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DOI: 10.1055/s-0041-1729876
Identifying Factors Affecting Outcomes in Scalp Replantation: A Systematic Review of the Literature
Funding None.![](https://www.thieme-connect.de/media/jrm/202201/lookinside/thumbnails/10-1055-s-0041-1729876_200467-1.jpg)
Abstract
Background Replantation is the ideal treatment in traumatic scalp defects to provide immediate coverage with restoration of hair-bearing skin. However, data are limited to case reports and small case series. Comprehensive analysis of techniques and outcomes is not available. Our aim was to systematically analyze the available literature to better understand management and postoperative outcomes of patients undergoing scalp replantation.
Methods A systematic review of the PubMed, Cochrane, and EBSCO databases was performed in October 2019. Search terms included “replantation,” “replant,” “revascularized,” “revascularization,” “avulsion,” and “scalp.” Only papers reporting microvascular replantation of completely avulsed scalps, including case reports, were included. Review articles, non-English language articles, articles discussing nonreplant coverage, incomplete scalp avulsions, and articles discussing delayed scalp replantation were excluded. Data extracted included demographics, percent of scalp affected, mechanism, operative technique, and postoperative outcomes. Statistical analysis was performed using Mann–Whitney U tests, Kruskal–Wallis, and chi-squared tests.
Results From a total of 704 initial results, 61 studies were included for analysis comprising 149 scalps. Complete survival was achieved in 54.7%, partial survival in 38.9%, and failure in 6.7%. Total ischemia time greater than 12 hours was associated with complete replant failure. Arterial anastomoses appeared to protect against complete loss. The number of venous repairs, proportion of venous-to-arterial repairs, use of vein grafts, thromboprophylaxis, or intraoperative complications did not affect outcomes. Patients required significant volumes of blood products, which was associated with partial success. Salvage rate after unplanned return to the operating room was 60.0%. Normal hair growth was achieved in all surviving native scalp tissue.
Conclusion Scalp replantations, while technically challenging, are the ideal treatment for scalp avulsions. Fortunately, these have high rates of success. And as a focal point of a patient's appearance, this is invaluable in restoration of a sense of normalcy.
Publication History
Received: 16 December 2020
Accepted: 28 March 2021
Article published online:
19 May 2021
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References
- 1 Herrera F, Buntic R, Brooks D, Buncke G, Antony AK. Microvascular approach to scalp replantation and reconstruction: a thirty-six year experience. Microsurgery 2012; 32 (08) 591-597
- 2 Cheng K, Zhou S, Jiang K. et al. Microsurgical replantation of the avulsed scalp: report of 20 cases. Plast Reconstr Surg 1996; 97 (06) 1099-1106 , discussion 1107–1108
- 3 Mowlavi A, Bass MJ, Khurshid KA, Milner S, Zook EG. Psychological sequelae of failed scalp replantation. Plast Reconstr Surg 2004; 113 (06) 1573-1579
- 4 Gatti JE, LaRossa D. Scalp avulsions and review of successful replantation. Ann Plast Surg 1981; 6 (02) 127-131
- 5 Miller GD, Anstee EJ, Snell JA. Successful replantation of an avulsed scalp by microvascular anastomoses. Plast Reconstr Surg 1976; 58 (02) 133-136
- 6 Ozek C, Guner U, Bilkay U, Alper M, Akin Y, Cagdas A. Superficial scalp necrosis after replantation. Ann Plast Surg 2001; 46 (02) 197-198
- 7 Sakai S, Soeda S, Ishii Y. Avulsion of the scalp: which one is the best artery for anastomosis?. Ann Plast Surg 1990; 24 (04) 350-353
- 8 Rivera ML, Gross JE. Scalp replantation after traumatic injury. AORN J 1995; 62 (02) 175-180 , 182, 184
- 9 Safa B, Greyson MA, Eberlin KR. Efficiency in replantation/revascularization surgery. Hand Clin 2019; 35 (02) 131-141
