Frimpong et al. Maxillofacial Plastic and Reconstructive Surgery (2020) 42:39 https://doi.org/10.1186/s40902-020-00283-2
CASE REPORT Open Access
Scalp injury management by a maxillofacial
surgeon in a low-resource hospital Paul Frimpong1† , Truc Thi Hoang Nguyen2† , Edinam Salia Nimatu1 , Emmanuel Kofi Amponsah1 andSoung Min Kim1,2*
Abstract
Background: Head or scalp injury is a life-threatening and typically accidental human injury. Most medicaldepartments require immediate medical treatment and proper treatment with specialized medical personnel andfacilities. However, in low-resource environments, such as the rural region of West Africa, the authors have treatedemergency trauma patients and provided immediate treatment despite lack of resources.
Case presentation: We reviewed three cases of scalp injury patients, with representative clinical information, andused these cases to outline feedback on scalp trauma treatment based on the specialty knowledge of general andemergency surgeon.
Conclusions: Oral and maxillofacial surgeons are medical specialists that can immediately diagnose and treat thesescalp injuries based on their medical knowledge and experience with the maxillofacial region.
Keywords: Head and scalp injury, Accident and emergency unit, Low-resource hospital, Scalp layer, Scalpadvancement flap
BackgroundThe scalp is the soft tissue envelope of the cranial vaultand consists of five layers of skin, dense connective tis-sue, epicranial aponeurosis, loose areolar connective tis-sue, and periosteum [1, 2]. These scalp layers can beaffected by accidents, benign or malignant tumors, andother necrosis-induced chemical agents or radiation.Thus, scalp injury could be classified as partial-thicknesswith intact periosteum or full-thickness with exposedcranium, exposed dura, or exposed cerebral tissue, ac-cording to injury depth and involved layers [1–3]. Thesedefects could be classified according to anatomical siteand size, as small when the size is less than 2 cm,medium when the size is 2 to 2.5 cm, and large whenthe size is more than 2.5 cm [3, 4].
* Correspondence: [email protected]; [email protected]†Paul Frimpong and Truc Thi Hoang Nguyen are co-first authors.1Oral and Maxillofacial Microvascular Reconstruction LAB, Brong AhafoRegional Hospital, P.O. Box 27, Sunyani, Ghana2Department of Oral and Maxillofacial Surgery, Dental Research Institute,School of Dentistry, Seoul National University, 101 Daehak-ro, Jongno-gu,Seoul 03080, South Korea
The skin of the scalp has unique characteristics, withlimited skin mobility, inelastic galea aponeurotic tissues,and dense hair follicles [4]; thus, it is difficult to closeeven a small defect. Most cases of medium or large de-fects could be covered using a unilateral or bilateral ad-vancement flap after wide subperiosteal dissection. Wepresent three representative scalp injury cases with scalpadvancement flap reconstruction and our managementof these cases in a low-resource health facility.
Case seriesFrom August 2014 to December 2018, more than 89 pa-tients who were diagnosed with scalp injury visited twosurgeons in the Department of Oral and MaxillofacialSurgery at Brong Ahafo Regional Hospital. We hereinreport three patients with frontoparietal scalp defectfrom motor vehicular accident and include clinical pho-tographs with each patient’s description and treatmentprocedures. The patients or their parents provided writ-ten informed consent for surgical reconstruction and ap-proved the use of their photographs in scientific
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Frimpong et al. Maxillofacial Plastic and Reconstructive Surgery (2020) 42:39 Page 2 of 5
publication. This case series report was evaluated andapproved by the Institutional Review Board of SeoulNational University (S-D20200021).
