a major challenge in the successful replantation / revascularization of an avulsed scalp is positioning of the patient 's head during and after the operation , because : 
 possibility of shearing between scalp and skull when the head is moved / rotated intra - operatively , leading to tearing of anastomosed vessels ; andpost - operatively , the possibility of necrosis of scalp over pressure - bearing areas . 
  possibility of shearing between scalp and skull when the head is moved / rotated intra - operatively , leading to tearing of anastomosed vessels ; and post - operatively , the possibility of necrosis of scalp over pressure - bearing areas .
an 18-year - girl presented to us with near total scalp avulsion due to machine belt injury [ figure 1a ] .
halo frame  to stabilize the scalp during and after operation [ figures 1c , d and 2a ] .
( a ) pre - operative view of avulsed scalp ( b ) pre - operative view of avulsed scalp after shaving ( c ) immediate post - operative cranial view of scalp with halo device in situ , and ( d ) frontal view showing halo device in situ ( a ) picture showing assembled halo device ( b ) computed tomography scan axial view showing halo device 's screw engaging outer cortex of cranium ( c ) 2-month post - operative : lateral view showing marking for screw entry point and ( d ) 4-month postoperative : frontal view the device we used is a 10 mm thick aluminum bar bent into a u - shape .
it has multiple - threaded holes in the axial plane , through which stainless steel screws are passed .
the superficial temporal vessels were identified and tagged in the avulsed scalp and in both the pre - auricular regions.the scalp was put in place and stapled at multiple points maintaining access to the vessels through oblique incisions.the halo was attached to the skull , with the open end of the u facing anteriorly , using 4 screws [ figure 1c and d ] .
the marking for the placement of screws was done as follows [ figure 2c ] : all the 4 screws were placed in the same axial plane about 3 cm above the upper margin of the helix .
the anterior screws were placed about 4 cm in front of a vertical line passing through the root of helix , and the posterior screws about 3 cm behind this line .
these points were chosen to avoid the ( i ) thin squamous temporal bone , ( ii ) the previously marked anterior and posterior branches of the superficial temporal vessels , and ( iii ) the major venous sinuses.the screws were passed through small stab incisions in the scalp and gradually tightened by hand till the tip of the screw touched the outer table .
care was taken to rotate the screws in small increments , one after the other , so that all the 4 screws went to the same depth and the gap between the halo and the scalp was equal all around .
once the screw tip had touched the outer table , each screw was tightened further by one full turn ( 1 mm depth ) .
at this point the halo had a firm grip on the skull without the screws having penetrated the outer table fully [ figure 2b ] .
the vascular anastomoses were carried out , and the skin edges closed.only a small dressing was applied along the suture lines and around the 4 screw entry points , leaving the entire replanted scalp exposed for easy monitoring [ figure 1c and d ] . 
  the avulsed scalp was cleaned and shaved [ figure 1b ] .
the superficial temporal vessels were identified and tagged in the avulsed scalp and in both the pre - auricular regions .
the scalp was put in place and stapled at multiple points maintaining access to the vessels through oblique incisions .
the halo was attached to the skull , with the open end of the u facing anteriorly , using 4 screws [ figure 1c and d ] .
the marking for the placement of screws was done as follows [ figure 2c ] : all the 4 screws were placed in the same axial plane about 3 cm above the upper margin of the helix .
the anterior screws were placed about 4 cm in front of a vertical line passing through the root of helix , and the posterior screws about 3 cm behind this line .
these points were chosen to avoid the ( i ) thin squamous temporal bone , ( ii ) the previously marked anterior and posterior branches of the superficial temporal vessels , and ( iii ) the major venous sinuses .
the screws were passed through small stab incisions in the scalp and gradually tightened by hand till the tip of the screw touched the outer table .
care was taken to rotate the screws in small increments , one after the other , so that all the 4 screws went to the same depth and the gap between the halo and the scalp was equal all around .
once the screw tip had touched the outer table , each screw was tightened further by one full turn ( 1 mm depth ) .
at this point the halo had a firm grip on the skull without the screws having penetrated the outer table fully [ figure 2b ] .
the vascular anastomoses were carried out , and the skin edges closed . only a small dressing was applied along the suture lines and around the 4 screw entry points , leaving the entire replanted scalp exposed for easy monitoring [ figure 1c and d ] . post - operatively the patient 's head was allowed to rest on the halo , and the head end of the bed was kept elevated [ figure 1c ] . from the first post - operative day
the whole of the scalp survived except for the partial thickness loss of two small patches where there had been direct deep grazing injury .
