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Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 74-76

Successful total scalp replantation using the retromandibular vein as a recipient vessel

Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Kocaeli University, İzmit, Kocaeli, Turkey

Date of Submission09-May-2019
Date of Acceptance30-Jun-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Can Ilker Demir
Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Kocaeli University, Derince, .zmit, Kocaeli
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_37_19

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Replantation is the first treatment in scalp amputations. Venous insufficiency is the most common cause of failure. There may be difficulties caused by venous anastomosis, especially in cases with cranial bone fractures. There is no agreement about the number of vessels that should be used for replantation. Depending on the severity of the injury, there may be concurrent injuries such as spinal fractures and other system pathologies, such as cranial bone fractures. In this article, we describe and discuss the surgical treatment of a patient with a temporal bone fracture concurrent with a total hairy skin amputation, which extended from both eyebrows anteriorly, in front of the ear laterally, to the hairline posteriorly. Single-artery and single-vein anastomoses were performed. The retromandibular vein was used as the recipient vein because an alternative appropriate vein was not available. Complete improvement was achieved in our patient, both aesthetically and functionally.

Keywords: Amputation, retromandibular vein, scalp

How to cite this article:
Demir CI, Yasar EK, Davun KE, Gok A, Rustamov N, Alagoz MS. Successful total scalp replantation using the retromandibular vein as a recipient vessel. Turk J Plast Surg 2020;28:74-6

How to cite this URL:
Demir CI, Yasar EK, Davun KE, Gok A, Rustamov N, Alagoz MS. Successful total scalp replantation using the retromandibular vein as a recipient vessel. Turk J Plast Surg [serial online] 2020 [cited 2020 Jul 12];28:74-6. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/1/74/274440

  Introduction Top

Although scalp amputations are rare, they may be life-threatening due to intracranial injury. Replantation became the first treatment option after Miller et al.[1] performed the first successful scalp replantation in 1976, and microsurgery techniques had developed sufficiently. The absence of a suitable recipient vein for venous anastomosis has been reported to be an important problem in replantation.[2]

In this case, we present a new concept, in which the retromandibular vein (RV) was used as the recipient vessel in a total scalp replantation concurrent with a temporal bone fracture.

  Case Report Top

A 16-year-old female was admitted to the emergency department 6 h after injury, with a total scalp amputation extending from both the eyebrows at the front and laterally from the ear posterior sulcus to the neck hairline in the posterior [Figure 1]. She had a fracture in the left temporal bone. The patient was scheduled for a replantation.
Figure 1: Scalp amputation extending from above both eyebrows in the front, to the ear posterior sulcus laterally, and neck hairline posteriorly

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The temporal bone fracture was reduced using plaque screws by the brain surgery team. The right-sided superficial temporal artery (STA) and superficial temporal vein (STV) were prepared after debridement of amputate. The STA was revealed in the right temporal region of the patient, but no suitable recipient vein was found. The RV under the parotid gland was prepared, with an incision extending from the right preauricular region to the mandibular angulus. STV-RV anastomosis was performed with a 10-cm cephalic vein graft taken from the right arm [Figure 2].
Figure 2: Computed tomography angiographic image of the right-sided superficial temporal vein–retromandibular vein anastomosis using the cephalic vein graft. The red arrows indicate the cephalic vein graft. The blue star indicates the meatus acusticus externus: (a) coronal section (b) sagittal section

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One week after the operation, self-regressive ecchymoses in the bilateral temporal regions and a 3-cm necrosis in the left eyebrow lateral were observed, which healed without any surgical intervention. The patient was discharged after 15 days. Successful survival of the replanted scalp was noted at 3-year follow-up [Figure 3].
Figure 3: (a and c) Postoperative 10th-day image of the patient (b and d) Postoperative 3rd-year image of the patient. It can be seen that right-sided preauricular incision is esthetically healed 3 years postoperatively

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  Discussion Top

Scalp avulsion generally occurs after injuries, in which long hair is trapped in by high speed rotating machines, dog attacks, or as a result of work accidents.[3] Avulsion due to trauma may be accompanied by other system injuries. Therefore, careful evaluation of the patient should be a priority on first presentation. Additional injuries that could pose a risk to life should be evaluated and treatment performed if required together with making a decision concerning planned replantation.[4] Our patient had a right temporal bone fracture. Cranial bone fracture can be considered to indicate that the avulsion is severe. The decision for replantation was made because the fracture was not life-threatening.