Case 1: a 5-year-old child hit by a motorbikeA 5-year-old toddler who had received all his childhoodimmunization vaccines presented with scalp injury fromimpact with a speeding motorbike 48 h. Upon arrival atEssam Government Hospital, he was managed with anti-biotics and pressure dressing to stop the bleeding fromthe scalp and later referred to Brong Ahafo RegionalHospital for expert management. The child did not loseconsciousness, there was no bleeding from his ears ornose, and he had not previously undergone any surgery.On presentation, the patient was a slightly febrile,
moderately pale toddler that was well-hydrated, conscious,and alert, with a 3 × 8-cm-sized complete avulsion injuryof the right scalp with scalloped margins extending fromthe right frontal region to the right parietal region expos-ing the underlying scalp (Fig. 1a). There was also an ob-lique 4-cm-sized laceration at the occipital scalp region;therefore, a clinical diagnosis of avulsion scalp injury withoccipital laceration was made in the accident and emer-gency unit. The child was evaluated with complete bloodcount laboratory test, moved directly to the operation the-ater, and prepared for wound debridement with a primarywound closure operation.Under general anesthesia with orotracheal intubation,
the patient was placed in the supine position on the op-eration bed. Margins of avulsion and lacerations wereshaved to about 3 cm from the edges of the wound, thescalp was washed thoroughly with about 100ml of Sav-lon® (Johnson & Johnson, Bangladesh) antiseptic solu-tion, and irrigation was performed with 1000ml ofnormal physiologic saline (Fig. 1b). After excision ofgranulation and necrotic tissues, surgical markings weredrawn, and incision sites were injected with 2 % lido-caine with 1:100,000 epinephrine (Huons, Seoul, Korea).
Fig. 1 Clinical photos of case 1, a 5-year-old child that was hit by a motorbskull periosteum. The design of the advancement skin flap was showed; deflap incision (white dotted line), the undermining of aponeurotic layer (lonposterior auricular artery (2), and occipital artery (3). Post-operative 1-day viclosure suture of the primary wound (black arrows), closure suture of anterundermining areas. d A view at 7 days’ post-operative
A bilateral anteroposterior regional scalp flap was raisedand advanced to cover the defect by careful dissection ofunderlying aponeurotic tissue to reduce raised flap ten-sion. Then, non-absorbable 2-0 Nylon® (Ailee, Busan,Korea) suture material was used to oppose the subcuta-neous edges of the wound to close the defect (Fig. 1c).Simple interrupted skin suturing was executed on theapproximate flap without introducing tension within theflap. The wound was dressed with povidone-iodine solu-tion and covered with sterile gauze and bandage. Anti-biotic therapy was administered, and the wound wasdressed daily. After continuous daily wound dressing forabout 12 days, stitches were carefully removed; the pa-tient had uneventful healing with a patch of alopecia oc-curring at the junction of the frontoparietal junction ofthe flap (Fig. 1d).
Case 2: a 40-year-old female with a degloving scalp injurydue to motorcycle accidentA 48-year-old female presented at the accident andemergency unit with an avulsion scalp injury after shewas involved in a motor accident as an unrestrained pas-senger (Fig. 2a). She had a 10 × 12-cm-sized frontoparie-tal defect that was thoroughly debrided and irrigatedwith normal saline in the emergency unit.The patient was moved immediately to the operation
theater for delicate debridement with a primary closureoperation under general anesthesia. The actual defectwas revealed after thorough debridement to remove allnecrotic tissue (Fig. 2b), and the surgical site was shavedwith a number 11 surgical blade and marked. Aninferior-based rotational advancement scalp flap wasplanned and designed, and the flap was incised and ele-vated in the loose connective tissue plan deep to thegaleal aponeurosis. Careful incision of the galea was per-formed at regular minimal intervals to avoid iatrogenicinjury to the scalp arterial blood supply. Approximationof the galea was conducted with monofilament
ike. Pre-operative upper (a) and lateral (b) views showing exposedbridement of the infected tissue (black arrowheads), the anterolateralg arrows), and scalp arteries including superficial temporal artery (1),ew with advancement skin flap coverage (c) showing appropriateolateral flap incision (white arrows), and shadow marking of the
Fig. 2 Clinical photos of case 2, a 40-year-old female with a degloving scalp injury due to a motorcycle accident. Pre-operative lateral view afterwashing (a). Exposed scalp structure at the skin degloving state showing the flap margin (white dotted line) with a minimized additional incisionline (b), and the rotation and closure of the advancement skin flap (black dotted line and arrows) after wound debridement (c)
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absorbable 3-0 Vicryl® (Johnson & Johnson, Busan,Korea) suturing to ensure minimal tension on thewound. The flap was planned to be slightly longer thanthe defect, and bilateral advancement flaps were used tocover the main scalp defect (Fig. 2c).A pressure dressing was applied to the surgical wound
immediately after surgery and removed after 1 day. Heal-ing involved partial flap necrosis at the ipsilateral supra-orbital region that was debrided and redressed daily.The patient was discharged from the hospital on the 7thpostoperative day after daily wound management care(Fig. 3). After continuous wound dressing for about 14days, stitches were carefully removed. The patient haduneventful healing without alopecia or loss of ear or eyefunction (Fig. 4).
