Scalp Repair Techniques

Robert W. Smith, MD, MBA, FAAFP and E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: Scalp Repair Techniques

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Introduction

Because the scalp contains one of the richest vascular supplies in the body, traumatic or surgical wounds there present special challenges for bleeding control. When scalp bleeding cannot be controlled with pressure, other emergent interventions must be applied often without sophisticated equipment. Scalp bleeding in the elderly can be especially brisk and life threatening. Two emergent field methods to control scalp bleeding and to approximate tissues are presented in this chapter: the hair-tying technique and the fishing line technique. A rapid hemostatic suture technique is described for management in controlled settings. These techniques are suitable for situations when hemostasis is immediately required. 
There are five layers to the scalp: the skin, subcutaneous tissue, musculoaponeurotic layer (i.e., galea), loose aponeurotic tissue, and periosteum. Hair roots are easily identified and must not be damaged when moving scalp wound edges. If undermining is required to close a wound, it should be performed close to the fat-galea junction, not near the lower dermis. Fibrous bands called retinacula in the subcutaneous layer provide support for blood vessels keeping them open when they are cut. This adds to the bleeding from scalp wounds. 
A single layer closure can usually be performed in the office or emergency room setting as the deep scalp tissues often are adherent to the skin. Large needles and large-diameter suture materials (e.g., 3-0 Prolene with FS-1 cutting needle) are selected for use on the scalp as they grasp a greater amount of tissue and, when tied, firmly to assist in hemostasis. Excessive trimming of a macerated wound can create wider wounds and excessive tension. 
Although many physicians have been instructed not to place crossing or “locking” stitches in skin, the scalp suturing technique demonstrated in this chapter involves placement of a skin suture that crosses. Although crossing sutures are appropriately avoided in many body locations to prevent avascular necrosis, the highly vascular scalp rarely experiences blood flow problems and necessitates a reliable hemostatic suture. 
The musculoaponeurotic layer contains muscle between two facial layers in the forehead and occipital regions. The muscle is absent on the top of the head, and the two fascial layers fuse into the fibrous sheet known as the galea. The space beneath the galea is known as the danger space as hematomas or infections can accumulate beneath the galea. Anesthesia is always administered above the galea because the nerves are superficial to it, hematomas (and abscess) can be avoided and the fluid will not dissect to other areas such as the periorbital tissues as it would if it were injected more deeply. 
If defects are found in the galea, they should be closed with interrupted absorbable sutures to prevent wounds with retracted skin edges and larger, thicker final scars. Tissue loss in the galea may require special intervention, because closure is difficult without scoring the surrounding galea. This will provide some stretch to help cover the defect. Pressure bandages or drains can be used to minimize subgaleal fluid accumulation. 
It is not recommended to remove hair when performing scalp repair. Shaving the scalp is associated with higher skin infection rates, and patients often are unhappy with the short term cosmesis. Hair can be taped away from a wound or tincture of benzoin can be used to chemically hold hair away from a surgical site. 
Although tissue glues are valuable on many areas of the body, they are more difficult to utilize and may not often provide adequate hemostasis on the scalp for larger wounds. Smaller wounds, however, can be managed by the hair apposition technique (HAT). One study demonstrated good cosmetic and functional outcomes with scalp closure using tissue glue in association with this technique. The sides of the wound are brought together using a single twist of hair and the hair was secured with the glue. The study demonstrated superior patient acceptance and less scarring with this closure technique. 
When performing elective procedures on the scalp (e.g., biopsy), 2% Lidocaine with epinephrine should be utilized for anesthesia. This will control bleeding and providing adequate anesthesia for the entire procedure. 

Equipment

  • The standard instruments used for office surgery are also used for scalp repair techniques (see Appendix G).

  • Suggested suture removal times are listed in Appendix J.

  • A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.

  • Skin preparation recommendations appear in Appendix E: Skin Preparation Recommendations.

  • Large sutures with large needles should be available

  • For field use, a large bore needle, fishing line, hairspray and epoxy can be utilized.

Indications

  • Scalp lacerations

  • Surgical wounds of the scalp

Contraindications

  • Patient with other conditions of greater life threat that require stabilization

  • Suspicion of underlying skull fracture

  • Evidence of foreign body in the wound which cannot be removed

The Procedure

Step 1

On-field First Aid can be performed for bleeding scalp wounds by twisting nearby hair and then tying the hair over the top of the wound. If a spectator or observer has hair spray, vigorously spray the tied hair to maintain the knot until arrival at a medical facility. 

Step 2

Keep a large hypodermic needle in the tackle box. If a laceration occurs in the field, the needle can be threaded through both wound edges. 

Step 3

Fishing line can then be threaded through the needle. 

Step 4

The needle is withdrawn with the line remaining within both wound edges. 

Step 5

The fishing line is tied. This technique usually provides very satisfactory closure with few infections because of the highly vascular scalp. 

Step 6

When giving anesthesia before repair of a scalp laceration, it is often less painful to inject through the laceration than doing a field block through uninjured skin. 

Step 7

Closure of a galeal defect in the base of a scalp wound is achieved with a figure-of-eight pattern using absorbable suture (see next steps). If there is tissue loss of the galea, consider scoring the galea to provide relaxation. 
  • PITFALL: When scoring the galea is required, the work is often done under sterile conditions.

Step 8

The hemostatic scalp suture is a simple, figure-of-eight closure. The suture is passed from the right side of the wound to the left side but not tied. 
  • PEARL: A smaller 4-0 nylon suture may be more appropriate in children.

  • PEARL: Ensuring that the wound is clear of all debris will reduce complications in the post procedure period.

Step 9

Move down the wound edge the width of the suture, and again pass the suture from the right side to the left side. 

Step 10

Tie the suture, with the suture strings crossing over the top of the wound in an X-shape configuration. 
Step 10
Step 10

Step 11

If the clinician does not like the suture crossing over the top of the wound, the suture can be made to cross beneath the surface. Pass from the right side of the wound to far down the left side of the wound. Do not tie the suture ends. 
Step 11
Step 11

Step 12

Then pass from far down the right side of the wound to the near point on the left side. 
Step 12
Step 12

Step 13

The suture should exit the skin on the left side across from where it first entered on the right side. Tie the suture, with the crossing of the suture threads beneath the wound. 
  • PEARL: A pressure bandage can be placed to reduce the likelihood of hematoma.

  • PEARL: Cleansing blood and debris from the surrounding hair at the time of the procedure will make the patient less likely to want to wash his or her hair immediately upon going home.

    Step 13
    Step 13

Complications

  • Excessive bleeding

  • Infection

  • Abscess (rare)

  • Scarring

  • Permanent hair loss

Pediatric Considerations

Assure the parent or guardian that there are appropriate numbers of personnel available to safely hold the child while the intervention is taking place. Do not attempt to suture the scalp while dealing with a “moving target” or close approximation will not take place and a more significant scar will occur. Proper approximation at the right level requires direct visualization of layers. A smaller 4-0 nylon suture may be more appropriate in children. 

Postprocedure Instructions

Routine instructions on follow-up for signs of significant head injury should be given to the patient and/or parent. The patient should not get the wound wet for at least 48 hours, as this will increase the likelihood of macerated wound edges and infection. Beyond that, every effort must be made to keep the wound dry. 
Suture removal should be scheduled in 7 days for most scalp repairs. 

Coding Information and Supply Sources

Bibliography

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Hock MO, Ooi SB, Saw SM, et al. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study). Ann Emerg Med.  2002;40:19–26. [View Abstract]
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