Delayed Total Scalp Replantation Following Catastrophic Blast: Success With Bilateral Single-vessel Anastomosis

Total scalp avulsion is a rare but severe injury that challenges both functional and aesthetic recovery. Microsurgical replantation is the gold standard treatment, though outcomes may be affected by prolonged ischemia and vascular complications. This case report details successful scalp replantation following a 15-hour ischemia period and delayed intervention, requiring comprehensive management. A 23-year-old woman presented with complete scalp avulsion 6 hours postinjury, caused by hair entanglement in a rotary turbine. Surgery was delayed to 12 hours postinjury due to the Beirut blast. Bilateral superficial temporal arteries and veins were anastomosed, and perfusion was restored 3 hours after the operation began. Postoperative venous congestion was managed successfully with re-exploration and vein grafting. Skin necrosis in the occipital and frontotemporal areas was managed with debridement, split-thickness skin grafting, and later, secondary reconstruction using tissue expanders and local advancement flaps. Despite using single-vessel anastomoses on both sides, the patient had excellent perfusion and successful replantation, highlighting the redundancy of the scalp's vascular network. Four years follow-up showed complete hair regrowth, no residual alopecia, and partial recovery of frontalis muscle function, despite the absence of direct nerve repair. Scar revision and fat grafting enhanced aesthetic outcomes, and no further complications were observed. This case demonstrates that, even with limited vascular repair, successful scalp replantation is achievable under challenging conditions. Our findings suggest that a streamlined approach may be advantageous in time-sensitive situations, provided meticulous surgical technique and vigilant postoperative care are maintained.