A Retrospective Review and a Discussion of Treatment Options for Complicated Scalp Injuries and
Avulsions at a Level I Trauma Center
Brian A. Janz, MD, Marcus J. Ko, MD, Ramon Garza, BA, C. Bob Basu, MD, MPH
Background: Scalp avulsions are relatively rare injuries but plastic and reconstructive surgeons are commonly
called on to either acutely manage or assist with reconstructive management of these injuries. The types of
injuries can range from a simple avulsion with an adequate blood supply to a complete avulsion necessitating a
microvascular reconstruction or free tissue transfer for coverage. The type of reconstructive options for such an
injury depends not only upon the type, size, and location of injury but also the available vascular supply to the
involved tissue.
While there are numerous publications describing the treatment of scalp defects [1-4] and injuries, review of the
literature reveals that there is no standard classification system established for describing traumatic scalp injuries.
Therefore, we set forth to accomplish two goals: 1. Present a scalp injury classification system that can be used
both to accurately and systematically describe a traumatic scalp injury; 2. Describe our experience with scalp
injuries at a Level I tertiary trauma center and present a treatment algorithm based on our classification schema.
Methods: This retrospective study was conducted at a major level I trauma center over a seven year period
spanning the years from 1999 to 2006. Patients were initially selected by reviewing the hospital ICD-9 codes for
complex scalp injuries. Ninety random charts over that time period were then reviewed to verify the diagnosis of a
complex scalp injury and / or avulsion. Injures were then graded on severity based on the type of injury. Type I-A
injuries included any laceration that violated the galea aponeurosis which exposed the deep loose areolar
connective tissue. An injury in which skin is "torn" partially or fully away is classified as an avulsion. A Type I-B
injury includes all avulsions where the tissue is partially torn from the scalp but an adequate blood supply remains
and there is no tissue deficit. The type II avulsion injury includes all partial avulsions where the involved tissue is
either non-viable or there is a partial tissue deficit (avulsion-abrasion injuries). Type III injuries include all
avulsions that involve amputated tissue with a resultant tissue deficit.
The classification scheme groups injuries based on the anticipated reconstructive plan. Type I-A and I-B injuries
can range from very small lacerations / avulsions to relatively large injuries, but they are treated similarly because
the involved tissue has an adequate blood supply. Type II injuries involve either a tissue deficit or ischemic /
nonviable tissue. These injuries, if small, can be treated with local tissue rearrangement or advancement flaps. If
the injury is more extensive then the treatment mirrors that of type III. Type III injuries, due to the complete
avulsion of tissue, can be treated with local tissue flaps, composite grafting of the avulsed tissue, microvascular
repair, tissue expansion, or free tissue transfer dependant on the severity of the lesion.
Results: The mean age of the ninety subjects reviewed in the study was 33.2 ± 15.9 (mean ± SD) years. The
vast majority (70%, n = 63) of subjects were between the ages of 20 and 50 and 75.5% (n = 68) were male. The
major cause of injury (49%, n = 44) was due to motor vehicle crashes (MVC), while the second major cause was
related to personal assaults (36%, n = 32). Pedestrians struck by automobiles accounted for 7% (n=6) of the
injuries while a compilation of ‘additional injuries’ (chain saws, falls, etc.) only accounted for 9% (n = 8) of the
cases. Of the subjects involved in motor vehicle crashes, data was available on the location of the patient within
the car for 35 of the 44 cases. In these cases, 68.6% (n = 24) of the 35 patients were positioned in the drivers
seat.
Injuries were associated with alcohol use 32.2% (n = 29) of the time and illicit drugs in 10% (n = 9) of the cases.
As expected, most scalp avulsions were accompanied by additional injuries, 57% (n = 51). Although initial loss of
consciousness was recorded in 28% of the cases (n=25), documented closed head injury by CT scan was only
seen 13% (n=11) of the time. Associated C-spine fractures were diagnosed radiographically in 7 patients (8%)
and concomitant craniofacial fractures were only seen in only 2 patients (3%). Additional soft tissue injuries
occurs in 41% of the cases (n = 35) and fractures not including head or neck were seen 12% of the time (n = 11).
Additional non-classified major injuries (splenic lacerations, intraperitoneal stab wounds, etc.) occurred in 4% of
the cases (n=4).
The frontal region of the head was involved the majority of the time, most likely because of the high number of
injuries related to motor vehicle crashes (30%). The parietal and occipital regions were the next two commonly
involved regions both occurring greater than 20% of the time.
