Galeal Scoring for Salvage Scalp Closure Following Cranioplasty Failure: A Case Report

Galeal Scoring for Salvage Scalp Closure Following Cranioplasty Failure: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Galeal Scoring for Salvage Scalp Closure Following Cranioplasty Failure: A Case Report Musawer Khan, Waseem Sajjad, Sajid Khan, Naeem Ul Haq, Shehzad Sadbar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7950346/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version 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 help by improving 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. Galeal scoring Galeotomy Scalp closure Decompressive craniectomy Cranioplasty Neurosurgical wound Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 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 (Figure 1) showed a large right fronto-parietal ASDH (>10 mm) with approximately 5 mm midline shift, basal cisternal effacement, and ipsilateral ventricular compression. 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 (Figure 2) confirmed adequate decompression with reversal of midline shift. 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 was performed using a patient-specific three-dimensional prosthesis (Figure 3). The postoperative course was uneventful, and the patient was discharged with a GCS of 15/15 and GOS 5. Third Surgery – Galeal Scoring for Definitive Closure Five months after cranioplasty, the patient developed a surgical site infection requiring prosthesis removal (Figure 4). Multiple debridements and wound care resulted in significant scalp fibrosis and poor pliability, precluding tension-free closure. During the final closure, multiple galeotomies were performed through the galea aponeurotica, substantially increasing flap mobility and enabling tension-free primary closure (Figure 5a, b). 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 (Figure 6). 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. Declarations ETHICAL CONSIDERATION Written informed consent was obtained from the patient for publication of this case report and accompanying images. CONFLICT OF INTEREST None. FUNDING No funding was received for this study. Author Contribution Dr Sajid Khan conducted the research. Dr Musawer Khan prepared the manuscript and designed the study. Dr Waseem Sajjad reviewed the article. Dr Naeem ul Haq and Dr Shehzad Sadbar helped with the data analysis. References Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, et al. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol. 2022;21(10):1004-60. https://doi.org/10.1016/S1474-4422(22)00309-X Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GWJ, Bell MJ, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;80(1):6-15. https://doi.org/10.1227/NEU.0000000000001432 Beucler N. Prognostic factors of mortality and functional outcome for acute subdural hematoma: a review article. Asian J Neurosurg. 2023;18(3):454-67. https://doi.org/10.1055/s-0043-1772763 Honeybul S, Ho KM. Long-term complications of decompressive craniectomy for head injury. J Neurotrauma. 2011;28(5):929-35. https://doi.org/10.1089/neu.2010.1612 Alvi S, Jenzer AC. Scalp Reconstruction. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [updated 2023 Jun 26; cited 2025 Oct 10]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539788/?utm_source. Raposio E, Santi P, Nordström RE. Effects of galeotomies on scalp flaps. Ann Plast Surg. 1998;41(1):17-21. https://doi.org/10.1097/00000637-199807000-00004 Shash H, Marzouq S, Alghamdi A, Alrayes M, Alkhaldi SK, Shash H, et al. The 1-2-3 cm advancement flap rule in scalp reconstruction. Cureus. 2023;15(4):e35301. https://doi.org/10.7759/cureus.35301 Yeo H, Seong J, Park H, Park H. Surgical technique applying mosquito forceps to galeotomies for scalp reconstruction. J Wound Manag Res. 2023;19(3):161-6. https://doi.org/10.22467/jwmr.2023.02502 Shiraishi T, Fujimoto AH, Takushima A. The effect of adding an incision to the galea during scalp defect closure. J Plast Reconstr Surg. 2024;4(1):61-8. https://doi.org/10.53045/jprs.2024-0001 Tyrell R, Choi YK, Tuncer F, Maglic D, Holoyda K, Hosein R, et al. The effects of sequential galeotomies and galea aponeurectomies on scalp flap advancement. Plast Reconstr Surg. 2021;147(2):363e-70e. https://doi.org/10.1097/PRS.0000000000007573 Halpern M, Adams C, Ratner D. Galeal hinge flaps: a useful technique for immediate repair of scalp defects extending to periosteum. Dermatol Surg. 2009;35(1):127-30. https://doi.org/10.1111/j.1524-4725.2008.34391.x Mahmood M, Eisen D. An algorithmic approach to scalp reconstructive surgery: maximization of cosmetic and functional outcomes. Arch Dermatol Res. 2024;316(2):137-45. https://doi.org/10.1007/s00403-024-02896-3 Mee H, Anwar F, Timofeev I, Owens N, Grieve K, Whiting G, et al. Cranioplasty: a multidisciplinary approach. Front Surg. 2022;9:864385. https://doi.org/10.3389/fsurg.2022.864385 Golas AR, Boulad T, Thomas S, Pereira S, Berenstein J, Schwartz J, et al. Prophylactic plastic-surgery closure of neurosurgical scalp incisions reduces wound complications in previously operated patients treated with bevacizumab and radiation. J Neuro-Oncol. 