Two cases of scalp reimplantation based on one artery and one vein with interposed vein grafts

The authors report their experience in successful reimplantation of avulsed scalp in two patients with one arterial and one venous anastomosis to the superficial temporal vessels. In both cases a double vein graft, harvested from the dorsum of the hand, was interposed between the pedicle of the scalp and the recipient temporal vessels to avoid tension after trimming of the damaged segments. Scalp replantation based on two or more vessels has previously been reported in the literature. In the present cases, the complete survival of the scalp on only a single vascular pedicle suggests that replantation should be considered also when the available vessels for the anastomosis are few. Moreover, even if these reconstructions are lengthy, a prolonged ischemic interval does not appear to be a significantly limiting factor for the success of the revascularization. The cosmetic and psychological success of these cases lend support to the idea that one should always attempt a microvascular replantation of avulsed scalps.     

Total scalp, ear, and eyebrow avulsion: aesthetic adjustment of the replanted tissue

A case of successful replantation of a total scalp avulsion, including both ears and one eyebrow, is presented with bilateral anastomoses to the superficial temporal vessels. While over 90 percent of the replant survived, partial loss of occipital and posterior neck skin and the inferior half of the left ear occurred. The patient subsequently required additional procedures, including skin grafting, scar revisions, and staged ear reconstructions. Thus, while microsurgery often provides the only hope for tissue salvage, there is a frequent need for additional revisions and aesthetic adjustment of portions of the replanted tissue.     

吻合血管的撕脱头皮回植21例

报告了21例吻合血管的头皮再植,其中全头皮撕脱20例,小块头皮撕脱1例,头皮离体时间3～13小时。在全头皮撕脱中有3例为多块头皮撕裂。21例头皮再植除1例失败外均获成功。文中详细介绍了头皮再植的手术方法,手术适应证,术后并发症及其处理原则。提出了撕脱头皮常有不同程度的挫伤,主张吻合双侧动静脉是非常必要的,动静脉吻合比例可按1:1。认为头皮再植是头皮撕脱伤病人的最佳治疗方法。     

吻合血管的撕脱头皮回植21例

报告了２１例吻合血管的头皮再植，其中全头皮撕脱２０例，小块头皮撕脱１例，头皮离体时间３～１３小时。在全头皮撕脱中有３例为多块头皮撕裂。２１例头皮再植除１例失败外均获成功。文中详细介绍了头皮再植的手术方法，手术适应证，术后并发症及其处理原则。提出了撕脱头皮常有不同程度的挫伤，主张吻合双侧动静脉是非常必要的，动静脉吻合比例可按１∶１。认为头皮再植是头皮撕脱伤病人的最佳治疗方法。     

严重全头皮撕脱伤的再植治疗

报道我院自１９９０ ～１９９６ 年治疗严重全头皮完全撕脱伤５ 例，经实施显微外科全头皮再植的成功经验。将撕脱完整的头皮经过彻底清创后，分别吻合两侧的头部颞浅动、静脉行头皮再植，当清创切除损伤血管后的缺损共８ 条，长度３ ～８ｃｍ ，即从前臂取浅静脉移植架桥修复。使撕脱头皮在伤后１０ ～１３ 小时重新恢复血液供应。经过术后随访至１ 年，全头皮再植成活９５％ ～１００ ％ ，全部头皮都长出了３０ｃｍ 长乌黑的秀发。结论：大面积头皮撕脱伤时，只要头皮层内的颞浅动、静脉主干血管无损伤和头皮尚完整，行撕脱头皮的再植治疗可获最佳效果。     

Replantation of amputated facial tissues with microvascular anastomosis

A challenge to the microsurgeon is perfecting the technique of replantation of small pieces of facial tissue, mainly because of the extremely small size of the arteries as well as a lack of suitable veins for drainage. In the past 4 years, we have had seven cases of facial amputations, which included one scalp, two nasal tips, two ears, one lower lip, and one eyebrow. All of these patients were replanted/revascularized by microvascular anastomosis. Only two of the cases had suitable veins for anastomosis. Alternative techniques used for improving venous outflow were arterio-venous fistula, chemical leeches, and pin pricks. Four of the cases were completely successful, two cases had partial loss of the replant, and one case failed due to absence of venous drainage. In facial amputation, an aggressive microsurgical attempt will result in more tissue surviving and a better cosmetic outcome than in any other reconstructive procedures. © 1994 Wiley-Liss, Inc.     

