complete avulsion of the scalp

COMPLETE AVULSION OF THE SCALP

By FRANK ROBINSON, B.Sc., M.B., F.R.C.S. Senior Registrar, Plastic Surgery, Burns and Jaw Unit,

lVythenshawe Hospital

WHILST a considerable number of cases of complete avulsion of part or the whole of the scalp have been reported in the literature, it remains a relatively uncommon industrial accident, and no surgical team is called upon to deal with many instances, except over a prolonged period.

During the past nine years, twenty-eight cases have been treated at this Unit, and it was felt that it would be profitable to report the experience gained. The first twenty-four have been analysed for this communication.

The t e r m " complete" implies that the avulsed portion of the scalp is detached entirely from its surrounding and underlying tissues, as distinct from the partial avulsion where some attachment persists.

~TIOLOGY

All were women whose hair had become entangled in moving machinery. The age incidence was as follows :--

14 to 20 years 9 3 ° to 4 ° years 4 2o to 3 ° years 8 40 to 50 years 3

Young and comparatively inexperienced female workers are thus the commonest victims of this severe and disfiguring injury. Many were wearing the protective headgear supplied by their employers, but this was by no means always arranged to cover most of the hair.

ANATOMY

From a strict anatomical viewpoint, the scalp consists of five layers--the skin, subcutaneous tissue, the occipito-frontalis muscle and its aponeurosis (galea aponeurotica), loose sub-aponeurotic tissue and the pericranium--but the first three of these are intimately connected, and surgically can be regarded as a single layer. Many of the hair follicles penetrate deeply into the subcutaneous tissue.

Therefore, when the hair is caught in machinery the avulsion occurs between the aponeurosis and the pericranium, through the loose sub-aponeurotic tissue. Loose tags of aponeurosis may be left, and in some cases pericranium is also avulsed or is ground off against moving machinery, exposing the outer table of the skull, usually over small areas.

The extent of the avulsion depends on the site and the amount of hair caught and the direction of the force exerted.

In a minority of cases the greater part of the hair is caught and almost the whole of the scalp is avulsed. The line of cleavage runs horizontally through the eyelids, crossing the root of the nose, and follows the zygomatic arches round to the superior nuchal line of the occipital bone. The upper part of one or both ears

37

38 BRITISH JOURNAL OF PLASTIC SURGERY

may be torn off with the scalp. This line corresponds closely with the peripheral attachment of the epicranial aponeurosis. There were three such cases in this series. In another extensive avulsion (Figs. I to 4) the greater part of the hair

FIG. I FIG. 2

Fig. I .--Extensive avulsion of the scalp with involvement of one ear prior to operation on the day of injury.

Fig 2.--Dermatome grafts applied and sutured into position.

FIG. 3. Final result. FIG. 4

had evidently been caught and dragged backwards, but the skin of the lower forehead, although loosened, remained attached.

The majority of cases lose only a portion of the scalp when a localised area of hair is caught in the region of the vertex.

The area most commonly extends from one side of the midline to just above the ear on the opposite side in the parieto-temporal region (Figs. 5 and 6).

COMPLETE AVULSION OF THE SCALP 39

Depending on the direction of pull, it may be almost central, may extend anteriorly towards the forehead, or posteriorly towards the occiput. It may involve almost half the head, extending from the forehead along the zygomatic arch to the occiput. There were twenty cases of this type of lesion.

FIG. 5

Less extensive avulsion prior to operation on the day of injury.

FIG. 6

Dermatome graft applied and sutured into position.

CLASSIFICATION OF CASES

Ten patients were first operated upon and grafted either on the day of injury or on the succeeding day, and these have been termed " Recent." Ten were treated elsewhere originally and operative treatment began at this Unit after a delay of at least a week, the actual period varying up to four and a half months. These, with two where the scalp was thinned down to a full-thickness graft and unsuccessfully replaced, have been termed " Delayed " cases. The remaining two patients had been injured over thirty years previously and were referred in 195o on account of late scar breakdown.