2014;119(3):557-64. https://doi.org/10.1007/s11060-014-1482-6 Lin SJ, Hanasono MM, Skoracki RJ. Scalp and calvarial reconstruction. Semin Plast Surg. 2008;22(4):281-93. https://doi.org/10.1055/s-0028-1095887 Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp defects: an algorithmic approach. Plast Reconstr Surg. 2005;116(7 Suppl):54e-72e. https://doi.org/10.1097/01.prs.0000179188.25019.6c Aufschnaiter-Hiessboeck KM, Stefanits H, Rossmann T, Aichholzer M, Senker W, Rauch P, et al. Challenging frontiers in neuroplastic cranial reconstruction: addressing neurosurgical wound-healing complications through interdisciplinary collaboration—an observational study. Acta Neurochir (Wien). 2024;166(3):432-41. https://doi.org/10.1007/s00701-024-06328-z Krishna D, Khan MM, Dubepuria R, Chaturvedi G, Cheruvu VPR. Reconstruction of scalp and forehead defects: options and strategies. Cureus. 2024;15(5):e41479. https://doi.org/10.7759/cureus.41479 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 30 Dec, 2025 Reviews received at journal 29 Dec, 2025 Reviewers agreed at journal 23 Dec, 2025 Reviews received at journal 16 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 01 Dec, 2025 Reviewers invited by journal 01 Dec, 2025 Editor invited by journal 10 Nov, 2025 Editor assigned by journal 28 Oct, 2025 Submission checks completed at journal 28 Oct, 2025 First submitted to journal 26 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7950346","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":554155271,"identity":"4e449cf3-6b1d-478c-ba93-8818d6625e95","order_by":0,"name":"Musawer Khan","email":"","orcid":"","institution":"Mardan Medical Complex/Bacha Khan medical College, Mardan","correspondingAuthor":false,"prefix":"","firstName":"Musawer","middleName":"","lastName":"Khan","suffix":""},{"id":554155274,"identity":"e69944af-e9f4-40a4-be41-4a9aecf9adc8","order_by":1,"name":"Waseem Sajjad","email":"","orcid":"","institution":"Peshawar Medical College","correspondingAuthor":false,"prefix":"","firstName":"Waseem","middleName":"","lastName":"Sajjad","suffix":""},{"id":554155275,"identity":"721c143d-1538-41c3-a397-26e8a46929f6","order_by":2,"name":"Sajid Khan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYBADHn4QmVBAjFo2qBbJBpAWAxK0MBgcAJNE6DC43534ubDNTsb4/OrEDw8MGOT5xQ4Q0HKMd7P0jDPJPGY33m6WADrMcObsBIJaNkjzVDADtZzdANKSYHCbsJbNv3kM6nmMZ5zd/INYLduAthzmMeDv3UacLZLHcrdZ85w5ziNxg3ebRYKBBGG/8B0+u/k2b1u1PX//2c03f1TYyPNLE9CCABJglRLEKgcB/gOkqB4Fo2AUjIKRBABUo0BSOVtrwgAAAABJRU5ErkJggg==","orcid":"","institution":"Peshawar Medical College","correspondingAuthor":true,"prefix":"","firstName":"Sajid","middleName":"","lastName":"Khan","suffix":""},{"id":554155282,"identity":"4cb3a356-4cf9-482e-8197-e8768c187102","order_by":3,"name":"Naeem Ul Haq","email":"","orcid":"","institution":"Mardan Medical Complex/Bacha Khan medical College, Mardan","correspondingAuthor":false,"prefix":"","firstName":"Naeem","middleName":"Ul","lastName":"Haq","suffix":""},{"id":554155283,"identity":"d1cb4b7e-5438-4e58-92a2-94729c1bb0fe","order_by":4,"name":"Shehzad Sadbar","email":"","orcid":"","institution":"Mardan Medical Complex/Bacha Khan medical College, Mardan","correspondingAuthor":false,"prefix":"","firstName":"Shehzad","middleName":"","lastName":"Sadbar","suffix":""}],"badges":[],"createdAt":"2025-10-27 11:10:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7950346/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7950346/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97674961,"identity":"9d66a54a-abb2-4802-a4b1-99db90c64037","added_by":"auto","created_at":"2025-12-08 09:44:59","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1990693,"visible":true,"origin":"","legend":"","description":"","filename":"GalealScoringforSalvageScalpClosureFollowingCranioplastyFailureACaseReport.docx","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/94e04c4494772a1f3e0ee3ce.docx"},{"id":97652988,"identity":"e95d3312-8c82-49ea-b28b-9488b2ac4168","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6332,"visible":true,"origin":"","legend":"","description":"","filename":"d5f85e24b03e4c29b4194c53de263e44.json","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/3a0a74d19cafcac89c2523b4.json"},{"id":97652991,"identity":"e2c1e815-0c60-4b42-82d1-35c158ad82cf","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":124959,"visible":true,"origin":"","legend":"","description":"","filename":"ethicalapprovelcertificate.