Bilateral eyebrow reconstruction using a unilateral extended superficial temporal artery flap

In cases of the bilateral eyebrow reconstruction in men, two superficial temporal artery (STA) flaps are usually designed for both temporal regions according to the flap movable range and the direction of hair growth. Recently, the authors have successfully reconstructed bilateral eyebrows with normal directions of hair growth using a unilateral STA flap, extended by anastomosis of the STA and the occipital artery, with two hair-bearing skin islands. Using this method, the direction of the hair growth can be optimally selected by changing the direction of the skin islands for each eyebrow. The authors were able to reconstruct symmetric eyebrows with the hair growing laterally and a little upward. The invasiveness, bleeding, and operating time required for this method are less than those for the bilateral STA flap method. For cases in which one temporal scalp could not be used, bilateral eyebrow reconstruction remains possible with this method.     

Rat-tail replantation model

The authors evaluated the reliability of a rat-tail replantation model Eleven male adult Sprague-Dawley rats were involved. The tails were completely amputated 3 to 6 cm distal to the base. They were then replanted in the following order: fixation of the coccygeal vertebrae; suturing of tendons; anastomosis of the artery; anastomosis of the two dominant veins (or one of them); and skin closure. Tails were inspected daily for 14 postoperative days for color, capillary refill, skin consistency and wound condition. Subsequently, ultrasound Doppler inspection and angiography were carried out to observe the patency of the vessels. All replanted tails were pink, viable, and had normal capillary refill and appearance. Complete survival was achieved. Doppler flow imaging and angiography demonstrated patency of the vessels. This rat-tail replantation is a reliable and reproducible experimental model of microvascular anastomosis. Crucial steps in the procedure are presented.     

Replantation of avulsed scalps and secondary aesthetic correction

Five patients with avulsed scalps were treated with replantation between 1992 and 1998. All patients were women age 20 to 36 years. The percentage of the avulsed scalp ranged from 50% to 100% of the whole scalp. The vessels chosen for anastomosis were the superficial temporal artery, occipital artery, and superficial temporal vein. A vein graft harvested from the cephalic vein of the forearm was performed on the venous and arterial sides in 1 patient. Two patients experienced complete survival of the replanted scalp. Three patients showed 40%, 50%, and 80% survival areas, with the remaining defects resurfaced as split-thickness skin grafts. Six months later, the scar areas in the last 3 patients were reconstructed with an expansion of the normal or replanted scalp. The follow-up period ranged from 1 to 7 years. In 4 patients a partial return of sensation in the replanted scalp and motor function of the frontalis muscle were observed. All patients were satisfied with the aesthetic results of their surgery.     

First successful replantation of face and scalp with single-artery repair: model for face and scalp transplantation

Successful replantation of the scalp with microanastomosis of a single artery and vein has been reported to produce reliable results. In fact, there have been several reports of scalp replantations based on one-artery and vein repair. There has been a face and scalp replantation reported in the literature, but this was as two separate parts and was based on several arterial and venous repairs. The authors performed the first successful replantation of a face and scalp with repair of a single artery and, of course, two veins. A 21-year-old man presented after his face and scalp were completely severed. The patient's long hair was caught in a conveyor belt at work. The face and scalp underwent replantation, with repair of the right superficial temporal artery with an interposition vein graft. A multiteam approach allowed for minimization of overall ischemic time and simultaneous preparation of the vessels on the patient and amputated part as well as vein graft harvest from the arm. Also critical to the success of the procedure, the small portions of the vessels of the amputated part were sent for frozen section to differentiate artery from vein. Initially, only the right superficial temporal vein was repaired. One week after replantation, the patient returned for treatment of venous congestion of an area to the opposite side of the forehead partial transection, with repair of the left superficial temporal vein, also. This saved the entire part that underwent replantation, and the entire part survived. The face and scalp can undergo replantation based on single-artery repair.     

