Avulsion injuries are one of the traumatic injuries which occur due to tangential
force and are difficult to reconstruct. Hence, scalp replantation remains the only
ideal surgical modality. Warm ischemia time of 17 hours and cold ischemia time of
24 hours is considered standard.[1]
[Fig. 1] shows the anatomy of the scalp. We present the case of a 45-year-old female who
presented 8 hours after injury with scalp avulsion due to entanglement of head scarf
(dupatta) in the motorized machine. The avulsed segment was brought after 1 hour of the presentation.
Line of avulsion was–both eyebrows, root of nose, above ears, and occipital area.
The plane of cleavage was loose areolar tissue. The preoperative photographs are shown
in [Figs. 2]
[Figs. 3]. Through washing with normal saline, manual picking of visible debris was done,
and hairs were trimmed all over the avulsed part. Left anterior branch of superficial
temporal artery and right posterior branch of vein accompanying it were anastomosed
using Nylon 8–0 under loupe magnification (4X) and general anesthesia by single team.
No neural repair was done. The approximate blood loss was 400 mL, postoperative hemoglobin
recorded 11 g%. No blood transfusion was done. Temperature, skin color, and scratch
test were used for clinical monitoring. Low-molecular weight dextran was given in
postoperative period for 5 days. First dressing was done on day 2 and discoloration
of the posterior part was noted. On day 4, debridement of necrosed area was done and
left to heal by secondary intenton, as shown in [Fig. 4]. After 1 year, she had normal hair growth, as shown in [Fig. 5].
Fig. 1 Diagram showing layers of scalp.
Fig. 2 Preoperative photographs showing the extent of avulsion.
Fig. 3 Photograph showing avulsed scalp segment with eyebrows.
Fig. 4 Postoperative photograph showing (a) completed anastomosis, (b) segmental loss at
occiput.
Fig. 5 Photograph showing postoperative results at 1 year.
Various authors have documented their experience.[2]
[3]
[4] Usually, the line of avulsion is just below eyebrows, as in this case. However,
avulsion at the level of medial canthal ligament has also been reported.[2]Cervical spine injury is considered an absolute contraindication for scalp replantation.
Malmande et al reported scalp replantation in a patient with suspected cervical spine
injury and limited neck mobilization.[5] We report this case to document the success even in nonideal conditions and emphasize
the importance of attempting replantation even in peripheral hospitals.
