A Challenging Scalp Replantation from the Remote Australian Outback

Scalp avulsion is a disfiguring injury caused by shearing forces acting obliquely at the interface between periosteum and galea. Before the advent of microsurgery these injuries were managed by relaying the avulsed segment as a composite graft, with failure resulting in areas of scarred non-hair bearing scalp. While it is recognized that success decreases substantially after 5-6 hours of ischemia time, there have now been reports of good outcomes with longer periods before revascularization. This is of particular relevance in Australia, where geographical isolation results in extended periods of ischemia before treatment can be delivered. Here we present a case of a 18 year old girl who sustained an avulsion of her left temporoparietal scalp after her hair was caught in a bore pump on a remote outback station. She was retrieved by plane to the Royal Darwin Hospital with a warm ischemia time of 5 hours, and total ischemia time of 13 hours. In theatre the avulsed scalp and the scalp defect were prepared concurrently, and a single artery and vein anastomosis were sufficient to revascularize the flap. At two weeks postoperatively the flap was healed well with a small area of distal necrosis, which was allowed to heal by secondary intention, and her hair has regrown. Despite the extended ischemia time, replantation of this scalp defect has been successful and will have significant impact on the life of this patient, avoiding the stigma that can be associated with obvious disfigurement.