Avulsion of the scalp: which one is the best artery for anastomosis?

We present a patient who underwent successful replacement of a large avulsed scalp with microvascular anastomosis of one artery and three veins. The left occipital artery in the avulsed scalp and a frontal branch of a right superficial temporal artery in the recipient forehead were anastomosed. Three veins in the occipital area in the avulsed scalp were anastomosed via vein grafts to three veins in the frontal area, respectively. For successful replacement, the selection of the vessels depends on each individual case. To give easy anastomosis, a good cosmetic result, and a comfortable postoperative period, it is not always necessary to reconstruct a previously normal anatomical position.     

Scalp replantation by arterialised venous network flow-through.

A successful clinical case of scalp replantation is presented where a suitable artery could not be identified in the amputated part. Reperfusion of the flap was achieved by an arteriovenous inflow anastomosis and a conventional venous anastomosis for drainage. The aesthetic and physiological success of this case suggests that arteriovenous scalp replantation is a potential avenue for treatment where arterio-arterial repair is not possible. The possible explanation for the success in this patient is the paucity of valves that exist in the venous network of the scalp and forehead, noted in our previous anatomical studies. Knowledge of the replanted tissue venous architecture provides an anatomical basis to understand the potential limitations of arteriovenous replantation.     

Validity of exploration for suitable vessels for replantation in the distal fingertip amputation in early childhood: Replantation or composite graft

Abstract

Composite grafting, grafting without microvascular anastomoses, has been widely performed for distal fingertip amputation in children with variable results, whereas successful replantation of these amputations using microsurgical technique has been reported. However, most of these reports included a wide age-range and a mix of different amputation levels. This study reviewed our cases of paediatric digital amputation, in order to verify the value of distal fingertip replantation over composite grafting, especially in early childhood. Seventeen young children (aged 3 years and 8 months on average), with single-digit fingertip amputations in Tamai zone I were reviewed from 1993–2008. Each amputation was subdivided into three types: distal, middle, and proximal. There were three distal, 13 middle, and one proximal type zone I amputations. All were crush or avulsion injuries. All three distal-type cases were reattached as primary composite grafts with one success. For middle-type cases, the survival rate of primary composite graft without exploration for possible vessels for anastomosis was 57%. On exploration, suitable vessels for anastomosis were found 50% of the time, in which all replantations were succeeded. The remaining cases were reattached as secondary composite grafts, with one success using the pocket method. Consequently, the success rate after exploration was 67%. The only one proximal-type amputation was failed in replantation. For the middle-type zone I amputation in early childhood, replantation has a high success rate if suitable vessels can be found. Therefore, exploration is recommended for amputations at this level with a view to replantation, irrespective of the mechanism of injury.     

Neurotization of the frontal muscle after scalp replantation: case report

A case of immediate replantation of an avulsed scalp by microvascular anastomosis is presented. Microvascular replantation of the scalp seems to offer significant social and psychological advantages over secondary reconstructive procedures. The significance of the case presented is the regaining of the motor neural function of the facial nerve after 38 months.     

Microsurgical replantation of the scalp

Our 7-year experience with seven patients who had suffered avulsion of 30% or more of the scalp is reviewed. Six of the seven, who were candidates for microsurgical replantation, underwent successful replantation with 100% survival in five, and 50% survival in one. All had luxuriant regrowth of hair. The mechanisms of injury, emergency management, indications, and operative techniques are discussed. The role of interpositional vein grafts, and choice of vessels in contributing to this success is emphasized. The superiority of replantation over other methods of reconstruction of major scalp defects is demonstrated.     

Technical considerations in replantation of total scalp avulsions.

Total scalp avulsions are devastating injuries and replantation is the best form of reconstruction. We present our experience of replantation of six totally avulsed scalps done between 1996 and 2004. All were technically successful, but one was lost in the post-operative period due to accidental shearing of the scalp during nursing care. A single team performed the surgery in all cases and the average operating time was 6 h. No vein grafts were used. Hair growth was satisfactory in all cases. None underwent formal nerve repair but there was adequate sensory recovery in all of them by 6-9 months. A small area of skin necrosis in the occipital area (three cases), telecanthus and epiphora (two cases) were the minor complications. The available Literature highlights the need for multiple teams to reduce the long operating time, the use of multiple vein grafts and the complexities involved. Since, they are rare injuries, gaining wide experience is difficult. In this article we offer recommendations in pre-op preparation, vessel identification, technique of anchoring the avulsed scalp prior to vessel anastomosis and post-op care to make this rare procedure quicker, easier and successful.     

