Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 9:
Scalp Transplantation Between Twins
  When the recipient vessels were ready and the donor scalp flap dissection completed, the flap was brought to the recipient twin. End-to-end microsurgical anastomoses were performed between the occipital artery of the flap and the superficial temporal artery of the recipient twin. The scalp flap vein was found to be fibrotic, and a smaller superficial scalp vein was anastomosed for venous drainage. The transplanted flap was inset over a Jackson-Pratt drain. The donor site was also closed over this type of drain. The donor twin had an uncomplicated postoperative course. The recipient twin, however, evidenced venous congestion several hours after surgery. The flap vein was felt to be too small and fragile to provide adequate outflow, and a more suitable vessel was not available. Venous insufficiency was therefore treated by use of leeches (see Chap. 40) which immediately improved the flap circulation as shown by return of normal pink color and capillary refill time. It was felt that the vasodilation, anticoagulants, and mechanical decompression activity of the leeches enhanced the flap perfusion and were largely responsible for its survival.


Several important principles are illustrated by this case. First, as Gillies suggested, whenever possible like should be replaced with like, and in this instance, as in their previous operations, the scalp of the donor twin was used to reconstruct the lost scalp of the recipient twin. To provide a larger flap, the skin expansion was used to expand the donor flap before transplantation. Not only did this increase the size of the flap and allow primary closure of the donor site, but the expansion may have enhanced the vascularity of the flap, perhaps in a way akin to the delay phenomenon. Expansion is particularly important when other techniques such as local flaps and free grafts are unavailable or unsatisfactory.


As alluded to in our previous report, this case of multiple flap transplantations between identical twins demonstrates the potential for greatly expanding the number of donor sites and the wide possibilities for microsurgical reconstruction once the problems of immunoincompatibility are resolved.

Clinical Case

A 23-year-old woman, one of a pair of identical twins, suffered an avulsion of the scalp, which failed to take when replaced as a free graft.

FIG. 9-01. A healed wound after skin grafting left the patient with only 40% of her hair-bearing scalp and unstable skin graft cover. Front view.

FIG. 9-02. Top view.

FIG. 9-03. Reconstruction was performed by a first-stage transplantation of a 3 1/2 x 17 cm free scalp flap donated by the patient's identical twin sister, based on the right superficial temporal artery. Donor flap outlined.

FIG. 9-04. Donor flap isolated on superficial temporal vessels.

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