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Table of Contents    
Year : 2020  |  Volume : 68  |  Issue : 6  |  Page : 1459-1461

Modified Method of Multiple Cranial Burr Holes for Treatment of Total Scalp Avulsion

1 Department of Neurosurgery, Bansal Hospital, Bhopal, Madhya Pradesh, India
2 Department of Plastic Surgery, Bansal Hospital, Bhopal, Madhya Pradesh, India

Date of Web Publication19-Dec-2020

Correspondence Address:
Dr. Harshad Patil
Department of Neurosurgery, Bansal Hospital, Bhopal, Madhya Pradesh – 462016
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.304076

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 » Abstract 

Scalp avulsion is a rare but severe injury. It usually happens while using industrial or agriculture machinery. Scalp avulsion results from hair entrapment in a rotating machine. There are various options for treatment of scalp avulsion. Herein, the authors present a case of total scalp avulsion which was treated by multiple trephination technique using neurosurgical burr.

Keywords: Microsurgical replantation, multiple burr holes, total scalp avulsion
Key Messages: Multiple large calvarium burr holes is also an effective method when microsurgical replantation is not possible.

How to cite this article:
Patil H, Rathore S, Garg N. Modified Method of Multiple Cranial Burr Holes for Treatment of Total Scalp Avulsion. Neurol India 2020;68:1459-61

How to cite this URL:
Patil H, Rathore S, Garg N. Modified Method of Multiple Cranial Burr Holes for Treatment of Total Scalp Avulsion. Neurol India [serial online] 2020 [cited 2021 Jan 16];68:1459-61. Available from:

Total scalp avulsion is a rare and catastrophic injury. It has serious consequence such as hospitalization, financial loss, devastating disfigurement, and psychological effects on the patient.[1]

It often occurs in females and caused by long hair getting caught in machinery. The treatment of choice for total scalp avulsion is microsurgical replantation. However, scalp coverage becomes a major problem when microsurgical replantation fails or contraindicated.[2]

Herein, the authors present a case of total scalp avulsion which was treated by multiple trephinations of calvarium using neurosurgical large burr.

 » Case Report Top

A 46-year-old female referred to tertiary care neurosurgical center after complete scalp avulsion. Her long hairs had been caught in an agricultural thresher machine. The patient was admitted almost 24 h after trauma. On admission, the patient was unconscious. A large part of the scalp was missing and periosteum was detached in some parts of the skull [Figure 1].
Figure 1: Total scalp avulsion

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Preoperative computed tomography head was normal. The patient also had anemia for that blood transfusion was given. In view of long time interval between trauma and surgery and the poor condition of the vascular bed, microsurgical replantation was not possible. So we decided to performed calvarium trephination. Multiple burr holes were made with help of neurosurgical pneumatic drill upto the diploe. During trephination, abundant saline irrigation was given to avoid heat trauma to the bone tissue. Surgical debridement was performed and split-thickness graft was applied over intact periosteum [Figure 2]. Occlusive dressing was done on every alternate day. Within three weeks, granulation tissue emerged through the burr holes and covered the calvarium [Figure 3]. A split-thickness skin graft was harvested from the thigh and covered the defect [Figure 4]. Postoperative period was uneventful. Two weeks later when dressing was removed, it showed complete uptake of graft without any graft necrosis [Figure 5].
Figure 2: Multiple calvarium trephinations with split thickness graft over intact periosteum

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Figure 3: Granulation tissue emerged through the burr holes and covered the calverium

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Figure 4: Split thickness skin graft applied over the defect

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Figure 5: Complete uptake of graft without any graft necrosis

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 » Discussion Top

Complete scalp avulsion is a rare, life-threatening injury which generally occurs when long hair is caught in rotating devices, such as agricultural or industrial machines. Sometimes, it occurs after bear maul or dog bite.[3],[4]

There are various options available for treatment of scalp avulsion. For small or medium defect primary closure, local flap, free flap, skin graft, and tissue expansion can be performed. For near-total or total scalp avulsion, treatment of choice is microsurgical replantation.[5] The first successful scalp replantation was reported by Miller et al. in 1976.[6] With the recent advances in microsurgery, management of scalp avulsion improved considerably by providing immediate, stable coverage with the detached tissue itself.[7],[8] However, replantation is not always possible due to a variety of factors such as severe shearing force causing extensive vessel intimal damage within the avulsed scalp, longer warm ischemia time (more than 30 h), and unfavorable preservation of the avulsed scalp.[9],[10]