Recent (IO)

Delayed (I2)

TABLE

Analysis of Twenty-two Cases of Avulsion

Number of Graft- ing Operations.

Average Delay Average Healing before Grafting. Time after Injury.

Nil 5 weeks

6½ weeks I3 weeks

Previous Treatment of Delayed Cases

Dressings only, average delay before grafting 3½ weeks .

17 (-<2 per case)

27 ( ~ 2 per case)

4 Scalp replaced (sloughing), average delay before grafting 7 weeks 8

4 ° BRITISH JOURNAL OF PLASTIC SURGERY

The table contrasts the progress of the two main types of case, and emphasises the great value of immediate grafting in achieving rapid healing and in shortening the length of hospital care. Recent cases were healed and discharged some five weeks after the accident but, in contrast, the delayed cases spent an average of thirteen weeks in hospital. During the last two years all cases have been referred on the day of injury, so it would appear that the necessity for immediate grafting is now more widely appreciated.

REPLACEMENT OF THE AVULSED SCALP

In six cases the avulsed scalp was replaced prior to transfer with sloughing of the whole of the tissue replaced. As the table shows, much time was lost by awaiting separation of the slough before referring the patients for grafting.

I t is surprising that this course has been followed in recent years, in that Davis (1911) in his monumental and fascinating paper reported eighty-one cases of industrial scalping, of which twenty-one were treated in this manner. In only one, where healing occurred in fourteen weeks deep to the mummified scalp, was it in any way successful. Later McWilliams (1924) stated that 173 cases had been reported and the scalp replaced in forty, again with no success. Eisenstodt (1945) reported a case where the scalp was replaced with great care. Separation occurred very slowly, and it was not until three months had elapsed that it was possible to begin grafting. Straith and Pilling (1947), referring to this record of failure, suggested shaving the scalp, thinning it, and replacing the skin only as a free full-thickness graft. Kazanjian and Webster (1946) had already reported the replacing of a scalp, and only 5 per cent. of it, where the fat had been tr immed away, remained viable. This method has been used at this Unit in 1945 and again in 1946 in the following two cases.

Case x.--A girl of 17 years was admitted in good general condition. Two pieces of scalp 3 by 3 in. and 6 by 5 in. were sent with her, wrapped in normal sah~ae. Five and a half hours after the accident the scalp was shaved, turned upside down, and laboriously cut down to a free full-thickness " graft." It was carefully sutured into position. Ten days later, at the first dressing, the " graft " appeared dry and mummified. During the next two months the dry scab was slowly removed by wet dressings to reveal what was thought to be deep layers of skin. Hairs were certainly present but, in the following weeks, most were shed and the whole area became covered by granulation. A thin split graft was applied in three sheets, with 7 ° per cent. " take," and the epithelialisation completed by patch grafts three weeks later. She was discharged, healed, five months after the accident.

When this patient was reviewed this year, the grafts had thickened considerably and were surrounded by a peripheral scar I in. in width. Both scar and grafts were movable on the skull, and there had never been any breakdown. There was, of course, no hair present, and the patient wore a wig. Had primary split grafts been applied, this patient would have been discharged in a matter of weeks, in very much the same condition she attained after five months.

Case 2.--A woman of 36 years. An incompletely detached flap 7 in. long with a pedicle 2½ in. wide was replaced, and a completely avulsed piece of scalp 3 by 2 in. thinned and re-applied in three pieces. Four inches of the flap sloughed, but at first it was thought that 5o per cent. of the replaced " graf t" had taken. Again, however, patch grafts were required to secure healing, and she was discharged after nine weeks. This patient also has never had a breakdown. She covers the totally bald area by rearranging her hair.