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/8ee4a0c74469f65df554a9ef.pdf"},{"id":97674907,"identity":"54ae96ba-6bf7-4523-bb8a-5dc39ba5f88a","added_by":"auto","created_at":"2025-12-08 09:44:42","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":53037,"visible":true,"origin":"","legend":"","description":"","filename":"d5f85e24b03e4c29b4194c53de263e441enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/23a8f1ec54601993ca8709dd.xml"},{"id":97652990,"identity":"91b91e50-8f7f-4225-8220-fa896cb9004b","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"eps","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":48323,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage1.eps","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/93b7b7ece92b5dd7d9cea4c9.eps"},{"id":97652999,"identity":"d6c4b533-6790-4bcf-b3d3-e9e7362a8ddd","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"eps","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":47673,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage2.eps","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/70fdc1c2c8cc59b7090a5319.eps"},{"id":97674891,"identity":"c9e12aee-a3bf-4a8a-b11a-341fa54c08ff","added_by":"auto","created_at":"2025-12-08 09:44:38","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":668404,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/17982b0cb75e5f3449e19de8.png"},{"id":97653003,"identity":"1be1d08c-5abe-4815-8092-3d903567e984","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"jpeg","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":255865,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/6e34c6005f56c43738bd9d6d.jpeg"},{"id":97652997,"identity":"7c94b8f7-42fd-4614-aa62-8b5b72192996","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"jpeg","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1074,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/b660d437573de223afaf5664.jpeg"},{"id":97653001,"identity":"47daa633-1dc7-4a2a-9afd-0b83362c583c","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"jpeg","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":65024,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage8.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/b8e5ed1fbfd7f3afd51903cd.jpeg"},{"id":97674978,"identity":"45e4b733-0419-47c7-8f31-76928696e752","added_by":"auto","created_at":"2025-12-08 09:45:05","extension":"jpeg","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":171716,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage9.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/3555276d2a5fcfa537c18d70.jpeg"},{"id":97653002,"identity":"8b62cd0c-e15c-47dd-a6ed-a25a9409c7d4","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":935,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/7a16b2831c63f5c56d16448a.png"},{"id":97653004,"identity":"18b1abc7-1535-4fc1-98de-e5f2b2d74a4b","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"xml","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":51354,"visible":true,"origin":"","legend":"","description":"","filename":"d5f85e24b03e4c29b4194c53de263e441structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/655fef5e4757e805877aa018.xml"},{"id":97652998,"identity":"1a06e579-1dd1-4524-acbf-19713d269c4f","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"html","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60296,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/7bc4ea38dd13009de701e9f3.html"},{"id":97652986,"identity":"bec75639-98a0-4533-90cf-450f2f1a3457","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1288039,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePreoperative CT showing right fronto-parietal ASDH with midline shift.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/a5135ccc4e377df368a58f51.png"},{"id":97652989,"identity":"0ea2f0b7-8049-4be6-8d0c-f11b569a6e9b","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1811417,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePostoperative CT confirming decompression and reversal of midline shift.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/67e134a44cbf02e59dc4eaca.png"},{"id":97674672,"identity":"abbd0377-7999-48c3-b460-76f3a0b05f2f","added_by":"auto","created_at":"2025-12-08 09:43:48","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":832635,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThree-dimensional reconstruction showing the cranial defect and dimensions before prosthetic cranioplasty.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/fec08c98664a824e7b21656c.png"},{"id":97652994,"identity":"e9f367f7-ddb0-40a0-b2ab-047ac2fe52a5","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1346793,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eScalp contraction following infection and repeated debridement.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/b985ce4ff802a605dead4264.png"},{"id":97672835,"identity":"da93c513-255c-4471-9e38-35b932939e01","added_by":"auto","created_at":"2025-12-08 09:38:51","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1859817,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea, b.