- 10 Cho HE, Zhong L, Kotsis SV, Chung KC. Finger Replantation Optimization Study (FRONT): update on national trends. J Hand Surg Am 2018; 43 (10) 903-912.e1
- 11 Efanov JI, Montoya IJ, Huang KN. et al. Microvascular replantation of head and neck amputated parts: a systematic review. Microsurgery 2017; 37 (06) 699-706
- 12 Arashiro K, Ohtsuka H, Ohtani K. et al. Entire scalp replantation: case report and review of the literature. J Reconstr Microsurg 1995; 11 (04) 245-250
- 13 Aydan Köse A, Sezgin M, Karabag-Li Y, Ozyilmaz M, Koçman E, Cetin C. Neurotization of the frontal muscle after scalp replantation: case report. J Reconstr Microsurg 2002; 18 (08) 677-680
- 14 Biemer E, Stock W, Wolfensberger C, Ingianni G, Götz WD. Successful replantation of a totally avulsed scalp. Br J Plast Surg 1979; 32 (01) 19-21
- 15 Bitter K, Howaldt HP. Experiences in surgical repair of a totally avulsed scalp. J Craniomaxillofac Surg 1991; 19 (05) 185-190
- 16 Buncke HJ, Rose EH, Brownstein MJ, Chater NL. Successful replantation of two avulsed scalps by microvascular anastomoses. Plast Reconstr Surg 1978; 61 (05) 666-672
- 17 Chen IC, Wan HL. Microsurgical replantation of avulsed scalps. J Reconstr Microsurg 1996; 12 (02) 105-112
- 18 Cho BC, Lee DH, Park JW, Byun JS, Baik BS. Replantation of avulsed scalps and secondary aesthetic correction. Ann Plast Surg 2000; 44 (04) 361-366
- 19 Chung KC. Successful replantation of a completely avulsed scalp. Ann Plast Surg 2000; 44 (02) 233-234
- 20 Dadaci M, Yildirim MEC, Ince B. Experience of replantation and reconstruction in total scalp, partial forehead, and ear avulsions. J Craniofac Surg 2019; 30 (07) 2268-2270
- 21 Eren S, Hess J, Larkin GC. Total scalp replantation based on one artery and one vein. Microsurgery 1993; 14 (04) 266-271
- 22 Fogdestam I, Lilja J. Microsurgical replantation of a total scalp avulsion. Case report. Scand J Plast Reconstr Surg 1986; 20 (03) 319-322
- 23 Güven E, Başaran K, Meyzin I, Keklik B, Emekli U. Replantation of scalp avulsion following a go-kart accident: a case report. Ulus Travma Acil Cerrahi Derg 2011; 17 (02) 177-179
- 24 Hallock GG. Secondary expansion of a replanted scalp salvaged by an intrinsic arteriovenous shunt. Plast Reconstr Surg 1999; 103 (07) 1957-1960
- 25 Henderson HP, Matti B, Laing AG, Morelli S, Sully L. Avulsion of the scalp treated by microvascular repair: the use of leeches for post-operative decongestion. Br J Plast Surg 1983; 36 (02) 235-239
- 26 Hentz VR, Palma CR, Elliott E, Wisnicki J. Successful replantation of a totally avulsed scalp following prolonged ischemia. Ann Plast Surg 1981; 7 (02) 145-149
- 27 Hu W, Henry A-S, Lucas C, Ta P, Philandrianos C, Kerfant N. Microsurgical replantation of a two-segment total scalp avulsion. J Craniofac Surg 2016; 27 (04) 1068-1069
- 28 Jeng SF, Wei FC, Noordhoff MS. Replantation of amputated facial tissues with microvascular anastomosis. Microsurgery 1994; 15 (05) 327-333
- 29 Jiang Z, Li S, Cao W. Emergency management of traumatic total scalp avulsion with microsurgical replantation. Ulus Travma Acil Cerrahi Derg 2014; 20 (01) 66-70
- 30 Jin Y, Hua C, Hu X. et al. Microsurgical replantation of total avulsed scalp: extending the limits. J Craniofac Surg 2017; 28 (03) 670-674
- 31 Juri J, Irigaray A, Zeaiter C. Reimplantation of scalp. Ann Plast Surg 1990; 24 (04) 354-361
- 32 Kaplan HY, Yaffe B, Borenstein A. Single artery replantation of totally avulsed scalp. Injury 1993; 24 (07) 488-490
- 33 Karibe J, Minabe T. Vascular consideration in repair of total scalp avulsion. BMJ Case Rep 2017;2017:bcr2017220605. DOI: 10.1136/bcr-2017-220605
- 34 Kashyap N, Singhal M, Tiwari R, Chauhan S, Manas R. Scalp avulsion injuries and replantation: is deep temporal artery an alternate option?. Ann Plast Surg 2020; 84 (02) 178-182
