Identifying Factors Affecting Outcomes in Scalp Replantation: A Systematic Review of the Literature

Abstract

Introduction 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.

Modified Scalp Replantation for Total Scalp Avulsion: Scalp-Shifting Technique

“…In our study, 3 patients presented with partial occipital scalp necrosis postoperatively, which was in agreement with a previous meta-analysis that most necrotic areas following avulsed scalp replantation occurred in the occipital region. 18 Some studies have suggested that the occipital scalp is more prone to necrosis owing to poorer blood perfusion, which is further aggravated by the patient being supine for a long time after the injury. 7 The tight connection between the occipital scalp layers may also play a role in postoperative occipital scalp necrosis.…”

Microsurgical Scalp Reconstruction: An Overview of the Contemporary Approach

“…Unique situations such as traumatic scalp avulsions should be addressed primarily with an evaluation for attempted replantation or revascularization. 37 However, in most other cases where scalp reconstruction is indicated, we believe that local factors such as presence of radiation or a moderate-to-severe local scar burden must be addressed by recruiting healthy distant tissue. 4 38 39 The complex factors associated with scalp wounds include margin-positivity in cases of tumor, presence of neoadjuvant radiation, as well as prior attempts at local scalp rearrangement.…”

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study

“…23,24 Historically, scalp replantation is typically achieved using bilateral STAs (95%) on a single-piece scalp flap (91%). 25 However, replantation of the total scalp via a single STA has been previously reported with good outcomes. [26][27][28] In this cadaveric study, osteocutaneous flaps were entirely perfused via a single STA pedicle, suggesting that skull perfusion territories mirror those of the scalp.…”