Successful Microsurgical Replantation of Scalp Amputation Using Medicinal and Chemical Leech Therapy: A Case Report

A 47-year-old woman presented to the hospital with a com- plete amputated scalp after her hair was caught in a laun- dry-packing machine. Compact compression dressing with gauze and elastic band was applied, owing to severe bleeding by completely ruptured both superficial temporal artery (STA) and superficial temporal vein (STV) (Fig. 1). The laceration ex- tended across the total scalp, forehead, both supratarsal fold, and levels I and II neck.

Upon arriving at the hospital, the patient received an initial evaluation and was stabilized in the emergency room. The pa- tient was immediately transported to the operating room after examination and exclusion of any other associated life-threat- ening injuries. The amputated scalp was rinsed with saline, and the total ischemic time was approximately 4 hours. The surgical procedures were performed under general anesthesia and distal vessels were identified under an operative microscope. The STA and veins were identified on the scalp first. Bilateral tem- poral arteries and veins were used as recipient pedicles. The temporal artery was dissected proximally in the patient and distally in the flap to mobilize as much length as possible for the reanastomosis. The left STA and STV were narrow and short, and additional anastomosis resulted in less blood flow without the use of vein graft. Thus, the vein graft was per- formed on the left temporal vein using the right posterior tibial vein with exploration.

Successful Microsurgical Replantation of Scalp Amputation Using Medicinal and Chemical Leech Therapy: A Case Report
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Fig. 1. Preoperative findings. (A) Completely amputated defect on
the scalp area. (B) Amputated stump.

MLT (three to four leeches per time) was performed four to six times a day to relieve venous congestion to maintain blood flow, and chemical leech therapy of 2-mg subcutaneous LMWH (40 mg of enoxaparin sodium; Clexane, Sanofi, Paris, France) was injected three times a day for 2 weeks after reanas- tomosis to manage severe venous congestion (Fig. 2). Continu- ous heparin-mixed wet saline gauze dressing was applied to prevent wound crust. The patient was massively transfused with packed red blood cells 5 days after reanastomosis with vein graft (mean volume, 1.12 L/day) and 4 more days thereaf- ter (mean volume, 1.1 L/day). The mean drainage volume (three drains on the scalp area and one drain on the neck area) after initial reanastomosis was 922.5 cm3 (range, 300 to 1,540 cm3) on the scalp area and 122.5 cm3 (range, 75 to 170 cm3) on the neck area until secondary operation. One negative pressure drain on the scalp area remained during the vein graft. The ini- tial drain was 1,600 cm3, which reduced gradually until 12 days postoperative removal (mean volume, 290 cm3; range, 10 to 1,600 cm3). The patient also underwent debridement twice and irrigation including wound revision during the period.

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Fig. 2. Severe venous congestion on the replanted scalp on postoperative day 2. (A) Anterior-posterior view, (B) left lateral view, and (C)
crown view.

The scalp mostly survived. However, partial skin necrosis developed in the lower left occipital area region. Therefore, the le- sion was debrided and reconstructed with a split skin graft 2 weeks after the operation. Exuberant hair was evident 2 months after the first operation, but the patient’s hair growth pattern was different on the sides. The right temporal area had greater hair growth compared with the occipital and the left temporal area of the scalp. At 3 years postoperative, hair had grown sufficiently in the rest of the scalp; approximately 85% of scalp flaps except the lower left occipital area of the scalp (Fig. 3). Several scar revisions were done on the neck and eyebrow for better aesthetic outcomes during 2 years postoperative.
Written informed consent for publication of the clinical images was obtained from the patient.

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Fig. 3. Postoperative findings after microsurgical replantation after 2 weeks (A), 6 weeks (B), and 4 months (C). Follow-up observation
was performed while continuing leech therapy. Venous congestion was improved in postoperative day 5, and wound healing was almost
completed at 2 weeks postoperative. The views of anterior-posterior (D) and posterior-anterior (E) after 3 years. Hair growth is observed
in approximately 85% of scalp flaps.