It may be concluded that replacement, even after thinning, is not to be recommended. This method has persisted because there is a natural reluctance to discard hair-bearing skin and to use a non hair-bearing graft. It must be remembered, however, that the skin of the scalp is very thick and that one would not expect a good " take " from such a graft even on a more vascular site than the pericranium. Moreover, the process of thinning down removes many of the deeply placed hair follicles. In this connection it is interesting to note that small "'eyebrow " grafts, taken from the scalp, only too often bear a very disappointing growth of hair.

I f it is not feasible to replace the whole or thinned-out scalp, it is certain that split grafts cut from it may survive, although the technical difficulties of such a procedure would appear formidable.

Osborne (195o) has reported a case in which, after the avulsed scalp had been shaved, it was glued to a dermatome drum and superficial grafts varying from o"o15 to 0'050 in. in thickness were cut from it. The grafts were applied to the pericranium with considerable success--about 70 per cent. being viable on the ninth day. No hair was grown from the grafts. This author then carried out experimental work on the hair-bearing skin of guinea-pigs, which closely resembles that of the scalp, and was able to show that thin sections of the deeper layers of the skin (split split grafts) at certain levels would give epithelial cover and also grow hair. On this basis he recommends cutting split split grafts with the dermatome from the scalp, using the layer between 0"025 and 0.05 ° in. in thickness. In one case, a male of 72 years, an extensive hmmangiosarcoma was excised and this deep split split graft applied. Regrettably, the patient died of cardiac failure on the twelfth day, so there is no record of ultimate growth. The graft had taken well, and a stubble of hair was present at this time.

This method has not, so far, been used at this Unit. I f successful it might result in achieving some growth of hair in an area otherwise certain to be bald. It is interesting in this connection to recall Mitchell's paper of 1924, in which he described the treatment of a localised loss by making concentric incisions round the defect and sliding multiple double-ended flaps towards the centre. Resultant gaps were allowed to close spontaneously, but the final photographs show such an excellent cover by hair that the method, modified by immediate graft-cover of the secondary defects, might be revived for some of the less severe cases.

In a recent case, not in this series, a sub-total loss extended through the frontal hair-line. A rotation flap was used to bring hair into this area prior to grafting the defect, so as to surround the graft completely with hair.

TREATMENT EMPLOYED IN THIS SERIES OF CASES

The immediate treatment may be divided into general and local. In addition, a proportion of cases required further operative work after healing was complete. This is described under the heading of Late Reconstructive Procedures.

General.--The majority of recent cases were admitted in a remarkably good general condition. Where only a localised area had been lost, it was usual to find a normal or only moderately reduced systolic blood-pressure, and only two were transfused. One, where the avulsion involved the upper forehead and parieto- temporal region, one ear being avulsed also, was given 2 pints of blood. Another, where the defect measured 6 by 5 in. only, was admitted in a shocked condition

42 B R I T I S H JOURNAL OF PLASTIC SURGERY

and had I pint of plasma and I pint of blood prior to the operation, during which a further pint of blood was given.

A.T.S. was administered and prophylactic chemotherapy begun on admission. The hmmoglobin level was checked on the day after operation and further blood was given if necessary. Thereafter, the hmmoglobin was estimated at least once a week and maintained at 75 to 80 per cent. All patients had routine vitamin supplements and ferrous iron by mouth.

With avulsion of the greater part of the scalp there is a much greater degree of initial blood loss, and patients may arrive in shock. They have to undergo an extensive grafting procedure with further blood loss at operation, especially from the donor areas. Plasma, latterly replaced by dextran, was given whilst grouping and compatibility were being done, followed by blood. In general, about 4 pints o f fluid were given in all.

Delayed cases were treated on their merits, blood being given as required and appropriate chemotherapy continued or begun.