There is no agreement on the optimal number of arteries or veins which should be anastomosed for scalp flap viability. Sabapathy et al.[5] suggested that at least two arteries and two vein anastomoses should be performed in scalp replantation. Jiang et al.[6] reported that at least two vein anastomoses were required for healthy venous return. In contrast, Yin et al. have argued that single-artery and single-vein anastomoses were sufficient for scalp circulation.[4] Venous insufficiency may be seen in the occipital region, especially in patients in whom single-vein anastomosis was performed. In the present case, single-artery and single-vein anastomoses were performed, and no venous insufficiency was evident in any areas of the scalp. We believe that the large lumen diameter of the RV, which was used as the receiving vein, was a significant factor in avoiding venous insufficiency in our patient.

Venous insufficiency is the most common cause of replantation failure.[7] The STV is frequently used as a recipient vein because the lumen of the STV is broad.[8] In a case reported by Kim and Kim with initial supraorbital vein anastomosis, progressive venous congestion regressed with the change of the recipient vein to the STV.[7] However, the STV may not be suitable for anastomosis depending on the severity of injury. The anastomosis can be performed with a vein graft after the vein is debrided up to the undamaged intima tissue. Galeal dissection in amputation may allow for tension-free anastomosis, but there is a risk of vessel injury. In our patient, traction force due to the severity of injury meant that the right-sided STV was not available for use in constructing the anastomosis. Thus, the use of the RV as the recipient's vein was planned. The posterior branch of the RV is combined with the posterior auricular vein and drains into the external jugular vein (EJV).[9] In our patient, the RV was prepared under the ipsilateral parotid gland before draining vein graft from the temporal region to the neck area, under the skin.

The general condition of the patient should be carefully evaluated before and after the operation. To prevent hemorrhagic shock due to blood loss, loss must be replaced. Care must be taken with the patient posture and dressing in the postoperative period. Too prevent pressure-induced necrosis, especially in the occipital area, due to the prone position, the head position should be changed every 2 h, and frequent examinations should be made.

  Conclusion Top

In severe scalp avulsions accompanied by cranial bone fractures, the RV can be used to form an anastomosis, if an alternative recipient vein cannot be identified.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Miller GD, Anstee EJ, Snell JA. Successful replantation of an avulsed scalp by microvascular anastomoses. Plast Reconstr Surg 1976;58:133-6.  Back to cited text no. 1
Jin Y, Hua C, Hu X, Chen H, Ma G, Zou Y, et al. Microsurgical replantation of total avulsed scalp: Extending the limits. J Craniofac Surg 2017;28:670-4.  Back to cited text no. 2
Plant MA, Fialkov J. Total scalp avulsion with microvascular reanastomosis: A case report and literature review. Can J Plast Surg 2010;18:112-5.  Back to cited text no. 3
Yin JW, Matsuo JM, Hsieh CH, Yeh MC, Liao WC, Jeng SF, et al. Replantation of total avulsed scalp with microsurgery: Experience of eight cases and literature review. J Trauma 2008;64:796-802.  Back to cited text no. 4
Sabapathy SR, Venkatramani H, Bharathi RR, D'Silva J. Technical considerations in replantation of total scalp avulsions. J Plast Reconstr Aesthet Surg 2006;59:2-10.  Back to cited text no. 5
Jiang Z, Li S, Cao W. Emergency management of traumatic total scalp avulsion with microsurgical replantation. Ulus Travma Acil Cerrahi Derg 2014;20:66-70.  Back to cited text no. 6
Kim EK, Kim SC. Total scalp replantation salvaged by changing the recipient vein. J Craniofac Surg 2012;23:1428-9.  Back to cited text no. 7
Cheng K, Zhou S, Jiang K, Wang S, Dong J, Huang W, et al. Microsurgical replantation of the avulsed scalp: Report of 20 cases. Plast Reconstr Surg 1996;97:1099-106.  Back to cited text no. 8
Choudhary S, Sharma AK, Undivided retromandibular vein continuing as external jugular vein with facial vein draining into it: An anatomical variation. JK Sci 2010;12:203.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3]


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