intra-operatively.  Due to problems in positioning and risk of disruption of anastomosis in the forehead, vessels in the occipital region were not repaired.  The surgery took six hours.  (including preperation and reattaching of the avulsed part).  The patient had a smooth post operative course.  The hair growth has already started.
 


  
Complete survival of the replanted scalp with early hair growth seen at the end of 2 weeks of post operative period.

Late Post Operative Photographs

    
The success of the replant was very crucial in this case as more than 3/4 th of the skull was devoid of periostium and would have needed a major microsurgical free flap for cover.

Team :  Dr. S. Raja Sabapathy,  Dr. Ravindra Bharathi, Dr. Hari Venkataramani, Dr. Deepak . K.L., Dr. Divakar Raju. K.
            (Department of Plastic and Reconstructive Micro Surgery)

             Dr. Ravindra Bhat, Dr. Venkatesh (Department of Anaesthesiology)