Local.uIn the ten recent cases operation was performed under intratracheal anmsthesia as soon as the patient was fit. The remainder of the scalp was shaved and the wound irrigated with cetavlon and saline. Very little in the way of excision was usually necessary, the edges being clean-cut. Small flaps present in some cases were sutured back. Although it is commonly stated that all flaps should be preserved, the long flaps occasionally encountered sometimes sloughed in part after replacement. It may well be better to adopt a rule found useful when dealing with gross lacerations in other parts of the body, that a badly traumatised flap should be cut down until its length is no greater than its width. Tags of aponeurosis were usually removed. Pericranial defects were dealt with as described later.

The defect was then grafted. In eight cases split-thickness grafts, I4/I,OOo in. thick, were cut with the dermatome and sutured into position. Io two large avulsions these were complemented by split grafts cut with the Humby knife. Two cases were treated solely with Humby grafts. Five required no further operative treatment, but in the remainder subsequent Thiersch grafts, in patches, were necessary to give complete cover.

The dressing was gauze wrung out in normal saline, followed by dry gauze and cr6pe bandage to exert moderate pressure. It was first removed seven to ten days after operation in the theatre, and further grafts were usually applied to any definite area of failure at this time.

Delayed Cases.--Where the scalp had been replaced elsewhere, and was still present as a slough, it was removed surgically. In two cases skin grafts were applied after forty-eight hours, whilst in a third the area was grafted at the same time. The majority of patients, in whom replacement had been carried out, were not transferred until the slough had been removed by wet dressings, this procedure delaying grafting by several weeks. Raw or granulating areas were grafted as soon as clinically receptive, a variety of grafts being used, in contrast to the fairly uniform method used for the recent cases. Two were grafted with dermatome sheets three weeks after injury with the remarkably good " take " of 7o per cent. in each. The remainder have had Thiersch grafts in sheets, strips, or patches. Whilst it is impossible to dogmatise from a small series of cases, it would appear that the use of strips and patches in recent years resulted in a higher percentage of " t a k e " and earlier healing.


I t is doubtful, however, f rom reviewing them, if this method should have been :adopted, for there is no doubt that areas grafted in sheets are much less liable to later scar breakdown. I t is felt that every effort should be made to graft with moderately thin sheets, reserving the patch method for the long-delayed and chronically infected cases.

Treatment where the P e r i c r a n i u m had b e e n R e m o v e d . - - I n two recent and four delayed cases (approximately 3o per cent. of the series) pericranium had been lost and bone was exposed.

Recent Cases.--Case i (I944).--An avulsion of 6 by 3 in., with a small area of raw bone in the centre. A flap of aponeurosis was rotated to cover this and a dermatome graft sutured on. The " take " was very nearly IOO per cent., and the patient was discharged on the twenty-sixth post-operative day.

I95 I. The patient did not attend for review but reported that the scalp was healed and had never broken down.

Case 2 (I947).--An avulsion 6 by 51 in. with an area of denuded bone anteriorly. The outer cortex was chiselled away until multiple bleeding points appeared and two dermatome grafts were applied to the whole of the defect. At the first dressing the area of graft over the bone was raised by serum, and this was evacuated. This portion of graft eventually necrosed and was excised, Thiersch grafts being applied. Subsequent healing was uneventful.

I95 I. The patient reported that the scalp was healed, but there had been small breakdowns for some months after injury.

Delayed Cases.--Three were treated in I943 and 1945. T h e wounds were granulating and small areas of bone were exposed, the largest measuring 2 by I in. In two, dermatome grafts, perforated over the bone, were used, and in one patch grafts. The initial " take " in all was 7 ° per cent. Granulations spread across the bone during further t reatment with wet dressings and patch grafts led to complete healing six, seven, and nine weeks after the first grafting ; nine, ten, and fourteen weeks after the injury, respectively.

In I948 a further case was admitted five days after injury with the replaced scalp riding on fluid. I t was removed, and patch grafts were applied forty-eight hours later. A small area of raw bone I in. in diameter was chiselled down to bleeding points. The grafts failed here, but more applied ten days later were successful. Complete healing was achieved after six weeks. Only one of these patients, treated in i945, at tended this year. T h e defect measured 8 by 7 in. Hal f was covered by thick movable dermatome grafts in contrast to the thinner, more adherent area of skin derived from the patch grafts. Where pericranium had been lost the surface of the bone was irregular, showing that small sequestra: had been discharged. The patient said that she had had breakdowns in this area about six times per year, due, she thought, to scratching. Th ey healed very easily and quickly. Small sequestrm had been discharged at intervals.