\u003c/strong\u003e \u003cem\u003eIntraoperative photographs showing (a) galeal scoring incisions and (b) tension-free wound closure.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/36932011eb2314142bd6356d.png"},{"id":97652995,"identity":"be7c0318-0ce7-4c60-8b2b-6b90c7a09dd5","added_by":"auto","created_at":"2025-12-08 06:45:29","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1488065,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePostoperative photographs demonstrate well-healed scalp coverage with no evidence of infection and a satisfactory cosmetic outcome.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/457efe46bf1eb3a849ed4bf3.png"},{"id":97678818,"identity":"93bb116d-22fd-48a9-9c29-caac3c4bc961","added_by":"auto","created_at":"2025-12-08 09:56:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":12134405,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7950346/v1/3c6d3137-5f8d-4a27-9c7a-efb3a24f5abb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Galeal Scoring for Salvage Scalp Closure Following Cranioplasty Failure: A Case Report","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTraumatic brain injury (TBI) remains a leading cause of mortality and long-term disability worldwide.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Among its various presentations, acute subdural hematoma (ASDH) carries high morbidity due to rapid neurological deterioration from mass effect and midline shift.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e 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.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDecompressive 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. \u003csup\u003e4, 5\u003c/sup\u003e Tension during closure increases the risk of wound dehiscence, infection, cerebrospinal fluid leakage, and impaired healing.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eGaleal 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.\u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e While established in reconstructive and plastic surgery, its application in neurosurgical wound closure remains underreported.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTo 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.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003e\u003cstrong\u003eClinical History\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeuroimaging\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-contrast CT of the brain (Figure 1) showed a large right fronto-parietal ASDH (\u0026gt;10 mm) with approximately 5 mm midline shift, basal cisternal effacement, and ipsilateral ventricular compression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFirst Surgery \u0026ndash; Emergency Decompressive Craniectomy\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;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 (Figure 2) confirmed adequate decompression with reversal of midline shift.\u003c/p\u003e\n\u003cp\u003ePostoperatively, 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecond Surgery \u0026ndash; Delayed Cranioplasty\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Six months later, following neurological stabilisation, delayed cranioplasty was performed using a patient-specific three-dimensional prosthesis (Figure 3). The postoperative course was uneventful, and the patient was discharged with a GCS of 15/15 and GOS 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThird Surgery \u0026ndash; Galeal Scoring for Definitive Closure\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Five months after cranioplasty, the patient developed a surgical site infection requiring prosthesis removal (Figure 4). Multiple debridements and wound care resulted in significant scalp fibrosis and poor pliability, precluding tension-free closure.\u003c/p\u003e\n\u003cp\u003eDuring the final closure, multiple galeotomies were performed through the galea aponeurotica, substantially increasing flap mobility and enabling tension-free primary closure (Figure 5a, b).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome and Follow-Up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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 (Figure 6).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBiomechanical Basis and Comparative Data\u003cbr\u003e\u003c/strong\u003eThe 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.\u003csup\u003e6\u003c/sup\u003e Furthermore, Tyrell et al. confirmed the incremental gains with each sequential incision, providing a quantitative basis for the technique.\u003csup\u003e11\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExperience from Reconstructive Surgery\u003cbr\u003e\u003c/strong\u003eIn 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.\u003csup\u003e8\u003c/sup\u003e The \u0026ldquo;1\u0026ndash;2\u0026ndash;3 cm Advancement Flap Rule\u0026rdquo; proposed by Shash et al. reinforces the role of adjunctive techniques like galeotomies when flap advancement alone is insufficient. \u003csup\u003e7\u003c/sup\u003e 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.