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\begin{document}

\title{Modified method of scalp fixation promotes survival of complete scalp
avulsion replantation}



\author[1]{Lei Xu}%
\author[1]{Guangliang Zhou}%
\author[1]{Wen Ju}%
\author[1]{Yujun Zhang}%
\author[1]{Qianheng Jin}%
\author[1]{Lei Li}%
\author[1]{Ruixing Hou}%
\author[1]{Jihui Ju}%
\affil[1]{Suzhou Ruihua Orthopedic Hospital}%


\vspace{-1em}



  
  \date{March 15, 2025}


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\textbf{Modified method of scalp fixation promotes survival of complete
scalp avulsion replantation}

\textbf{Key Clinical Message}

A complete scalp avulsion injury is rare but extremely challenging to
treat. Due to the dense blood vessel bundles present in the scalp,
replantation failure may occur if there is a subcutaneous hematoma. The
method of scalp fixation is crucial for replantation to be successful.
We successfully treated a total scalp avulsion injury using a modified
scalp fixation method, coupled with microsurgical anastomosis, to avoid
subcutaneous hematoma effectively and achieved a satisfactory outcome
with a follow-up of nine years postoperatively.

\textbf{Keywords:} Scalp fixation, Microsurgical replantation, Complete
scalp avulsion, Case report

\textbf{Introduction}

Full-scalp avulsion injuries are often caused by hair being caught in
rapidly rotating machinery, frequently accompanied by extensive skin
loss and even exposure of the cranial bones\textsuperscript{[1-2]}.
The scalp comprises dense hair follicles, a thick dermis, and nerves and
blood vessel bundles. Significant blood loss often occurs in cases of
full scalp avulsion injury, which can be life-threatening in severe
cases. In recent years, advancements in microsurgery have provided new
approaches for treating complete scalp avulsion
injuries\textsuperscript{[3-4]}. In some cases, the success of
microsurgical replantation can be negatively affected by subcutaneous
hematoma or inadequate drainage. Most of the literature on scalp
avulsion has focused on scalp replantation, with few addressing the
scalp's fixation in replantation. Replantation failure may occur if
there is a subcutaneous hematoma or inadequate drainage due to the dense
blood vessel bundles in the scalp. In addition to efficiently preventing
scalp separation from subcutaneous bruising, suturing the scalp to the
periosteum can stop bleeding by compression and increase the survival
probability after scalp replantation. In this study, the author presents
a technique utilizing a spider web-like suturing method to secure the
scalp, effectively preventing subcutaneous hematoma formation and
promoting successful replantation of total scalp avulsion injuries and
achieves satisfactory results with a follow-up of nine years
postoperatively.

\textbf{Case History}

A 36-year-old female patient suffered a total scalp avulsion injury due
to her hair getting caught in the rotating shaft of a machine. The scalp
is avulsed from the galea aponeurotic, anteriorly extending from the
nasion, the mid-eyebrows, and lower eyelids bilaterally, posteriorly to
the occipital scalp, laterally reaching the bilateral auricular roots
and zygomatic arches, with an approximate area of 35.0 cm \selectlanguage{ngerman}× 40.0 cm. The
left auricle is torn and severely abraded, with exposed frontal,
parietal, occipital, and temporal bones (Figure 1). The patient was
admitted almost 3.5 hours after the trauma.

\textbf{Methods}

The surgery was conducted in two groups: one group managed the scalp by
cutting the hair, disinfecting the scalp with iodine, trimming the skin
edges, identifying and marking blood vessels, while the other group
managed the skull by disinfecting the skin and wound with iodine. After
cleaning the wound, carefully identifying the blood vessels, and marking
the superficial temporal arteries, veins, and occipital subcutaneous
veins on both sides for later use, a spider-web suture technique was
used. Starting from the cranial vertex, the scalp was meticulously
sutured in place, one layer at a time, with absorbable sutures. The
subcutaneous tissues on the left and right temporal sides were sutured
and fixed to the periosteum. Under the surgical microscope, the two
arteries and four veins were delicately anastomosed using 10-0
non-traumatic sutures, restoring blood circulation to the scalp. The
subcutaneous tissues were sutured and fixed to the periosteum of the
skull using 4-0 absorbable sutures to ensure close approximation of the
skin to the skull and prevent subcutaneous hematoma. Drainage tubes were
placed under the scalp and incision sites (Figure 2). Postoperatively,
the drainage tubes were removed on the second postoperative day.