T h e other patient treated by dermatome graft in 1945 reported that she had never had any breakdowns. Only very small areas o f bone were exposed here.

METHODS AVAILABLE FOR THE TREATMENT OF EXPOSED BONE

These may be summarised as follows : - - 1. Wet dressings only. 2. Boring holes into the vascular diplo~ to allow granulations to emerge

and spread over the raw bone. 3. Surgical excision o f the outer table of the skull.


Method I was described by Davis (I9II), who pointed out that continual wet dressings prevented the bone " drying out," and would eventually lead to cover with granulations, at least in small areas. Three cases mentioned above had nothing more than this but, although healing was achieved in a reasonable time, the results cannot be regarded as satisfactory as there was a strong tendency to repeated ulceration and sequestration. More active treatment is indicated in the present state of our knowledge.

Method 2 was not employed in any case in this series. Ryslander and Kisner (1942 ) described its use. Granulations first appeared twelve days after boring, and grafts were applied five weeks later. Kazanjian and Webster (1946) compared this procedure with

Method 3--surgical removal of bone--after excision of an extensive temporal basal-cell carcinoma. An area of raw bone was treated by making several burr-holes. Eighteen days later only feeble granulations were present in each hole. The exposed bone was then chiselled away until multiple bleeding points appeared, and seven days later it was covered with a thin layer of vascular granulations. After another week a dermatome graft was applied with success. These authors recommend covering the raw bone with flaps if possible, but if not, excision of the outer table of the skull and grafting two to three weeks later when the bone is covered with granulations.

In this Unit surgical excision of the outer table of the skull and immediate grafting is the method used where bone is exposed. Whilst it has been employed only in the few cases of avulsion referred to above, it has been used frequently in the treatment of extensive exposure of bone due to burns. Cortical bone has been chiselled away until multiple bleeding points have appeared and then Thiersch grafts have been applied direct to the raw surface. " Take " has been variable--- at times almost complete but more often partial. Further excision of bone and grafting have been required in large areas on several occasions. The skin cover thickens considerably and has become stable in the majority of cases.

The radical excision of recurrent or radio-resistant carcinomata of the forehead and scalp may also necessitate the removal of all soft tissue and exposure of the skull. The method has been used in these cases with a more certain " take ," although further grafts have been required in some.

In both the above classes of case, if failure occurs, cover by granulations is slow and often accompanied by sequestration of thin flakes of bone.

FOLLOW-UP EXAMINATION

Although every case had been seen regularly for at least six months after discharge, it was thought advisable to attempt to review all cases this year. The response was disappointing in that only eight attended, although eight more replied to a questionnaire that was enclosed when requesting their attendance.

The results may be summarised as follows : -

Number of cases healed (includes one case where the bald grafted area had been totally excised and replaced by local hair-bearing flaps) 16

Number subject to occasional ulcerations in the grafted area 5 Number who have had no ulceration since discharge IO Number wearing a wig 8


It was apparent from the patients examined that those treated with dermatome, Humby, or Thiersch grafts applied in sheets had been, in general, free from ulceration. Those who had suffered from partial failure, with complementary patch grafts later, and those who had had patch grafts applied originally were subject to ulceration following upon minor injury, such as catching the grafted area with hair-grips. The ulcerations healed uneventfully in two or three weeks and became much less frequent after the first few months.

Whereas sheet grafts had thickened and were movable on the skull, areas of patch graft cover were thinner and more fixed, due to the scars between the grafts. Protopathic sensation was present in all cases over a peripheral zone I to 2 in. in .depth, but the central area was insensitive.