\u003csup\u003e12\u003c/sup\u003e 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.\u003csup\u003e13\u003c/sup\u003e These findings collectively support galeotomies as a safe, tissue-sparing adjunct in reconstructive planning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRelevance to Neurosurgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeurosurgical 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.\u003csup\u003e10\u003c/sup\u003e 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.\u003csup\u003e14\u003c/sup\u003e This further supports the integration of reconstructive principles, including galeal scoring, into neurosurgical wound management protocols.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisks and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKey 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.\u003csup\u003e11-15\u003c/sup\u003e Electrocautery should be avoided during scoring to reduce thermal injury to adjacent vasculature.\u003csup\u003e16\u003c/sup\u003e 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.\u003csup\u003e17\u003c/sup\u003e Moreover, Krishna et al. emphasised that scoring should follow tension vectors and remain parallel to vascular channels to preserve perfusion and optimise tissue viability. \u003csup\u003e18\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTherefore, 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFuture Implications\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;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.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eGaleal 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\u0026rsquo;s armamentarium for challenging scalp closures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eETHICAL CONSIDERATION\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eCONFLICT OF INTEREST\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDr Sajid Khan conducted the research. Dr Musawer Khan prepared the manuscript and designed the study. Dr Waseem Sajjad reviewed the article. Dr Naeem ul Haq and Dr Shehzad Sadbar helped with the data analysis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMaas AIR, Menon DK, Manley GT, Abrams M, \u0026Aring;kerlund C, Andelic N, \u003cem\u003eet al.\u003c/em\u003e Traumatic brain injury: progress and challenges in prevention, clinical care, and research. \u003cstrong\u003eLancet Neurol.\u003c/strong\u003e 2022;21(10):1004-60. https://doi.org/10.1016/S1474-4422(22)00309-X\u003c/li\u003e\n\u003cli\u003eCarney N, Totten AM, O\u0026rsquo;Reilly C, Ullman JS, Hawryluk GWJ, Bell MJ, \u003cem\u003eet al.\u003c/em\u003e Guidelines for the management of severe traumatic brain injury, fourth edition. \u003cstrong\u003eNeurosurgery.\u003c/strong\u003e 2017;80(1):6-15. https://doi.org/10.1227/NEU.0000000000001432\u003c/li\u003e\n\u003cli\u003eBeucler N. Prognostic factors of mortality and functional outcome for acute subdural hematoma: a review article. \u003cstrong\u003eAsian J Neurosurg.\u003c/strong\u003e 2023;18(3):454-67. https://doi.org/10.1055/s-0043-1772763\u003c/li\u003e\n\u003cli\u003eHoneybul S, Ho KM. Long-term complications of decompressive craniectomy for head injury. \u003cstrong\u003eJ Neurotrauma.\u003c/strong\u003e 2011;28(5):929-35. https://doi.org/10.1089/neu.2010.1612\u003c/li\u003e\n\u003cli\u003eAlvi S, Jenzer AC. Scalp Reconstruction. In: \u003cstrong\u003eStatPearls [Internet].\u003c/strong\u003e Treasure Island (FL): StatPearls Publishing; 2023 [updated 2023 Jun 26; cited 2025 Oct 10]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539788/?utm_source.\u003c/li\u003e\n\u003cli\u003eRaposio E, Santi P, Nordstr\u0026ouml;m RE. Effects of galeotomies on scalp flaps. \u003cstrong\u003eAnn Plast Surg.\u003c/strong\u003e 1998;41(1):17-21. https://doi.org/10.1097/00000637-199807000-00004\u003c/li\u003e\n\u003cli\u003eShash H, Marzouq S, Alghamdi A, Alrayes M, Alkhaldi SK, Shash H, \u003cem\u003eet al.\u003c/em\u003e The 1-2-3 cm advancement flap rule in scalp reconstruction. \u003cstrong\u003eCureus.\u003c/strong\u003e 2023;15(4):e35301. https://doi.org/10.7759/cureus.35301\u003c/li\u003e\n\u003cli\u003eYeo H, Seong J, Park H, Park H. Surgical technique applying mosquito forceps to galeotomies for scalp reconstruction. \u003cstrong\u003eJ Wound Manag Res.\u003c/strong\u003e 2023;19(3):161-6. https://doi.org/10.22467/jwmr.2023.02502\u003c/li\u003e\n\u003cli\u003eShiraishi T, Fujimoto AH, Takushima A. The effect of adding an incision to the galea during scalp defect closure. \u003cstrong\u003eJ Plast Reconstr Surg.\u003c/strong\u003e 2024;4(1):61-8. https://doi.org/10.53045/jprs.2024-0001\u003c/li\u003e\n\u003cli\u003eTyrell R, Choi YK, Tuncer F, Maglic D, Holoyda K, Hosein R, \u003cem\u003eet al.