PMC6900851_01
A preoperative photograph revealed total hairy scalp and forehead avulsion with only a connection in the nuchal area
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Fig1
On physical examination, the avulsed scalp involved almost the entire hairy scalp and forehead, sparing the occipital region in the nuchal area (Fig. 1).
Schematic diagram of the microsurgical anastomosis of vascular stumps with vein grafts. (Bold arrow) The right temporal artery and vein; (arrow) the left supratrochlear vein; (dashed arrow) the left supraorbital artery
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Fig2
End-to-end anastomosis was performed between vessels in the recipient area and counterparts area with vein grafts from the forearm (Fig. 2).
Intraoperative images after scalp replantation. After microsurgical anastomosis, a the left and b the right scalp tissue showed well perfusion according to clinical assessment. (White arrow) Please note the patency of the supraorbital artery and supratrochlear vein after anastomosis
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Fig3
The entire scalp appeared well perfused, was flush red in color, and had positive pinprick bleeding and restored capillary refill (Fig. 3a, b).
The intraoperative and postoperative indocyanine green angiography (ICGA) mapping results. a Intraoperative ICGA mapping with SPY-Q analysis of perfusion in the replanted scalp. Asterisk represents the left temporal area that is automatically selected as a reference with a 100% perfusion value. Areas with 25% perfusion relative to the maximal perfusion reference were traced with blue lines. Areas confined by the blue lines represent well-perfused tissue with more than 25% of the reference area perfusion. b The color reversal version of ICGA image when the necrotic area became mature. Please note the hypoperfused frontoparietal area represented by the color white
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Fig4
Unexpectedly, ICGA mapping showed hypoperfusion in multiple areas that adequately perfused by the clinical assessment (Fig. 4a). Tissue perfusion was assessed again with ICGA mapping, which showed a wide range of hypoperfused frontoparietal areas with a pattern in accordance with the intraoperative ICGA mapping results (Fig. 4b). SPY-Q analysis (Fig. 4a and Fig. 5). Split skin grafting was performed with grafts from the back.
All skin grafts survived with acceptable cosmetic results at the 1-month follow-up
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Fig6
Acceptable cosmetic results were achieved at the 1-month follow-up (Fig. 6).