1 Case Presentation

A 42-year-old woman suffered a total scalp avulsion caused by the braid involved in the rotating machine. Physical examination: The wound and alvused scalp were seriously polluted. The laceration extended from the nose root in the anterior to the occipital hair in the posterior, and it extended across the back of two ears including part of the left ear with area about 18 cm × 14 cm bone exposed. The avulsed scalp was without blood supply, and we could see a 6.5 cm × 10.5 cm contusion of the occipital region and multiple lacerations. The patient was brought to the operating room when the vital signs were stable after hemostasis by compression bandage, antishock treatment, and completing essential examinations. The avulsed scalp was replanted in situ after complete debridement by anastomosing both superficial temporal arteries and veins, both posterior auricular arteries and veins, and two occipital nerves. After the replantation, the scalp had a good blood supply, and then we sutured the wound with 3–0 silk sutures, installed the Halo-vest head ring (Fig. 37.1), placed half tube drainage, and wrapped it with sterile gauze in order. The scalp was completely alive after 72 months of follow-up, and the patient was satisfied with the hair growth and the appearance (Fig. 37.2).

Fig. 37.1
figure 1

Halo-vest head ring

Full size image
Fig. 37.2
figure 2figure 2

(a) The avulsed scalp. (b) The prepared scalp. (c) The wound of the head. (d) The replanted scalp. (e) The installment of Halo-vest head ring. (f) 1 week after operation. (g, h) 4 months after operation

Full size image

2 Choice of Treatment

By now, the common treatments for total scalp avulsion that is a serious trauma and hard to be cured are in situ repair, transplantation of free skin graft, thinned scalp in situ repair, free flap transplantation, and so on what is usually single used and the result is hard to be satisfied [1,2,3,4]. The combination of the Halo-vest ring which is usually used in the injury of cervical spinal cord and microsurgery technique could improve the survival rate and the recovery of appearance significantly. The main advantages of the new try are: (1) Cotton washer is instead of the Halo-vest ring that is installed on the skull with four points what could avoid necrosis caused by compression; (2) The Halo-vest ring could fix the replanted scalp and induce the cavity under the scalp which is helpful in reducing the occurrence of vascular crisis, hemorrhage, and infection, and the microcirculation would be rebuilt earlier; (3) It would reduce the workload of nursing staff to turn the head regularly; (4) Patients could rest in the supine position but not the half-lying position which could get better comfort and be helpful to coordinate to treatment; (5) It could alleviate the psychological burden of injury, pain, and so on. Otherwise, “purse string suture” (Fig. 37.3) would be convenient for taking off the hair and reduce the difficulty for debridement which would save operation time, reduce the infection rate and improve the survival rate.

Fig. 37.3
figure 3

Purse string suture

Full size image

3 Operative Technique

Anti-shock therapy should be first performed and the operation could be carried out until the general condition is stable. The operation is divided into two groups: (1) One group is to take off the hair of the avulsed scalp using “purse string suture”. Remove the suture after taking off the hair and complete debridement and mark the vessels and nerves on both sides under the eightfold microscope for in situ replantation. (2) The other group is to perform complete debridement for the wound of the head. The key point is to pay attention to the vessels and nerves of temporal, superior orbital, posterior auricular, and posterior occipital and mark them. The bilateral superior temporal arteries and vein should be anastomosed for 6–12 needles by 10–0 or 9–0 under the eightfold microscope, and the vessels of other parts should be anastomosed as far as possible. The scalp could be reserved to perform strict hemostasis on bleeding points after anastomosis for one side. The Halo-vest head ring should be installed at the point 2 cm above the eyebrow arch and back pillow with four screws after the scalp obtains good blood supply and the wound is closed with 3–0 silk and pay attention to balance the distance between the scalp and the head ring. Half tube drainage should be placed around the wound which should be wrapped with sterile gauze. After the operation, the change in vital signs and blood supply of the scalp should be strictly observed. Routine treatment including anemia correction, anticoagulation, anti-spasm, anti-infection, and fluid infusion should be performed. Avoid pressure on the scalp and reinforce dressing change. In the absence of infection, the dressing and suture could be removed 7 days after the operation and observe the scalp survival, and the Halo-vest head ring could be removed 10–14 days later.

4 Clinical Implications

(1) Due to abundant blood circulation of the scalp, patients would be accompanied by shock caused by much more bleeding, pain, and other reasons. Therefore, observation about general conditions and the changes to promote treatment of shock in time. (2) “Purse string suture” is convenient to take off the hair which helps shorten operation time and prevent short hair from entering the tendinous cap that would result in infection. (3) The scalp could be trimmed reasonably, but the wound should be closed without tension. We can make a patch for fixation with thick needle internal distance so as not to leave cavity under the scalp [5]. (4) Place drainage tube as much as possible to prevent hemorrhage infection. (5) Pay attention to prevent postoperative complications such as vascular crisis, subcutaneous hematoma, infection, necrosis, and so on [6, 7].