\textbf{Conclusion and Results}

Scalp replantation can achieve satisfactory results, while spider-web
fixation of the scalp can effectively prevent subcutaneous fluid
accumulation, significantly improving the survival rate of scalp
replantation. By the tenth day postoperatively, the scalp had fully
healed. Viable scalp hair growth was observed two months
postoperatively, and at nine years postoperatively, hair growth was
dense and nearly equivalent to preoperative levels. Eyelashes grew well,
there was no local alopecia, the scalp texture was soft, the protective
sensation was restored, and there was no impairment of eyelid opening or
closing (Figure 3).

\textbf{Discussion}

Complete scalp avulsion is a rare and life-threatening injury typically
resulting from the entanglement of long hair in rotating machinery, such
as agricultural or industrial equipment. Various treatment methods for
scalp avulsion include thinning the scalp into medium-thick skin flaps
and replanting them in situ\selectlanguage{english}\textsuperscript{[5]}. However, the success
rate of this method is relatively low. For cases with exposed cranial
bones, skull perforation can be performed, and skin grafting is done
after granulation tissue formation. Another approach involves using the
greater omentum for free transplantation to the head, with skin grafting
on the greater omentum\selectlanguage{english}\textsuperscript{[6-7]}. However, these methods
may result in alopecia deformities. With the advancement of
microsurgical techniques, utilizing vascular anastomosis for full scalp
replantation is considered the best method for treating scalp avulsion
injuries. This approach ensures blood supply to the scalp and promotes
hair regrowth, typically avoiding alopecia deformities.

The scalp receives a generous supply of blood from various arteries
located in the subcutaneous layer above the galea, including the
superficial temporal, occipital, supraorbital, and supra-auricular
arteries. If postoperative drainage is inadequate, leading to the
formation of a subgaleal hematoma, it can cause separation of the scalp
and ultimately result in the failure of scalp replantation. Therefore,
preventing scalp separation is key to ensuring scalp replantation's
success. In this work, we have refined the technique for fixing the
scalp, presenting a novel method that secures the scalp sporadically
using a spider-web-like design. First of all, spider web anchoring of
the scalp efficiently prevents displacement of the scalp during or after
surgery, which could lead to vascular rips, breaks, anastomotic
distortion, and the production of large subcutaneous hematomas after
surgery. It also makes intraoperative vascular anastomosis easier.
Second, it makes it easier for the recipient site and the replanted
scalp to come into close contact, which promotes the development of a
shared blood supply. Finally, it lessens subcutaneous oozing,
successfully stopping hematomas from forming under the scalp. As a
result, the enhanced scalp fixation technique can significantly increase
the success rate of replantation.

\par\null

\textbf{Conflicts of interest}

There are no conflicts of interest.

\textbf{Authors' contributions}

All authors were involved in this surgery. Lei Xu, Guangliang Zhou, Wen
Ju, Yujun Zhang, Qianheng Jin, Lei Li collected and assembled the data.
Lei Xu drafted the manuscript. Jihui Ju and Ruixing Hou critically
revised the manuscript for intellectual content. All authors read and
approved the final manuscript.

\textbf{Consent}

Written patient consent has been signed and obtained from the patient.

\textbf{Founding}

This study was mainly supported by a grant from the Suzhou Science and
Technology Development Plan (Medical Innovation Applied Research)
Project (SKY2023107, SKY2023108, SKYD2022073) and Suzhou Key Disciplines
(SZXK202127).

\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Lin J, Wei P, Wang Y, Song Q, Yang Z, Xu Y. Experience in
  microsurgical treatment of complete scalp avulsion. \emph{Ann Plast
  Surg} 2023;90(4):331-333.
\item
  Staley CK, Hallock MM, Younggren BN. Complete scalp avulsion. \emph{J
  Emerg Med} 2011;40(1): e19-e20.
\item
  Jennings M, Willet J, Cook S, Harbison J, Caplash Y, Solanki NS. Total
  scalp avulsion: Practical tips for successful replantation. \emph{ANZ
  J Surg} 2022;92(4):880-881.
\item
  Madsen CB, Poulsen L, Bakholdt V, Sorensen JA. Microsurgical
  replantation of a traumatic total scalp avulsion. \emph{BMJ Case
  Rep}2023;16(1): e252570.
\item
  Fija\selectlanguage{polish}ł\selectlanguage{english}kowska M, Antoszewski B. Complications after scalp suturing
  posttraumatic avulsion. \emph{J Craniofac Surg} 2018;29(7): e670-e672.
\item
  Wu PF, Qing LM, Tang JY. One-stage reconstruction of huge scalp defect
  with a free vascularized greater omentum. \emph{Ann Plast
  Surg}2019;82(1):128-129.
\item
  Browning FS, Eastwood DS, Price DJ, Kester RC. Scalp and cranial
  substitution with auto-transplanted greater omentum using
  microvascular anastomosis. \emph{Br J Surg} 1979;66(3):152-154.
\end{enumerate}

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