The scalp contains one of the richest vascular supplies in the body. Traumatic or surgical wounds to the scalp present special challenges for bleeding control. Medical personnel are often asked to intervene in emergency situations in which scalp bleeding cannot be controlled with pressure. Immediate action may be required away from medical services or equipment such as on an athletic field. 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.
The scalp includes five layers: the skin, subcutaneous tissue, musculoaponeurotic layer (i.e., galea), loose aponeurotic tissue, and periosteum. Hair follicle bulbs often are found in the subcutaneous layer; these hair roots must not be damaged when moving scalp wound edges. Undermining of the scalp should be performed close to the fat-galea junction, not near the lower dermis. The subcutaneous layer contains fibrous bands called retinacula. The retinacula connect the skin to deeper scalp layers and provide support for blood vessels. The retinacula help to keep blood vessels open when they are cut, adding to the bleeding from scalp wounds.
Closure of scalp lacerations in an office or emergency room setting is usually performed in one layer, because the deep scalp tissues often are adherent to the skin. Large needles and large-diameter suture materials (e.g., 3-0 Prolene) are selected for use on the scalp. The large needles can grasp a greater amount of tissue, and the larger-diameter suture can be tied firmly to assist in hemostasis. Minimal trimming of macerated wound edges is recommended, because excessive trimming can create wider wounds and excessive tension at closure.
The scalp suturing technique demonstrated in this chapter involves placement of a skin suture that crosses. Many physicians have been instructed not to place crossing or “locking” stitches in skin. This instruction is based in a concern for avascular necrosis induced by the crossing suture material. Although crossing sutures are appropriately avoided in many body locations, the highly vascular scalp rarely experiences blood flow problems and necessitates a 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; hematomas or infections can
accumulate beneath the galea. Anesthesia is always administered above the galea because the nerves are located above, and fluid beneath can dissect to other areas such as the periorbital tissues.
If defects are found in the galea, they should be closed with interrupted absorbable sutures. Failure to close the galea in large scalp lacerations often results in wounds with retracted skin edges and larger, thicker final scars. Tissue loss in the galea often precludes direct closure and may require special intervention. One technique used for this problem is to score the surrounding galea to provide some stretch to help cover the defect. Pressure bandages or drains can be used to minimize subgaleal fluid accumulation.
It is recommended that hair not be removed when performing scalp repair. Shaving the scalp is associated with higher skin infection rates, and patients often are unhappy when clipping leaves large hairless areas. The hair can be taped away from a wound, or common agents in the physician's office (e.g., tincture of benzoin) can be used to chemically remove hair from a surgical site.
The hair apposition technique (HAT) study demonstrated good cosmetic and functional outcomes with scalp closure using tissue glue. Patients had the sides of the wound brought together using a single twist of hair, and then the hair was secured with the glue. The study demonstrated superior patient acceptance and less scarring with this closure technique.
On-field first aid can be performed for bleeding scalp wounds by twisting nearby hair (Figure 1A) and then tying the hair over the top of the wound (Figure 1B). If a spectator or observer has hair spray, vigorously spray the tied hair to maintain the knot until arrival at a medical facility.
(1) The emergent field technique of hair tying.
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 and fishing line threaded through the needle (Figure 2A). The needle is withdrawn with the line remaining within both wound edges. The fishing line is tied (Figure 2B). This technique usually provides very satisfactory closure with few infections because of the highly vascular scalp.
(2) The emergent field technique of fishing line closure.
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 (Figure 3A). Move down the wound edge, and again pass the suture from the right side to the left side (Figure 3B). Tie the suture, with the suture strings crossing over the top of the wound in an X-shape configuration (Figure 3C).
(3) The hemostatic scalp suture.
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 (Figure 4A). Do not tie the suture ends. Then pass from far down the right side of the wound to the near point on the left side (Figure 4B). 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 (Figure 4C).
(4) A variation of the hemostatic scalp suture.
Closure of a galeal defect in the base of a scalp wound is achieved with a figure-of-eight pattern using absorbable suture.
(5) A figure-of-eight, absorbable suture closure of a galeal defect in the base of a scalp wound.
If there is tissue loss of the galea (Figure 6A), consider scoring the galea to provide relaxation.
(6) If there is tissue loss of the galea, consider scoring the galea to provide relaxation.
The repair codes used for these techniques are found in Chapter 14.
INSTRUMENT AND MATERIALS ORDERING
The standard instruments used for office surgery are also used for scalp repair techniques (see Appendix A). Suggested suture removal times are listed in Appendix C, and a suggested anesthesia tray that can be used for this procedure is listed in Appendix G. Skin preparation recommendations appear in Appendix H.
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