\u003c/em\u003e The effects of sequential galeotomies and galea aponeurectomies on scalp flap advancement. \u003cstrong\u003ePlast Reconstr Surg.\u003c/strong\u003e 2021;147(2):363e-70e. https://doi.org/10.1097/PRS.0000000000007573\u003c/li\u003e\n\u003cli\u003eHalpern M, Adams C, Ratner D. Galeal hinge flaps: a useful technique for immediate repair of scalp defects extending to periosteum. \u003cstrong\u003eDermatol Surg.\u003c/strong\u003e 2009;35(1):127-30. https://doi.org/10.1111/j.1524-4725.2008.34391.x\u003c/li\u003e\n\u003cli\u003eMahmood M, Eisen D. An algorithmic approach to scalp reconstructive surgery: maximization of cosmetic and functional outcomes. \u003cstrong\u003eArch Dermatol Res.\u003c/strong\u003e 2024;316(2):137-45. https://doi.org/10.1007/s00403-024-02896-3\u003c/li\u003e\n\u003cli\u003eMee H, Anwar F, Timofeev I, Owens N, Grieve K, Whiting G, \u003cem\u003eet al.\u003c/em\u003e Cranioplasty: a multidisciplinary approach. \u003cstrong\u003eFront Surg.\u003c/strong\u003e 2022;9:864385. https://doi.org/10.3389/fsurg.2022.864385\u003c/li\u003e\n\u003cli\u003eGolas AR, Boulad T, Thomas S, Pereira S, Berenstein J, Schwartz J, \u003cem\u003eet al.\u003c/em\u003e Prophylactic plastic-surgery closure of neurosurgical scalp incisions reduces wound complications in previously operated patients treated with bevacizumab and radiation. \u003cstrong\u003eJ Neuro-Oncol.\u003c/strong\u003e 2014;119(3):557-64. https://doi.org/10.1007/s11060-014-1482-6\u003c/li\u003e\n\u003cli\u003eLin SJ, Hanasono MM, Skoracki RJ. Scalp and calvarial reconstruction. \u003cstrong\u003eSemin Plast Surg.\u003c/strong\u003e 2008;22(4):281-93. https://doi.org/10.1055/s-0028-1095887\u003c/li\u003e\n\u003cli\u003eLeedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp defects: an algorithmic approach. \u003cstrong\u003ePlast Reconstr Surg.\u003c/strong\u003e 2005;116(7 Suppl):54e-72e. https://doi.org/10.1097/01.prs.0000179188.25019.6c\u003c/li\u003e\n\u003cli\u003eAufschnaiter-Hiessboeck KM, Stefanits H, Rossmann T, Aichholzer M, Senker W, Rauch P, \u003cem\u003eet al.\u003c/em\u003e Challenging frontiers in neuroplastic cranial reconstruction: addressing neurosurgical wound-healing complications through interdisciplinary collaboration\u0026mdash;an observational study. \u003cstrong\u003eActa Neurochir (Wien).\u003c/strong\u003e 2024;166(3):432-41. https://doi.org/10.1007/s00701-024-06328-z\u003c/li\u003e\n\u003cli\u003eKrishna D, Khan MM, Dubepuria R, Chaturvedi G, Cheruvu VPR. Reconstruction of scalp and forehead defects: options and strategies. \u003cstrong\u003eCureus.\u003c/strong\u003e 2024;15(5):e41479. https://doi.org/10.7759/cureus.41479\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Galeal scoring, Galeotomy, Scalp closure, Decompressive craniectomy, Cranioplasty, Neurosurgical wound","lastPublishedDoi":"10.21203/rs.3.rs-7950346/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7950346/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e 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 help by improving scalp mobility. Although this technique is well known in plastic surgery, it is not commonly reported in neurosurgical work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome:\u003c/strong\u003e The wound healed completely without further infection. At six months, the patient remained neurologically stable with a satisfactory cosmetic appearance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e 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.\u003c/p\u003e","manuscriptTitle":"Galeal Scoring for Salvage Scalp Closure Following Cranioplasty Failure: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 06:45:24","doi":"10.21203/rs.3.rs-7950346/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-30T07:16:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-29T05:55:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15531074191125570169684984346863293452","date":"2025-12-23T11:36:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T18:40:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203332243257091105419837748825850980671","date":"2025-12-02T14:58:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88554672735085209366243764127655886181","date":"2025-12-01T10:25:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-01T10:09:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-10T09:35:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-28T04:56:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-28T04:56:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2025-10-26T12:04:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2a2697d5-03c3-44fb-b378-37bc67d844c3","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T07:41:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 06:45:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7950346","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7950346","identity":"rs-7950346","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}