SCALP AVULSIONS : ATTEMPT TO RESTORE HAIR GROWTH By EMIL MEISTER From Surgical Clinic I, University of Vienna IN the treatment of avulsions of the scalp the covering of the wound with grafts or flaps is no serious problem for a surgeon familiar with the basic rules of plastic surgery. The principles of the treatment have been outlined by Davis (IgII) and have been well established since then. In more recent summarising papers (Kazanjian and Webster, I946 ; Straith, I946) the method of choice is stated : covering of the denuded cranium with split-skin grafts as soon as possible. Adequate function of the lids seems attainable by primary grafting with vast allowance for shrinkage (Figs. 3, 4, 6, and 7). The one remaining problem is the restoration of a serviceable hair growth. Extensive complete avulsions are comparatively rare to-day. Few surgeons have the opportunity to gain experience with more than one case. We feel justified, therefore, in relating our attempts to restore a growth of hair by utilising the avulsed scalp even if we failed. In our first case we tried to cut small full-thickness grafts from the scalp. In spite of a quick recovery the result was not quite satisfactory because the superficial layers of the grafts became necrotic. Nevertheless there was rapid epithelialisation, but apparently originating from epithelial elements on the lower side of the grafts. The result, therefore, represents a spontaneous epithelialisation rather than a successful split-skin graft. Case i.--ida F., aged 45- Accident (ISt June I948).--Caught with her hair by the shaft of an ice-cream machine. No unconsciousness. State on Admission.--In the right temporal region of the hair-bearing skin defect of t5 by 2o cm. The periosteum was denuded in the larger part of the lesion but otherwise intact. Treatment.--Local anaesthesia. Excision of the margins of the wound. All the fat was trimmed off the scalp and full-thickness grafts of about half postage-stamp size were cut and fixed to the wound by means of plasma thrombin. Open treatment of the wound. Course.--A great part of the grafts became wholly or superficially necrotic, a few showed a good take and for a short time even grew hair. Upon removal of the necrotic grafts the wound below was found to be epithelialised almost completely. Patient discharged on 24th June I948. Follow-up Examination (I5th September i95i).--the grafted area resembled very much a scar with atrophic epithelium. The scar was only slightly movable. No hair growth. Occasionally small, slowly healing ulcers. No sensibility except in a narrow strip along the margin of normal skin. The cosmetic result was very good, since the patient was able to cover the defect with her own hair completely. To our knowledge our second case is among the most extensive in the literature. Here we were able to use a dermatome for the first time, and the cutting of the large amount of grafts no longer represented a problem. We 44
SCALP AVULSIONS." ATTEMPT TO RESTORE HAIR GROWTH 45 covered the larger part of the wound with medium-thickness dermatome grafts and concentrated upon the treatment of the eyelids. Following the suggestions of Straith (1946) and Osborne (195o), which are discussed below, we also tried to cut from the scalp the layer which bears the hair follicles. This attempt failed for reasons of a purely technical nature. A small portion of the wound was--as in the previous case--covered by small full-thickness grafts from the scalp. These grafts mostly became necrotic, the few remaining ones after eighteen months still bear some hair. Case 2.--Marie V., aged 52. Accident (3Ist May I95I).--Caught with her hair by a transmission belt. Extreme pain reported, no unconsciousness. State on Admission.--Marked shock. Local State.--Skin loss, including the whole of the hair-bearing skin, the skin of the FIG. I FIG. 2 Figs. I and 2.--Case 2. Condition upon admission two hours after the accident. The periosteum is denuded throughout but intact. forehead, the upper three-quarters of both eyelids, the saddle of the nose, the nape of the neck down to the sixth vertebral process, loss of the upper half of the right ear. The periosteum was denuded throughout but otherwise intact (Figs. I and 2). Treatment.--Covering of the upper lids by dermatome grafts sewn on stent moulds. Five more dermatome grafts of full drum size were laid on the wound. There remained a small raw area which was grafted with full-thickness grafts taken from the scalp. The grafts on the lids were 'sewn in place ; all the other grafts were held in place only by means of a compression dressing of tulle gras, wool, and elastic bandages. Fixation of the head by a plaster cast. Antibiotics, several blood transfusions. Course.--One hundred per cent. take of the grafts of the lids and the forehead. On the crown of the head and the nape of the neck two more graftings became necessary, with good results. Upon discharge of the patient on 4th August 1951 there remained three small wounds, the size of a fingernail, in the right temporal region. Follow-up Examination (I5th October I952).--All the grafts were easily movable and in good nutritional condition. No ulcers. A few grafts from the scalp bore some white hair. Closure of lids perfectly free (Figs. B and 4). Patient was working
4 6 BRITISH JOURNAL OF PLASTIC SURGERY again, but complained of headache and a certain feeling of tension in the forehead. With a wig and pencilled eyebrows the cosmetic result was satisfactory. Our third case was very similar to the previous one. Here also the skin of the upper lids was torn off to a great extent and therefore treatment of the lids FIG. 3 FIG. 4 Fig. 3 and 4.--Case 2. Condition of lids eight months after the operation. Eyebrows pencilled ; up to now no secondary operations. was our main concern. Two teams of surgeons took over. One team was occupied with cutting of grafts, the other one with the fixation of the grafts. With this division of work we succeeded in cutting grafts from the scalp on a big scale from the surface as well as from the deeper layers (Osborne, I95O). The result of the operation was very good ; only in the region of the " deep " scalp grafts some epithelial defects developed in the postoperative course, which, however, healed by spontaneous epithelialisation. The functional and cosmetic results are satisfactory. We did not succeed in the restitution of hair growth. Case 3.--Inge Sch., aged I9 (Figs. 5, 6, and 7). Accident (February I952).--Patient was looking ~'i ~ for a tool under a machine and was caught with her hair by a shaft. No unconsciousness. Extension of Skin Loss.--Two-thirds of both upper lids, bridge of the nose, forehead, entire hairbearing skin, loss of the upper half ofthe right ear, laceration of the right cheek. Periosteum denuded but intact. Case 3. FIG. 5 Condition on admission, Treatment.--Cleaning of the wound and excision of the wound margin. Suture of the laceration on the cheek. Stent moulds were taken from the upper lids. A dermatome graft from the thigh was sewn on this mould and sutured to the margins. The remaining wound was covered with grafts from the surface and the deeper layers of the scalp. All the grafts were sutured to each other as well as to the wound margins. Compression dressing with tulle gras, wool, and elastic bandages. Antibiotics and blood transfusions.