Case 3: a 55-year-old female with a depressed fronto-temporal bony fracture after being thrown off amotorbikeA 55-year-old woman was rushed to the accident andemergency unit of Brong Ahafo Regional Hospital afterbeing thrown off a motorbike on which she was ridingas a passenger without a helmet. She lost but laterregained consciousness upon arrival at the emergencyunit. Detailed clinical examination revealed a middle-aged woman lying supine in bed, anicteric, afebrile, and
Fig. 3 Clinical photos of case 2 at 7 days post-operative: lateral (a), frontal (
not pale. She was not in respiratory distress, demonstrat-ing adequate air entry into both lungs with a respiratoryrate of 23 cpm, a blood pressure of 135/64 mmHg, apulse rate of 82 beats/min, and a Glasgow Coma Scaleof 15/15. She also had multiple facial abrasions with adegloving left scalp injury that extended from thefrontal through the supraorbital to the left temporalregion and an open depressed fronto-temporal skullfracture (Fig. 5a). A computed tomography scan ofthe head indicated an open fronto-temporal skullfracture and deep scalp laceration with bilateral max-illary sinus hemorrhage.Thorough debridement of the degloving scalp injury
was performed in the operation theater (Fig. 5b). Openreduction and direct fixation were performed usingmicro-miniplates and screws for the open depressedfronto-temporal skull fracture. Two-layered scalp closurewas performed using a 2-0 multifilament polyglactic acid(Johnson & Johnson, Busan, Korea) and 2-0 Nylon®(Ailee, Busan, Korea) suture for connective tissue re-arrangement and skin adaptation, respectively (Fig. 5c,d). A pressure dressing with head bandages was appliedto the surgical wound. Stitches were removed after 12days of continuous daily wound dressing; healing wasuneventful, and she did not experience neurologic com-plications during the first 18 months of follow-up.
b), and upper (c) views
Fig. 4 Clinical photos of case 2 at 40 days post-operative: frontal (a), lateral (b), and oblique upper (c) views
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DiscussionScalp layers are comprised of the following components:(1) the skin, which is thick and hair-bearing and containsnumerous sebaceous glands; (2) connective tissue, whichis referred to as the superficial fascia, a fibro-fatty layerthat connects the skin to the underlying aponeurosisand provides a passageway for nerves and blood vessels;(3) epicranial aponeurosis, or galea aponeurotica, whichis a thin tendinous structure that provides an insertionsite for the occipitofrontalis muscle; (4) loose areolar tis-sue, which loosely connects the epicranial aponeurosisto the pericranium and allows the superficial three layersof the scalp to move over the pericranium; and finally,(5) pericranium, which is the periosteum of the skullbones and is continuous with the endosteum [1–4].Reconstruction of a scalp injury is difficult due to the
complexity of the underlying skeleton, inelasticity of thescalp skin such as the galea aponeurotica and paucity ofadjacent tissues [3]. Basically, would closing starts fromapproximation of the aponeurotic layer with continuousabsorbable suture materials, and then full-thickness sim-ple or mattress sutures could be considered and com-bined with hemostasis. However, if there is a scalpdefect from severe trauma or an accident, representativerotation or advancement along the loose areolar tissue isrecommended and occurs in most cases [5–7]. Our pre-sented cases had large-sized defect in the anterior and
Fig. 5 Clinical photos of case 3, a 55-year-old female with a depressed fronoperative view showing frontal and temporal bone fractures with torn periduring surgery (b), and flap closure state after plate fixation and layer appr
lateral scalp region, for which a sliding advancement flapafter wide undermining was recommended. Although afull-thickness skin graft or other skin grafts, includinghair follicles, are treatment options, these procedureswere not possible in the low-resource hospital environ-ment in this article.The rural areas of Ghana, West Africa, lack medical
