Galeal scoring for salvage scalp closure following cranioplasty failure: a case report

Abstract

Introduction

Achieving tension-free scalp closure after decompressive craniectomy or cranioplasty can be quite demanding, especially in patients who have developed fibrosis or infection from previous procedures. In such situations, galeal scoring (galeotomies) can improve scalp mobility. Although this technique is well known in plastic surgery, it is not commonly reported in neurosurgical work.

Case presentation

A 30-year-old man sustained a high-velocity head injury that produced a large right fronto-parietal acute subdural hematoma with marked midline shift. He underwent an emergency decompressive craniectomy, leaving the bone flap off. After recovery, a delayed cranioplasty was performed using a custom implant, but the wound later became infected, requiring removal of the prosthesis and repeated debridement. As a result, the scalp contracted, and primary closure became difficult. During the final reconstruction, several small galeal-relaxing cuts were made to relieve tension and allow a comfortable closure.

Outcome

The wound healed completely without further infection. At six months, the patient remained neurologically stable with a satisfactory cosmetic appearance.

Conclusion

Galeal scoring offers a simple, inexpensive, and safe way to gain additional scalp mobility when closure is tight. It can often prevent the need for complex flap or graft procedures and is worth considering in similar neurosurgical cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-026-04905-6.

Introduction

Traumatic brain injury (TBI) remains a leading cause of mortality and long-term disability worldwide [1]. Among its various presentations, acute subdural hematoma (ASDH) carries high morbidity due to rapid neurological deterioration from mass effect and midline shift [2]. Current management guidelines recommend surgical evacuation when hematoma thickness exceeds 10 mm or midline shift is greater than 5 mm, irrespective of Glasgow Coma Scale (GCS) score [3].

Decompressive craniectomy (DC) is often performed without bone flap replacement in the acute phase to accommodate cerebral oedema. However, achieving tension-free scalp closure under these conditions can be challenging. The galea aponeurotica, a dense, inelastic fibrous layer between subcutaneous tissue and pericranium, restricts scalp mobility and predisposes closures to excessive tension [4, 5]. Tension during closure increases the risk of wound dehiscence, infection, cerebrospinal fluid leakage, and impaired healing [4].

Galeal scoring (galeotomy) involves making controlled, relaxing incisions through the galea to enhance flap advancement and reduce closure tension. Experimental and clinical studies have demonstrated measurable reductions in tension and improved flap mobility using this method [6–9]. While established in reconstructive and plastic surgery, its application in neurosurgical wound closure remains underreported [10].

To our knowledge, only isolated reports have described galeal scoring in post-cranioplasty and post-infective settings. This case highlights the feasibility and safety of using galeotomies to achieve tension-free scalp closure after decompressive craniectomy, cranioplasty, and secondary infection.

Case presentation

Clinical history

A 30-year-old male labourer with no comorbidities sustained a high-velocity road traffic accident while working abroad. On arrival, his GCS was 6/15 (E2V2M2). Neurological examination revealed a dilated, sluggishly reactive right pupil and a briskly reactive left pupil, consistent with severe TBI.

Neuroimaging

Non-contrast CT of the brain (Fig. 1) showed a large right fronto-parietal ASDH (> 10 mm) with approximately 5 mm midline shift, basal cisternal effacement, and ipsilateral ventricular compression.

Fig. 1.

Preoperative CT showing right fronto-parietal ASDH with midline shift (approximately 12 mm in anteroposterior dimension with 5 mm midline shift)

First surgery – emergency decompressive craniectomy

The patient underwent an emergency right fronto-parietal decompressive craniectomy with evacuation of the hematoma. Bone flap replacement was deferred due to marked cerebral oedema and risk of brain herniation. The scalp was closed primarily under minimal tension. Postoperative CT (Fig. 2) confirmed adequate decompression with reversal of midline shift.

Fig. 2.

Postoperative CT confirming decompression and reversal of midline shift ( note the skull defect after decompressive craniectomy)

Postoperatively, the patient was managed in the neuro-intensive care unit with mechanical ventilation, sedation, and gradual weaning. He achieved full neurological recovery (GCS 15/15) and was discharged with a Glasgow Outcome Scale (GOS) score of 5.

Second surgery – delayed cranioplasty

Six months later, following neurological stabilisation, delayed cranioplasty using polymethylmethacrylate (PMMA) was performed using a patient-specific three-dimensional prosthesis (Fig. 3). The postoperative course was uneventful, and the patient was discharged with a GCS of 15/15 and GOS 5.