DISCUSSION

We are now in a position to discuss the treatment of the recent cases. It would seem advisable for selected cases to be treated on the lines proposed

by Osborne (I95O). An attempt to split a portion of a scalp on the lines indicated in his article has been made in one case recently, but it was not found possible to glue the scalp securely to the dermatome drum and only small grafts were cut, eventually to be discarded. It is hoped to experiment further in due course.

Until this method has been under trial for longer, split grafts should be applied as a primary measure to all areas with a pericranial base. These are best cut with a dermatome for, by its use, long sheets of uniform thickness, well adapted to suture one to the other and to the edges of the defect, are obtained. These need not be thicker than 14/1,ooo in., and at this depth the donor area will heal spontaneously in two to three weeks. It is recognised, however, that if the condition of the patient gives rise to anxiety, a simpler and more expeditious technique gives comparable results. Long sheets of graft are cut with a Humby knife, spread on tulle gras, and laid on the raw area in parallel series. This simple method has been used to a considerable extent to cover forehead and scalp defects in elderly patients, created by flap repairs after the radical excision of facial carcinomata. The results have been uniformly good. The method is also recommended by Kazanjian and Webster (1946).

In severe cases with avulsion of the forehead skin, the eyebrows and portions of the eyelids, it is particularly important to graft this anterior area with especial care, not only to ensure a good cosmetic result but also to forestall the development of ectropion and damage to both eyes. Kazanjian and Ropenian (195 o) recommend primary tarsorrhaphy in such cases, but this has not been found necessary.

Where there is periosteal damage with exposure of bone, the bone should be chiselled down until bleeding points appear. After grafting the remainder of the defect with thick split grafts it is suggested that Thiersch grafts in sheets should be applied to the bone. This procedure will result in a satisfactory " take " in the majority of cases, with a stable and permanent cover. It is felt that it is preferable to proceed in this way rather than to leave the areas to granulate and to graft later. Immediate grafting forestalls the development of infection and avoids the wait for granulations to cover the bone, often a slow and imperfect process. I f it fails, little is lostmthe area can be re-excised and re-grafted, or, alternatively, then left to granulate and be covered later.

In the delayed case, which should be encountered much less frequently than


formerly, every effort should be made to apply sheet grafts in preference to patches. The latter method, used commonly in this Unit, may lead to quicker immediate cover, but one that is essentially unstable and which should be replaced at a later date.

La t e Recons t ruc t ive P r o c e d u r e s . - - I n this series of cases the following have been employed : - -

I. Dermatome grafts to the forehead. 2. Hair-bearing flaps, used to remove small bald area completely or to centralise

a larger area to enable thc patient to cover it by rearranging her hair.

I. Dermatome Grafts.--These were used on four occasions. They are mainly indicated in avulsion of the forehead skin, with an unsatisfactory cosmetic result

FIG. 7 FIG. 8

Fig. 7 . - -Resul t of grafting with strips and patches in a delayed case. A poor cosmetic result, although ectropion has been prevented.

Fig. 8.--After a dermatome graft had been applied. The eyebrows have been pencilled on.

from the use of patches and strips in delayed cases, or partial failure of sheet grafts in recent cases (Figs. 7 and 8). Unless a good primary " t a k e " is obtained there is a tendency to retraction of the eyebrows if present, and the upper eyelids.

Three delayed cases had such grafts for cosmetic reasons ; two where the whole forehead was involved, whilst in the third the area of avulsion extended down the right fronto-parietal region on to the cheek. Grafts were applied two months, five months, and seven months after healing respectively. The " t a k e " was complete in all.

In another case the forehead skin was not avulsed but freed from the sub- aponeurotic layer. A central slough developed and was excised. Patch Thiersch grafts were applied and, three weeks after complete healing, the forehead skin was replaced by a dermatome sheet. I t " t o o k " perfectly.