facilities or medical support items and do not employmaxillofacial specialties. Although accurate statistics arenot available, many disadvantages, including traffic andclimatic conditions including repeated heavy rain duringthe rainy season, can result in fatal accidents and in-crease the number of life-threatening facial injuries. Inaddition, terminal scalp hair characteristics differ ac-cording to ethnicity, such as diameter, cross-sectionalshape, and general appearance [8]. The hair of thosewith African ethnicity typically has an elliptical andribbon-like shape with a curly appearance, which is ad-vantageous during scalp injury management comparedwith straight or wavy characteristics typical of Asians orCaucasians [https://en.wikipedia.org/wiki/Hair_follicle].Regardless of scalp skin thickness, excessive tension
should be considered [7], and a rotational flap with orwithout advancement based on vascular anatomy couldbe considered [9]. Bilateral advancement flaps for recon-structing medial or large scalp defects could be consid-ered, as in our cases. Additionally, accurate debridement
to-temporal bony fracture after being thrown off a motorbike. Pre-osteum and subgaleal layers (a), cleaned state after debridementoximation (c, d)
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of devitalized tissue with correct approximation of epi-cranial aponeurosis should be confirmed in every scalpinjury patient. In literature, the recommended timing ofstitch removal in the scalp is 7 to 10 days [10]. In ourcases, the stitches were removed after 10 to 14 days toensure the adequate healing of the wound. The follow-up visit was made at 1 week; 1, 3, 6 months; and 1 yearand 2 years postoperative.Due to the circumstances, randomized controlled trials
cannot be conducted in these emergency situations, andsterile irrigation is not sufficient for cleaning wounds ofdebris but does dilute bacterial load before closure inscalp injury management. A Cochrane review supportsthe use of potable tap water, as opposed to sterile saline,for wound irrigation [11]. In addition, the use of cleannonsterile gloves, rather than sterile gloves, duringwound repair management has little influence on therate of subsequent wound infection. At presentation, lac-erations are considered to be contaminated, and physi-cians should make every effort to avoid introducingadditional bacteria to the wound [11]. In most cases,physicians wear protective masks and gloves to try andmaintain strict sterile environments; therefore, to furtherunderstand patient history, physicians and hospital staffshould try to obtain a detailed history, including tetanusvaccination and previous allergies, and determine thetiming and situational circumstances to optimize treat-ment of scalp injury patients.
ConclusionsScalp injury management is considered very difficult,and the procedures demand careful attention to performquick and accurate diagnoses and operations. Patientswith wide, large scalp defects located in the frontal orparietal regions cannot achieve primary closure withouta wide undermining. Oral and maxillofacial surgeonsshould be active and prepared to assist in any situationas specialists who can immediately diagnose and treatthese head injuries based on their extensive knowledgeand experience with the maxillofacial skin, muscles, andmasticatory muscles. Fundamental management of theseinjuries is very important to optimize patient care andoutcomes.
AcknowledgementsThis research was supported by Basic Science Research Program funded bythe Ministry of Education (2017R1D1A1B04029339) and by grant no 03-2019-0043 from the SNUDH Research Fund.
Authors’ contributionsAll authors read and approved the final manuscript. P read and wrote theentire manuscript preliminary, TTH revised and corrected the manuscript, ESand EK prepared patient data and prepared for journal submission, and SMdesigned and wrote the entire manuscript finally.
FundingThere is no funding related to this article.
Availability of data and materialsData sharing is not applicable to this article as no data sets were generatedor analyzed during the current study.
Ethics approval and consent to participateThe study protocol and access to patient records were approved by theInstitutional Review Board of Seoul National University (S-D20200021).
Consent for publicationWritten informed consent was obtained from the patient for publication ofthis case report and accompanying images
Competing interestsThe authors declare that they have no competing interests.
Received: 7 November 2020 Accepted: 25 November 2020
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