Fig. 3.

Three-dimensional reconstruction showing the cranial defect and dimensions ( Approximately 5 to 8 cm in the greatest dimension, though it was defect-specific) before prosthetic cranioplasty

Third surgery – galeal scoring for definitive closure

Five months after cranioplasty, the patient developed a surgical site infection requiring prosthesis removal (Fig. 4). The blood cultures were inconclusive, and the prosthesis was sent for culture and sensitivity. The initial broad-spectrum antibiotics, as per our department policy, included a combination of sulbactam/cefoperazone 2gm i/v twice daily, inj. Amikacin 500 mg twice daily, and inf. Metronidazole 500 mg three times daily. Culture and sensitivity report revealed a Staphylococcal infection, which was sensitive to inj Vancomycin; hence, the antibiotic coverage was switched to inj Vancomycin 1 gm i/v twice a day. Multiple debridement sessions (up to three) and wound care resulted in significant scalp fibrosis and poor pliability, precluding tension-free closure.

Fig. 4.

Scalp contraction following infection and repeated debridement

During the final closure, after the infection was dealt with completely through antibiotics, wound debridement and wound care in almost 12 weeks, multiple galeotomies were performed.

Technique of galeal scoring

To address the scalp defect, a thorough assessment of the defect and various management techniques were considered. The plastic surgeon was also involved in the decision-making, and it was decided not to use the rotational and free flaps and other more technically complicated techniques and use galeal scoring instead. The patient was kept informed of the various alternatives for closing the scalp defect and galeal scoring was opted with patient consent. Before the final surgery, the scalp deficit noted was approximately 5 cm in the sagittal plane and 7 cm in the coronal plane. The scalp was undermined, and the galea was exposed. Multiple cuts were made in the galea at approximately Icm intervals. These incisions were performed in the frontoparietal scalp flap (galea) in the direction perpendicular to the required advancement of the scalp. The direction of advancement of the frontoparietal scalp flap was kept towards the sagittal skull suture. These were partial-thickness incisions in the galea aponeurotica, not extending to the skin, to avoid damaging the underlying vessels and to provide significant scalp stretch, allowing scalp closure without undue tension. During the procedure, sequential testing of scalp advancement was performed after each galeotomy, and once complete scalp closure was achieved, the scalp was closed with 4/0 Vicryl subcutaneously to minimise skin stretch. The skin was then closed with Prolene 2/0, and no postoperative drain was placed. (Fig. 5a, b).

Fig. 5.

Intraoperative photographs showing (a) galeal scoring incisions and (b) tension-free wound closure

Outcome and follow-up

The patient recovered uneventfully with complete wound healing and no recurrence of infection. At six months postoperatively, he maintained full neurological function, intact scalp coverage, and satisfactory cosmetic results (Fig. 6).

Fig. 6.

Postoperative photographs demonstrate well-healed scalp coverage with no evidence of infection and a satisfactory cosmetic outcome

Discussion

This case demonstrates that galeal scoring is a simple, low-morbidity adjunct for achieving tension-free scalp closure in complex neurosurgical wounds, particularly those with prior infection, fibrosis, or multiple surgeries. Although well-established in plastic surgery, its adoption in neurosurgery has been limited. Our successful application underscores its potential value in selected cranioplasty and post-infective scenarios.

Biomechanical basis and comparative data

The galea aponeurotica is the principal tensile layer restricting scalp mobility. Controlled, full-thickness incisions (galeotomies) relieve this tension and permit incremental flap advancement. For instance, Raposio et al. demonstrated that three parallel galeotomies yielded an approximately 40% reduction in closure tension, with about 1.67 mm of expansion per incision [6]. Furthermore, Tyrell et al. confirmed the incremental gains with each sequential incision, providing a quantitative basis for the technique [11].