SCALP AVULSIONS: ATTEMPT TO RESTORE HAIR GROWTH 47 Course.--I7th February 1952 : First changing of dressing. Good take of all grafts. 25th February I952: Removal of sutures, the " deep " scalp grafts were almost completely epithelialised. Partial necrosis of a graft in the right temporal region. FIG. 6 Figs. 6 and 7.--Case 3. FIG. 7 Condition eight months after the operation. free without secondary operation. Closure of lids 26th March 1952 : The remaining wound was grafted with an intermediate dermatome graft. Good take. 29th March 1952 : Circumscript " melting away " of parts of the " deep " scalp grafts. 4th May I952: Discharged. New defects almost completely re-epithelialised. No hair growth. DISCUSSION In attempting to restore the hair growth in cases of scalp avulsions, the surgeon is faced by the task of grafting a rather thick and complex structure on a relatively avascular bed. The idea of using the scalp in its original form is rather tempting, and a number of instances are reported in which this was tried. The failure was general--due to insufficient nutrition ; its anatomical causes are discussed by Davis (1911) and by Straith (1946). The process of cutting Thiersch grafts from the scalp originates from Gussenbauer (1883) and was performed repeatedly in the course of time. The cutting of these grafts is quite difficult and a restitution of hair growth is not effected : we cannot see any particular advantage of this method over the taking of grafts from the thighs. The preparation of full-thickness grafts from the scalp is especially tedious. We did so in our first and second case; scarcely any hair growth was achieved. The method of Osborne (I95 o) seemed most interesting ; he, in variation of a procedure described by Zintel (1945) for re-splitting split skin, cut the hair-bearing deep layer out of the scalp. Experiments with suckling pigs were repeatedly successful. A patient with a malignant tumour of the skull died on the twelfth post-operative day ; there was a good take of the " deep " grafts, which showed a stubble of hair.
4 8 BRITISH JOURNAL OF PLASTIC SURGERY We tried this method in our last two cases. In the first instance we were unable to overcome technical and organisational difficulties. In the second case these troubles were mastered ; there was an almost IOO per cent. take of the " deep " grafts and a rapid epithelialisation. After fourteen days a promising hair growth showed, but all these stubbles later came off. There was also some melting away of the epithelium of these grafts with spontaneous epithelialisation from the margin and epithelial islands. For the time being there does not seem to exist a method of restituting hair growth. We feel, nevertheless, that the principle of "deep " split-skin grafts, which contain part of the hair follicles, is sound and may give good results some day ; our failure is possibly due only to technical shortcomings. Better results could perhaps be achieved if it were possible to preserve the scalp until granulations have formed on the epicranium, in order to give better nutritional conditions. Sir Harold Gillies suggested to us the temporary grafting of the scalp to the hip as a means of preservation. SUMMARY Three cases of scalp avulsion are presented. An attempt was made to restore hair growth by utilising the avulsed scalp in the form of full-thickness grafts of postage-stamp size and " deep " split-skin grafts containing part of the hair follicles. In spite of good take and rapid epithelialisation no hair growth was achieved. REFERENCES DAvxs, J. S. (1911). Johns Hopk. Hosp. Rep., 16, 257. GILLIES, Sir HAROLD (1954). Personal communication. GOSSENBAUER, K. (1883). Z. Heilk., 4, 38o. KAZANJIAN, V. H., and WEBSTER, R. C. (1946). Plasr. reconstr. Surg., i, 360. OSBORNE, M. P. (195o). Ann. Surg., 132, 198. STRAITH, C. J. (1946). Occup. Med., 1,451. ZJNTEL, H. A. (1945). Ann. Surg., 12I, I.