2. Flaps.--These may be used to remove the defect completely, as in the case illustrated in Figs. 9 and Io. An area 2 by 3 in., resulting from scalp replacement and sloughing, was grafted. One month later the area was excised and closed completely by a series of local flaps. Seen three years later, the patient was


completely normal in appearance, the very small amount of residual scarring on the forehead being hidden by her hair.

More usually a flap is designed to swing hair from one border to another of a bald area, to shift the latter centrally and surround it with hair-bearing skin. I t

FIG. 9 FIG. IO

Fig. 9.--Granulating defect anteriorly after sloughing of the replaced scalp, and prior to grafting

Fig. Io.--Grafted area excised, and triangulated defect closed by local hair-bearing flaps.

FIG. i i FIG. 12

Figs. I I and i2.--Right-sided avulsion healed for seven years. Note loss of hair in fronto-temporal region.

is of most use in localised losses involving the frontal and fronto-parietal regions where the absence of hair is such a disfigurement.

Two cases have been thus treated. The first had a bald area 6 by 4 in. with loss of the frontal hair. One month after healing a flap 4 by 3 in., with a right anterior base, was rotated through 9o degrees to produce hair in the frontal region, a dermatome graft being applied to the residual defect. She is now able to cover the bald area completely with her hair.

The second case (Figs. II and 12) was admitted with considerable peripheral

48 B R I T I S H J O U R N A L OF P L A S T I C SURGERY

healing four and a half months after injury in I943. The granulating area was excised and grafted in one sheet. In I95O, the area having remained healed for seven years, she then asked if it would be possible to transfer hair anteriorly, so that she could grow this long and avoid wearing her wig. A tong rectangular flap, with branches of the temporal artery in its base, was rotated through 90 degrees with considerable folding (Figs. I3 to I5). The flap was divided to remove the dog-ear after two weeks. The very satisfactory growth of hair three months after operation can be seen in Figs. I6 to I7. It is regrettable to have to report that

FIG. 13 FIG. 14

FIG. 15

Figs. 13 to I 5 . - - H a i r - b e a r i n g flap f rom left side o f scalp rota ted t h rough 9o degrees to restore hair

anteriorly and on the r ight side.

when seen in the follow-up for this paper she confessed to having cut her hair short again as it had become coarse and stood up from her head. It was suggested, somewhat forcibly, that she should endeavour to persist in training her hair, but whether she will do so remains doubtful.

Straith and Beers (I95 o) have recently described the use of a double-ended visor flap by which occipital hair was transferred to the frontal region, where the avulsed scalp had been thinned and replaced only to slough. This ingenious method, they suggest, might be used primarily in selected cases.

Late Complicat ions.- -These include repeated ulceration, seen chiefly in cases

allowed to epithelialise spontaneously or inadequately grafted. Benedek (i95o) has described the microscopical appearances where this occurred after small deep grafts had been used as being progressive occlusion of vessels in the dermis, followed by superficial necrosis. Eventually malignant degeneration may supervene (Burns, 1935 ; Kazanjian and Webster, 1946). There is also scar contraction, especially liable to cause severe ectropion of the upper eyelids if the forehead is involved. Two patients referred in I95O illustrate these complications.

Case x.--Aged 58 years, a diabetic. Forty-four years prior to admission she had sustained an extensive avulsion involving the right upper forehead, temporal and parietal regions. It healed, no grafts being used, after " a very long time "--about two years,


she thought. Breakdowns had occurred for two years prior to admission, and at this time there were two granulating areas 4 cm. in diameter, with bone exposed at their centres. It was necessary to excise the superficial layer of the bone and graft each area on two occasions to obtain complete healing. Ten months after the last operation she

FIG. I6 FIG. 17 Showing the growth of hair three months after operation.

FIG. I8 FIG. 19

Fig. I8 . - -Mahgnant ulceration of scar epithelium thirty-three years after avulsion. Anterior view shows tightness of the scar, and previous correction of right-sided

ectropion by graft. Fig. I9 . - -Mal ignant ulceration of scar epithelium. Posterior view showing multiple

ulcerated areas, bone being exposed in places.