Experience from reconstructive surgery

In plastic and dermatologic surgery, galeal scoring is routinely used to facilitate closure of scalp and forehead defects. Yeo et al. described a successful technique using small-incision galeotomies performed with mosquito forceps, achieving stable closure without grafts or complications [8]. The “1–2–3 cm Advancement Flap Rule” proposed by Shash et al. reinforces the role of adjunctive techniques like galeotomies when flap advancement alone is insufficient [7]. Reviews on scalp reconstruction emphasise that scoring the galea in the direction of intended movement can yield additional tissue gain, typically in 1-cm increments, while preserving vascular integrity. Halpern et al. introduced the concept of galeal hinge flaps, highlighting that modifying the galea itself can serve as a functional reconstructive layer for scalp defects, thereby enhancing mobility and durability of closure [12]. Similarly, Mahmood and Eisen proposed an algorithmic approach to scalp reconstruction in which galeal scoring or limited advancement flaps are preferred for small- to medium-sized defects where tension-free closure is achievable without grafting [13]. These findings collectively support galeotomies as a safe, tissue-sparing adjunct in reconstructive planning.

Relevance to neurosurgery

Neurosurgical scalp closure following DC or cranioplasty often poses unique challenges due to prior surgeries, infection, or soft-tissue loss. Mee et al. emphasised that meticulous scalp closure planning is integral to cranioplasty success [10]. In this case, galeal scoring provided a low-morbidity alternative to rotational or free flaps, achieving satisfactory coverage without additional complex reconstructive procedures. Golas et al. demonstrated that prophylactic collaboration with plastic surgery for high-risk neurosurgical scalp incisions significantly reduces wound complications and reoperations [14]. This further supports the integration of reconstructive principles, including galeal scoring, into neurosurgical wound management protocols.

Risks and limitations

Key risks include potential vascular compromise if incisions are placed too close together or violate subgaleal vessels. Scoring should be performed parallel to subaponeurotic vessels, with adequate spacing (e.g., ~ 1 cm), and tested sequentially rather than through liberal incision [11–15]. Electrocautery should be avoided during scoring to reduce thermal injury to adjacent vasculature [16]. Aufschnaiter-Hiessboeck et al. reported rare but serious wound-healing complications after galeal incision and flap advancement, including postoperative bleeding and delayed healing, reinforcing the need for judicious, anatomically guided incision placement [17]. Moreover, Krishna et al. emphasised that scoring should follow tension vectors and remain parallel to vascular channels to preserve perfusion and optimise tissue viability [18].

Therefore, proper spacing, orientation, and a conservative, sequential approach are essential. A limitation of this report is the lack of quantitative measurement of closure tension before and after scoring.

Future implications

Prospective studies in larger neurosurgical cohorts are needed to quantitatively measure closure tension, compare outcomes with flap-based reconstructions, and clarify indications. Biomechanical modelling, such as finite element simulation, may help optimise incision spacing and predict safety margins in future cases.

Conclusion

Galeal scoring is a simple, effective, and low-cost method to achieve tension-free scalp closure, particularly in cases complicated by fibrosis, infection, or limited scalp mobility. Its use can reduce wound complications and minimise the need for extensive reconstructive procedures. This technique should be considered as part of the neurosurgeon’s armamentarium for challenging scalp closures.

Abbreviations

TBI

Traumatic Brain Injury

ASDH

Acute Subdural Hematoma

GCS

Glasgow Coma Scale

DC

Decompressive Craniectomy

EVM

Eye, Verbal, Motor response

CT

Computed Tomography

GOS

Glasgow Outcome Score

PMMA

Polymethylmethacrylate

Authors’ contributions

Dr. Musawer Khan conducted the research and provided manuscript writing assistance. Dr. Waseem Sajjad contributed to manuscript writing and editing. Dr. Sajid Khan reviewed the manuscript and is the corresponding author. Dr. Naeem ul Haq assisted with the interpretation of clinical data. Dr. Shehzad Sadbar designed the study.

Funding

No funding was received for this study.

Data availability

Data is securely stored on a server and is available from the Principal/corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

In keeping with the WMA Declaration of Helsinki, it was necessary to obtain ethical approvals from the institute. Ethical approvals for this research were granted by the Institutional Review Board (IRB) of the Prime Foundation Pakistan. The IRB Approval number is Prime/IRB/2023 − 1011. Informed consent has been recognised as a crucial component of ethical research. Data collection was conducted to ensure the confidentiality of private information, and any data that could compromise participant anonymity was removed. The participant information was kept strictly confidential, and data was stored under password protection or in a locked cupboard. All methods carried out were in accordance with the Prime Foundation Pakistan guidelines and the Declaration of Helsinki.

Consent for publication

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient.

Competing interests

The authors declare no competing interests.