Hair growth following scalp microvascular flap transfer for baldness due to burn injury.

A female patient, 8 years of age, presented with baldness of the right scalp following deep scalds from boiling soup landing on the head, neck, and chest. The depth of the burn was severe enough to cause baldness. She was primarily advised to wear a wig to address the problem of baldness on one side. Surgery was planned to use uninjured scalp skin to offer hairy skin coverage of the bald site. A left scalp skin flap (2.5 by 7 cm) based on the superficial temporal artery and vein was transferred to the bald area, with microvascular anastomosis to the superficial temporal vessels on the right side. There was complete survival of the flap with uneventful recovery and satisfactory growth of hair. Hair growth from the flap was comparatively thicker than from the rest of the scalp. This microvascular flap has produced sufficient hair to cover the entire area of the baldness and the patient does not need to wear a wig.     

针具打孔法单株毛发移植行眉毛美容性再造

目的:探索一种单株毛发移植修复眉毛永久性缺损的技术。方法:切取近后发际区域处含有完整毛发毛囊的条形头皮组织,借助于手术放大镜,将之分割,制备成单株毛发移植物待用。然后在预先设计的眉缺失区域内,以医用注射针具制备孔洞。继之,将这些待用之移植物按眉的自然走向植入到眉区预制的孔洞之中。结果:自2005年至2006年6月,共完成了52例89侧眉的美容性再造。所有患者一期手术均取得满意的美学修复效果。经术后6个月以上的临床随访见:再造的眉毛生长良好,成活率可达到98.5%。再造的眉形态走向较自然,较接近于正常的眉毛。从患者对术后再造眉的形态评价来看,非常满意者占84.6%;满意者占15.4%。结论:针具打孔法单株毛发移植技术手术方法简便快捷,出血少,手术野较清洁,再造的眉毛更加自然优美,是目前眉毛美容性再造较为理想的方法。     

Open guide suture technique for safe microvascular anastomosis

Despite the evident advances in microsurgery, anastomosis of small vessels or anastomosis of vessels having size discrepancy, remains one of the most precise and technically demanding issues in replantation surgery and free tissue transfer procedure. The patency of the vascular anastomosis is critical and essential for a successful outcome. In this study, a microvascular anastomosing technique called open guide suture technique is introduced. The technique starts with a conventional whole-layer stitch and continues under the control of a guided suture that is inserted but not completed to a knot 180 degrees distant from the initial suture. Recently, we used this technique in 30 free flap transfers and 4 replantation procedures. A total of 103 anastomoses were performed. Only 1 flap, which had both arterial and venous problems, and 1 finger replantation case that had arterial problems required revision. Both the revised cases were salvaged, giving a revision rate of 2.91% for the total number of anastomoses (3 of 103), and a 100% success rate for final flap and replanted part survival. In conclusion, this technique provides a safe anastomosis performed under completely clear visualization at each step with well-arranged knot intervals.     

Eyebrow, face, and neck lifts for males

Alternate locations to skin excisions adjacent to the eyebrows for correction of eyebrow ptosis have been presented. Excisions in the upper forehead or in the scalp permit flexibility in width and length of skin or scalp to be excised and may be extended laterally to produce a temporal lift which not only improves the lateral canthal area of sagging skin but also may improve the lower eyelid surgical correction results (Figs. 1 and 3). By use of adequate lipectomy and full-width platysma muscle flaps to support the new neck contour, better and longer lasting results have been accomplished. The currently used techniques for eyebrow, face, and neck lifts for males produce better and longer lasting results than could have been accomplished with previously used techniques. The continued search for improvement in techniques by many surgeons in different areas of the world has enabled these longer lasting and better results to be accomplished.