- 35 Khandelwal S, Wall J, Kaide C, Katz G. Case report: successful use of hyperbaric oxygen therapy for a complete scalp degloving injury. Undersea Hyperb Med 2008; 35 (06) 441-445
- 36 Kim EK, Kim SC. Total scalp replantation salvaged by changing the recipient vein. J Craniofac Surg 2012; 23 (05) 1428-1429
- 37 Kim JT, Kim YH, Yang EZ, Kim JB. Total scalp replantation--salvage following prolonged ischaemia with poor prognostic factors. J Plast Reconstr Aesthet Surg 2010; 63 (11) 1917-1920
- 38 Kind GM, Buncke HJ, Muncke GM, Schreiber JS, Siko P, Venter TH. Microvascular replantation of scalp and facial parts. Surg Technol Int 1995; Iv: 400-408
- 39 Libermanis O, Kapickis M, Krustiņs J. An unusual case of microvascular replantation of the scalp. Plast Reconstr Surg 1998; 102 (06) 2273-2274
- 40 Lin J, Zhou F, Wu L-Z. et al. Preferred experience of modifications to emergency surgical treatment for total scalp avulsion with Halo-Vest head ring and quick hair removing. J Craniofac Surg 2019; 30 (03) 900-906
- 41 Liu T, Dong J, Wang J, Yang J. Microsurgical replantation for child total scalp avulsion. J Craniofac Surg 2009; 20 (01) 81-84
- 42 Livaoğlu M, Uraloglu M, Imamoğlu Y, Altun EM, Karaçal N. Microsurgical replantation of two consecutive traumatic total scalp avulsions. J Craniofac Surg 2016; 27 (08) e767-e768
- 43 Maladry D, Brabant B, Berard V, Dupuis P, Mitz V. Secondary expansion of a totally replanted scalp for aesthetic adjustment. Plast Reconstr Surg 1994; 94 (07) 1052-1054
- 44 Malmande V, Rao N, Biradar A, Bansal A, Dutt C. Scalp replantation in a cervical spine injury patient: lessons learnt. Indian J Plast Surg 2018; 51 (02) 243-246
- 45 McCann J, O'Donoghue J, Kaf-al Ghazal S, Johnston S, Khan K. Microvascular replantation of a completely avulsed scalp. Microsurgery 1994; 15 (09) 639-642
- 46 McGrouther DA, Chan TS, Downie PA, Scully L, Webster MH. Reconstruction of a scalp avulsion injury by replantation and a local skin flap. Br J Plast Surg 1981; 34 (01) 44-46
- 47 Morris SF, MacGill KA, Taylor GI. Scalp replantation by arterialised venous network flow-through. Br J Plast Surg 1992; 45 (03) 187-192
- 48 Nahai F, Hester TR, Jurkiewicz MJ. Microsurgical replantation of the scalp. J Trauma 1985; 25 (09) 897-902
- 49 Nasir S, Karaaltin M, Erdem A. Total scalp replantation: surgical tricks and pitfalls. J Craniofac Surg 2015; 26 (04) 1192-1195
- 50 Nguyen HH. The microsurgical replantation of seven complete scalp avulsions: is one artery sufficient?. J Plast Reconstr Aesthet Surg 2012; 65 (12) 1639-1644
- 51 Plant MA, Fialkov J. Total scalp avulsion with microvascular reanastomosis: a case report and literature review. Can J Plast Surg 2010; 18 (03) 112-115
- 52 Sabapathy SR, Venkatramani H, Bharathi RR, D'Silva J. Technical considerations in replantation of total scalp avulsions. J Plast Reconstr Aesthet Surg 2006; 59 (01) 2-10
- 53 Sadove AM, Moore TS, Eppley BL. Total scalp, ear, and eyebrow avulsion: aesthetic adjustment of the replanted tissue. J Reconstr Microsurg 1990; 6 (03) 223-227
- 54 Svensson H, Njalsson T. Microsurgical replantation of partial avulsion of the scalp. Case report. Scand J Plast Reconstr Surg Hand Surg 1995; 29 (02) 177-180
- 55 Thomas A, Obed V, Murarka A, Malhotra G. Total face and scalp replantation. Plast Reconstr Surg 1998; 102 (06) 2085-2087
- 56 Topalan M, Ermis I. Replantation and triple expansion of a three-piece total scalp avulsion: six-year follow-up. Ann Plast Surg 2001; 46 (02) 167-169
- 57 Ueda K, Nomatsi T, Omiya Y, Tajima S. Replanted scalp recovers normal sensation without nerve anastomosis. Plast Reconstr Surg 2000; 106 (07) 1651-1652
- 58 Ulatowski L, Kaniewska A. Successful replantation of the scalp with a good aesthetic outcome and return of sensation - a case report and literature update. Handchir Mikrochir Plast Chir 2018; 50 (02) 142-148
- 59 Van Beek AL, Zook EG. Scalp replantation by microsurgical revascularization: case report. Plast Reconstr Surg 1978; 61 (05) 774-777