~till experienced minute breakdowns which were easily controlled by dressings. Sections never showed any evidence of malignant change.

Case 2.--Aged 62 years. An extensive avulsion thirty-three years prior to admission. She was under treatment for two years, grafts being applied at intervals. The scar epithelium was thin and stretched taut, with blood-vessels showing through it, and she had developed severe ectropion, corrected some years previously (Fig. 18). There was a large granulating area with bone exposed in the left occipito-parietal region (Fig. 19).

I D


This was excised, cortical bone being removed and grafts applied. These " took " well, but recurrent ulceration necessitated three further operations before healing was achieved. Biopsies from the first two operations revealed low-grade epitheliomatous change, but those from the latter were negative. She is healed ten months after the last operation, and at no time have any glands been palpable.

Kazanjian and Webster (I946) have suggested and employed the use of a tubed pedicle in this type of case, which may require the excision of the full thickness of the bone. Both of the above patients are followed up at three-monthly intervals but, so far, nothing has occurred to suggest the use of more radical procedures, to which both are averse.

SUMMARY

r. Treatment and its results in a series of twenty-four cases of complete avulsion of the scalp are reported.

2. The inadvisability of replacing the avulsed scalp, either as a whole or thinned down to a full-thickness graft, is emphasised. In no case yet reported has it been successful.

3. I t is suggested that, until further work has been performed on the use o f split split grafts cut from the avulsed scalp itself, the treatment of choice is immediate cover of areas with a pericranial base with split-thickness skin, best cut with the dermatome. Small areas of exposed bone, present in approximately 3 ° per cent. of cases, should be treated by excision of the superficial compact bone and immediate Thiersch grafting.

4. Late reconstructive procedures which have been employed in certain cases after initial healing are described. These include dermatome grafts to the forehead and the use of hair-bearing flaps to remove or alter the position of the bald area.

5. In cases inadequately treated, recurrent ulceration and severe scar contracture may occur as late complications. Recurrent ulceration may lead eventually to carcinomatous degeneration. Two cases are reported in illustration.

The cases that have been discussed were admitted under the care of Mr P. Gabarro, Mr A. H. R. Champion, and Mr A. McDowall. My sincere thanks are due to them for having interested me in this subject, and for their guidance in the treatment of some of the cases.

During the preparation of this paper the constant help and advice given by Mr Champior~ and Mr McDowall have been invaluable.

The photographs and table are the work of Miss E. Gibbon, A.I.B.P., A.R.P.S.

REFERENCES

BANKS, A. G. (I928). Brit. reed. ft., z, 593. BENED~K, T. (I95o). Plast. & Recons. Surg.~ 6, 287. BURNs, E. L. (I935). Arch. Surg., 3 o, 266. DAvis, J. S. (r9II). ffohns Hopk. Hosp. Rep., x6, 257. EISENSTODr, L. W. (r945). Amer. ft. Surg., 68, 376. KaZANJIaN, V. H., and ROVENIAN, N. (I95O). New Engl. ft. Med., ~42, 539. K~ZANJIAN, V. H., and WEBSTER, R. C. (I946). Plast. & Recons. Surg., x, 36o. MCWILLIAMS, C. A. (r924). ft. Amer. reed. Hss., 83, I83. MITCHELL, G. F. (I933). Brit. reed. ft., x, I3. OSBORNE, M. P. (I95O). Ann. Surg., *3z, I98. RYSLANDER, C. M., and KISNER, W. H. (r942). Amer. ft. Surg., 58, I5o. STV.aITH, C. L., and BEERS, M. D. (I95O). Plast. 6" Recons. Surg., 6, 3I 9. SrRA~TH, C. L., and PILLING, M. A. (I947). Amer. ft. Surg., 74, 328.

complete avulsion of the scalp

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