the halo was removed at bedside , without any anesthesia , on the 14 post - operative day .
the superficial temporal vessels were identified and tagged in the avulsed scalp and in both the pre - auricular regions.the scalp was put in place and stapled at multiple points maintaining access to the vessels through oblique incisions.the halo was attached to the skull , with the open end of the u facing anteriorly , using 4 screws [ figure 1c and d ] .
the marking for the placement of screws was done as follows [ figure 2c ] : all the 4 screws were placed in the same axial plane about 3 cm above the upper margin of the helix .
the anterior screws were placed about 4 cm in front of a vertical line passing through the root of helix , and the posterior screws about 3 cm behind this line .
these points were chosen to avoid the ( i ) thin squamous temporal bone , ( ii ) the previously marked anterior and posterior branches of the superficial temporal vessels , and ( iii ) the major venous sinuses.the screws were passed through small stab incisions in the scalp and gradually tightened by hand till the tip of the screw touched the outer table .
care was taken to rotate the screws in small increments , one after the other , so that all the 4 screws went to the same depth and the gap between the halo and the scalp was equal all around .
once the screw tip had touched the outer table , each screw was tightened further by one full turn ( 1 mm depth ) .
at this point the halo had a firm grip on the skull without the screws having penetrated the outer table fully [ figure 2b ] .
the vascular anastomoses were carried out , and the skin edges closed.only a small dressing was applied along the suture lines and around the 4 screw entry points , leaving the entire replanted scalp exposed for easy monitoring [ figure 1c and d ] . 
  the avulsed scalp was cleaned and shaved [ figure 1b ] .
the superficial temporal vessels were identified and tagged in the avulsed scalp and in both the pre - auricular regions .
the scalp was put in place and stapled at multiple points maintaining access to the vessels through oblique incisions .
the halo was attached to the skull , with the open end of the u facing anteriorly , using 4 screws [ figure 1c and d ] .
the marking for the placement of screws was done as follows [ figure 2c ] : all the 4 screws were placed in the same axial plane about 3 cm above the upper margin of the helix .
the anterior screws were placed about 4 cm in front of a vertical line passing through the root of helix , and the posterior screws about 3 cm behind this line .
these points were chosen to avoid the ( i ) thin squamous temporal bone , ( ii ) the previously marked anterior and posterior branches of the superficial temporal vessels , and ( iii ) the major venous sinuses .
the screws were passed through small stab incisions in the scalp and gradually tightened by hand till the tip of the screw touched the outer table .
care was taken to rotate the screws in small increments , one after the other , so that all the 4 screws went to the same depth and the gap between the halo and the scalp was equal all around .
once the screw tip had touched the outer table , each screw was tightened further by one full turn ( 1 mm depth ) . at this point
the halo had a firm grip on the skull without the screws having penetrated the outer table fully [ figure 2b ] .
the vascular anastomoses were carried out , and the skin edges closed . only a small dressing was applied along the suture lines and around the 4 screw entry points , leaving the entire replanted scalp exposed for easy monitoring [ figure 1c and d ] .
post - operatively the patient 's head was allowed to rest on the halo , and the head end of the bed was kept elevated [ figure 1c ] . from the first post - operative day onwards ,
the whole of the scalp survived except for the partial thickness loss of two small patches where there had been direct deep grazing injury .
the halo was removed at bedside , without any anesthesia , on the 14 post - operative day .
from our experience of scalp replantation in the past , and as reported by others , replanted scalps are susceptible to shearing and avulsion , as well as pressure necrosis at occipital region .
one of the ways of avoiding these problems is to keep the patient in a sitting posture at all times .
once a scalp replant fails , it not only results in multiple stages of surgery , but also causes great financial loss and emotional trauma to the patient .
use of this halo device can make the intra- and post - operative management of scalp replantations easier and ensure more complete survivals [ figure 2c and d ] .
we present a new technique for stabilization of a replanted scalp and avoiding pressure on the scalp post - operatively .
this technique is safe , simple and has the additional advantage of avoiding a bulky dressing and allowing continuous easy monitoring of vascularity .
 we present a new technique for stabilizing an avulsed scalp during and after replantation / revascularization . 
 we used an aluminium  halo  frame with 4 screws . 
 this technique can rigidly stabilize an avulsed scalp and eliminate the possibility of shearing / pressure necrosis . 
 this device can make perioperative management easier and more comfortable for the patient and caregivers . 
INTRODUCTION
CASE REPORT
Operative steps
DISCUSSION
SUMMARY