- 60 Wilhelmi BJ, Kang RH, Movassaghi K, Ganchi PA, Lee WP. First successful replantation of face and scalp with single-artery repair: model for face and scalp transplantation. Ann Plast Surg 2003; 50 (05) 535-540
- 61 Winters HA, Hage JJ, van der Biezen JJ, de Graaf FH. Scalping injuries: dos and don'ts. Injury 1994; 25 (07) 439-442
- 62 Yaffe B, Shvoron A. Successful replantation of a totally avulsed scalp. J Reconstr Microsurg 1986; 2 (03) 171-173
- 63 Yin JW, Matsuo JM, Hsieh CH, Yeh MC, Liao WC, Jeng SF. Replantation of total avulsed scalp with microsurgery: experience of eight cases and literature review. J Trauma 2008; 64 (03) 796-802
- 64 Zhang Y-M, Li J-M, Jiang X. Successful salvage in a scalp avulsion through unilateral microvascular anastomosis. Chin Med J (Engl) 2013; 126 (07) 1386-1387
- 65 Wolfe VM, Wang AA. Replantation of the upper extremity: current concepts. J Am Acad Orthop Surg 2015; 23 (06) 373-381
- 66 Huang X, Wang Z, Liu C. et al. A case of scalp avulsion with prolonged ischemic time: indocyanine green angiography can aid in predicting replant survival. Burns Trauma 2019; 7: 36
- 67 Maladry D, Bérard V, Dupuis P, Mitz V, Lemerle JP. [Scalp reconstruction after avulsion: emergency microsurgery and secondary tissue expansion. Apropos of 3 cases caused by farming machines]. Ann Chir Plast Esthet 1994; 39 (02) 169-175
- 68 Milone MT, Klifto CS, Lee ZH, Thanik V, Hacquebord JH. Relationships between vein repairs, postoperative transfusions, and survival in single digit replantation. Hand (N Y) 2020; 15 (04) 488-494
- 69 Lee BI, Chung HY, Kim WK, Kim SW, Dhong ES. The effects of the number and ratio of repaired arteries and veins on the survival rate in digital replantation. Ann Plast Surg 2000; 44 (03) 288-294
- 70 Matsuda M, Chikamatsu E, Shimizu Y. Correlation between number of anastomosed vessels and survival rate in finger replantation. J Reconstr Microsurg 1993; 9 (01) 1-4
- 71 Matsusue T. Is antithrombotic therapy necessary following replantation of an amputated digit?. J Hand Surg Asian Pac Vol 2019; 24 (01) 1-5
- 72 Kotamarti VS, Shiah E, Rezak KM, Patel A, Ricci JA. Does anticoagulation improve flap outcomes in hypercoagulable patients? A systematic review. J Reconstr Microsurg 2020; 36 (03) 204-212
- 73 Kruse AL, Luebbers HT, Grätz KW, Obwegeser JA. Factors influencing survival of free-flap in reconstruction for cancer of the head and neck: a literature review. Microsurgery 2010; 30 (03) 242-248
- 74 Pederson WC. Replantation. Plast Reconstr Surg 2001; 107 (03) 823-841
- 75 Nelson JA, Chung CU, Bauder AR, Wu LC. Prevention of thrombosis in hypercoagulable patients undergoing microsurgery: a novel anticoagulation protocol. J Plast Reconstr Aesthet Surg 2017; 70 (03) 307-312
- 76 Chia DS, Tay SC. A retrospective review of troubled replantations. Hand Surg 2015; 20 (01) 127-132
- 77 Hatchell AC, Sandre AR, McRae M, Farrokhyar F, Avram R. The success of salvage procedures for failing digital replants: a retrospective cohort study. Microsurgery 2019; 39 (03) 200-206
- 78 Buntic RF, Brooks D, Buncke GM. Index finger salvage with replantation and revascularization: revisiting conventional wisdom. Microsurgery 2008; 28 (08) 612-616
- 79 Chang D-H, Ye S-Y, Chien L-C, Ma H. Epidemiology of digital amputation and replantation in Taiwan: a population-based study. J Chin Med Assoc 2015; 78 (10) 597-602
- 80 Hung YC, Huang JJ, Hsu CC. Emergency management of total scalp avulsion. Emerg Med J 2009; 26 (03) 225-226
- 81 Xu H, Zhang Y, He J, Lin Y, Wang T, Dong J. Ectopic implantation of an avulsed scalp with a tissue expander on a forearm for combined total scalp avulsion and spine injuries: a case report. Microsurgery 2017; 37 (07) 819-823
- 82 Zhao JX, Guo Q, Yuan Y, Xu W, Zhao NH. Scalp avulsion combined with unusual severe open craniocerebral avulsion injury. Chin Med J (Engl) 2015; 128 (20) 2839-2840