In 1904, Mellish reported the first method of calvarium trephination.[11] Terzioğlu et al. proposed two alternative methods for reconstructing the scalp when the periosteum is not viable: (1) removal of the outer cortex of the skull and direct grafting on the cancellous bone and (2) drilling of the outer cortex of the skull upto diploe, aiming at granulation tissue formation and subsequent grafting.[12]

In 2000, Pitkanen et al. reported a one-stage surgical removal of the outer table of the skull with a high-speed drill, followed by immediate application of a skin graft over the bleeding bone.[13]

Later, many authors proposed various techniques of calvarium trephination. In calvarium trephination techniques, multiple burr holes are made with the help of pneumatic, electric, or hand drill upto diploe. During trephination, abundant irrigation should be given to avoid heat trauma to the bone tissue. Then an occlusive dressing is done on every alternate day. Gradually, granulation tissue starts emerging through the burr holes and covers the calvarium. After that, a split-thickness skin graft is applied over the defect. This whole procedure takes around 6–8 weeks.[11],[12],[14] In our case, we used large neurosurgical drill for making burr. After that, within three weeks granulation tissue covered the calvarium and skin grafting is done. This whole procedure takes only four weeks. Therefore, large neurosurgical drill is better than conventional drill.

 » Conclusion Top

Treatment of total scalp avulsion is difficult and challenging. Calvarium trephination is a safe and effective method for treating such type of injury when microsurgical replantation is not possible.

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Conflicts of interest

There are no conflicts of interest.

 » References Top

Plant MA, Fialkov J. Total scalp avulsion with microvascular reanastomosis: A case report and literature review. Can J Plast Surg 2010;18:112-5.  Back to cited text no. 1
Furlanetti LL, de Oliveira RS, Santos MV, Farina JA Jr, Machado HR. Multiple cranial burr holes as an alternative treatment for total scalp avulsion. Childs Nerv Syst 2010;26:745-9. doi: 10.1007/s00381-010-1145-7.  Back to cited text no. 2
Feierabend TC, Bindra RN. Injuries causing major loss of scalp. Plast Reconstr Surg 1985;76:189-94.  Back to cited text no. 3
Yin JW, Matsuo JM, Hsieh CH, Yeh MC, Liao WC, Jeng SF. Replantation of total avulsed scalp with microsurgery: Experience of eight cases and literature review. J Trauma 2008;64:796-802. doi: 10.1097/TA.0b013e3180341fdb.  Back to cited text no. 4
Desai SC, Sand JP, Sharon JD, Branham G, Nussenbaum B. Scalp reconstruction: an algorithmic approach and systematic review. JAMA Facial Plast Surg 2015;17:56-66. doi: 10.1001/jamafacial. 2014.889.  Back to cited text no. 5
Miller GD, Anstee EJ, Snell JA. Successful replantation of an avulsed scalp by microvascular anastomoses. Plast Reconstr Surg 1976;58:133-6.  Back to cited text no. 6
Biemer E, Stock W, Wolfensberger C, Ingianni G, Götz WD. Successful replantation of a totally avulsed scalp. Br J Plast Surg 1979;32:19-21.  Back to cited text no. 7
Yaffe B, Shvoron A. Successful replantation of a totally avulsed scalp. J Reconstr Microsurg 1986;2:171-3.  Back to cited text no. 8
Cheng K, Zhou S, Jiang K, Wang S, Dong J, Huang W, et al. Microsurgical replantation of the avulsed scalp: Report of 20 cases. Plast Reconstr Surg 1996;97:1099-108.  Back to cited text no. 9
Jia L, Li GP, You C, Li H, Huang SQ, Yang CH, et al. The epidemiology and clinical management of craniocerebral injury caused by the Sichuan earthquake. Neurol India 2010;58:85-9. doi: 10.4103/0028-3886.60406.  Back to cited text no. 10
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Mellish EJ. Total avulsion of the scalp. Ann Surg 1904;40:644-9.  Back to cited text no. 11
Terzioğlu A, Aslan G, Saydam M. Trephination in the treatment of scalp avulsion: Successful application of a historical method. J Oral Maxillofac Surg 1999;57:204-6.  Back to cited text no. 12
Pitkanen JM, Al-Qattan MM, Russel NA. Immediate coverage of exposed, denuded cranial bone with split-thickness skin grafts. Ann Plast Surg 2000;45:118-21.  Back to cited text no. 13
Singh P. Missile injuries of the brain: Results of less aggressive surgery. Neurol India 2003;51:215-9.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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