In this study, 90 patients were chosen for review over a 7 year period (Table I). The vast majority of patients had
injuries which could be closed primarily without the need of local flaps or additional reconstruction. Local tissue
transfer, composite grafts or tissue expansion were used in less than 5% of the cases.
Classification
Type
%
N
I-A
48.9
44
I-B
46.7
42
II
3.3
3
III
1.1
1
Table I: Classification of Complex Scalp Lesions
Type I-A:
Type I-A scalp injuries include deep laceration that enter into the loose areolar tissue deep to the galea
aponeurosis but are not avulsion type injuries. Forty-four (48.9%) patients with a mean age of 35.8 ± 18.5 in the
study had injuries classified at Type I-A. The mean injury size, which was available for 41 of the 44 patients, was
6.4 ± 2.9cm. The mean Glascow Coma Scale on presentation to the emergency department for this group was
14.5 ± 2.1 cm. Initial loss of consciousness (LOC) was documented in 16 (36.45) cases. Intravenous
resuscitation was initiated in only 11 of 44 patients. The mean total intravenous fluid administration was 1013.6 ±
403.2 cc. Forty-two of the 44 patients were treated in the emergency department with either a multi-layer closure
or with the use of staples. Two patients were treated in the operating room due to additional concomitant injuries.
Type I-B:
Type I-B injuries are similar to I-A, but involve a tearing or laceration of the tissue in such a way that a
skin paddle or segment is created. The average age for the 42 (46.7%) patients with injuries classified as type I-B
was 31 ± 13.1. The mean injury size, which was documented as a length of avulsed tissue, was 15.4 ± 10.1 cm.
Patients with Type I-B injuries had an initial emergency department GCS score of 14.6 ± 0.94. 35.7% of the
patients had a documented LOC at the time of the injury. Seventeen of the 33 patients were resuscitated with
intravenous fluids in the emergency department with a mean volume of 1567.6 ± 1145.2 and no blood products
were required for any resuscitation. 71.4% of the injuries were treated in the emergency department, while 28.5%
(n = 12) of the patients were repaired in the operating room. The complication rate in this group was 7.1% (n=3)
with two related to wound infections and one related to a wound dehiscence.
Type II:
Type II injuries are avulsions which result in an inadequate blood supply to part of the flap or a moderate
size tissue defect, either of which would require a form of soft tissue coverage. The three patients with Type II
injuries had a mean age of 39.2 ± 8.5 years. The average injury size was 300 ± 86.6 cm 2. The mean initial
resuscitation volume was 1000 cc of crystalloid and once again, no blood products were required during the initial
resuscitation. All three patients were successfully treated in the operating room with rotational advancement flaps
or adjacent tissue transfer. No major complications were recorded for this group of patients.
Type III:
Only one patient in this study was classified as a Type III injury, which involves the complete amputation
of tissue. The injury was due to a motor vehicle accident and the involved area encompassed a 150 cm 2 area of
scalp. The patient was treated in the operating room and since there were no identifiable vessels for replantation
and the majority of pericranium was intact, the tissue was reattached as a composite graft. At a four-month
follow-up, the composite graft had a 100% take with alopecia only seen at the suture lines. No additional
surgeries were required for the treatment of this patient.
Conclusion: In this study, the vast majority of injuries were either type I or II-A. Both injury types I and II-A can
be repaired in the emergency department with a low associated complication rate. Type II-B and III injuries are
best treated in the operating room and usually require a local tissue transfer, flap or free tissue transfer for
closure, dependant on the type of injury. The majority of cases were related to motor vehicle accidents and as
expected the frontal region was commonly involved. When evaluating these injuries, it is important to remember
that greater than 50 percent of the cases are associated with additional injuries and that 8 percent are associated
with C-spine injuries necessitating a thorough physical exam and appropriate imaging. A significant number of
cases were also associated with alcohol or illicit drugs which can hinder the initial examination for concomitant
injuries. Regardless of the type of injury or repair utilized, all cases were associated with a low complication rate.
References
1. Leedy JE, Janis JE, Rohrich, RJ. Reconstruction of acquired scalp defects: an algorithmic approach. Plast
Reconstr Surg, 116(4): 54e-72e, 2005.
2. Orticochea M. Four flap scalp reconstruction technique. Br J Plast Surg 20(2): 159-71. 1967.
3. Orticochea M. New three-flap reconstruction technique. Br J Plast Surg 24(2): 184-8. 1971.
4. Kazanjian VH. Repair of partial losses of the scalp. Plast Reconstr Surg 12(5): 325-34. 1953.