Management of alopecia of the scalp by a combination of excisions and transplantations

Surgical Management for Hair Restoration: A Review of Contemporary Techniques

BACKGROUND

Hair loss can cause psychological distress for patients, regardless of the etiology or extent of the defect. Many conservative and pharmacological approaches are successful in management, but refractory or severe cases often mandate surgical treatment. Surgical techniques have been refined over the course of a century, and we aim to review the most contemporary strategies.

METHODS

A review of the literature was performed using the databases PubMed, Web of Science, and Embase, in May 2020. Articles were included if they discussed techniques used within the past 10 years, in search of more contemporary strategies and the most widely used approaches.

RESULTS

The use of local flaps, scalp reduction surgery, and hair transplantation techniques are all used for various indications. Modern hair transplantation can be further divided into follicular unit excision and follicular unit transplantation, each with its own advantages. Local flaps are most often used for post-traumatic and reconstructive indication, while hair transplantation can be used for smaller cosmetic lesions or in combination with a variety of other reconstructive techniques.

CONCLUSION

Hair loss continues to be a challenging pathology for both patients and physicians, regardless of etiology. When conservative treatment is inadequate, there exist multiple surgical techniques that can feasibly restore hair, though the exact degree of success may vary between patients. The proper technique is dependent upon etiology, patient specific factors, as well as surgeon experience and comfort.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evolution of Hair Transplant Surgery in India: A Plastic Surgeon's Perspective

This article is mainly aimed to delve into the history of hair transplant and its evolution in India. As a plastic surgeon in practice for the past 35 years, I have seen hair transplant surgery undergoing various transformations starting with initial use of plugs and flaps. Scalp reduction surgery also played an important role. Plugs slowly gave way to mini- and micrografts. With the incorporation of the microscope and popularizing of strip surgery and improved slivering techniques, mega sessions came to the fore thereby covering large areas. Follicular unit extraction and use of body hair have also been discussed.

Role of Hair Transplantation in Scarring Alopecia-To Do or Not to Do

Alopecia in the scalp region leads to psychosocial embarrassment for an individual. Alopecia could be due to several reasons, including genetic, hormonal, traumatic and infections. Cicatricial alopecias (CAs) are considered as trichological emergency, since their progression is rapid and always results in permanent hair loss. The pathogenesis, disease progression and prognosis of CA are poorly understood, and the treatment process is still evolving. An early diagnosis must be established, and aggressive treatment protocol should be followed in the management of scarring alopecia. This article presents various aspects of CA and determines whether hair transplant (HT) should be done in this condition.

History of Dermatologic Cosmetic Surgery

Dermatology has been one of the major disciplines that has contributed to the rapid advancement of cosmetic surgery. Various cosmetic procedures including chemical peel, dermabrasion, hair transplantation, laser surgery, soft-tissue augmentation, and liposuction have been refined or developed by dermatologists. This article describes the involvement by dermatologists in these cosmetic procedures.

Key moments in the history of dermatologic surgery (1952-2000)

The history of surgery in dermatology ("dermatologic surgery") is rich with significant developments and advances by multiple individuals. Only a few of these pioneers can be highlighted in this report because of space limitations. My apologies to colleagues and friends who have not been included or mentioned in this article. The Timeline: Major milestones in the history of dermatologic surgery in this article tells some of the story. The biographic pieces on 15 outstanding physicians add additional detail and perspective. Many major developments have occurred since 2000, but they are beyond the scope of this article.

A review of modern surgical hair restoration techniques

The field of hair restoration has had a chequered history. From the days of punch grafting to the present day techniques of follicular unit hair transplantation, the field has seen a number of new advances. This article reviews these developments.

Hair deformities

To be able to treat the wide spectrum of hair deformities, a surgeon must possess a wide spectrum of skills in HRS, cosmetic surgery, and reconstructive surgery. Specific education and training in HRS is not a traditional part of formal surgical training, although much information is available through several national and international organizations. Being sensitive to the unique variables associated with HRS increases the chances of achieving a superior functional and cosmetic result when treating significant hair deformities.

Serial scalp reductions: a biomechanical approach

BACKGROUND

Several technical aspects of scalp-reduction procedures still need to be clearly elucidated: in particular, (a) the quantitative effects provided by different amounts of subgaleal undermining, (b) the immediate gains provided by increasing amount of tension when advancing a scalp flap, and (c) the eventual benefits provided by galeotomies.

OBJECTIVE

The aim of the present paper is to report on some biomechanical properties of scalp flaps as related to serial scalp reduction procedures for correction of male pattern baldness.

METHODS

Data were collected by stepwise loading of 20 scalp flaps, obtained by a reversed-Y scalp incision, after increasing amounts of undermining, as well as after performing three galeotomies.

RESULTS

Increasing amounts of tension (while advancing a scalp flap) affect the compliance of a scalp flap in a non-linear fashion; increasing amounts of undermining permit obtaining significant, but not proportional, gains; performing galeotomies is a useful adjunct to decrease the amount of closing tension when performing scalp-reduction procedures.

CONCLUSION

When performing serial scalp reductions, to take into account the biomechanics of scalp flaps may be of some utility in obtaining an optimal result.

Anchoring galeal flaps for scalp reduction procedures

This article describes an operative technique, based on the use of three anchoring galeal flaps, aimed at reducing the percentage of "stretch-back" that occurs after performing scalp reduction procedures. In 12 male patients undergoing a midline scalp reduction procedure, three rectangular (2 x 3 cm) galeal flaps in direct continuity with the longitudinal margin of the left scalp flap were sutured individually to the galeal undersurface of the right scalp flap to draw the two scalp flaps toward the midline of the scalp and to relieve the wound margins of closing tension. Tattoo marks were placed on the patient's scalp at the level of the vertical lines drawn through the external auditory meatuses (A1-A2) and 6 cm more posterior (B1-B2) to measure the movement and stretching of the scalp. The results were compared with those obtained from a control group of 13 male patients who underwent the same surgical procedure but without the use of the anchoring galeal flaps. Mean stretch-back (as measured 4 weeks postoperatively) at level A1-A2 was 8.3 mm in the control group and 1.6 mm in the experimental group. The mean stretch-back at level B1-B2 was 7.7 mm in the control group and 0.9 mm in the experimental group. A statistically significant difference (p < 0.005) was found between data from the control and experimental groups regarding the above-reported stretch-back values at both levels. The use of the described galeal flaps allowed us to obtain an 80.93-percent and an 88.09-percent stretch-back reduction at levels A1-A2 and B1-B2, respectively, 1 month postoperatively.

Chest hair used as donor material in hair restoration surgery

BACKGROUND

This article describes a technique for transplanting hair from the chest to the balding scalp.

OBJECTIVE

The objective is to describe an alternative route of harvesting donor hair in the situation when donor scalp hair is depleted.

METHOD

A fusiform donor harvest was removed from the sternal region. The tissue was divided into one- and two-haired micrografts and subsequently transplanted.

RESULTS

The technique worked extremely well with good take of the hair grafts. The donor site healed inconspicuously.

CONCLUSION

The technique of transplanting hair from the chest to the balding scalp can be a viable alternative when confronted with donor scalp hair depletion.

Scalp lifting. Anatomic and technical considerations

BACKGROUND

Extensive scalp lifting, though offering the potential for tremendous benefit to the patient with extensive male-pattern alopecia, has not been widely accepted or understood.

OBJECTIVE

The anatomic and technical features of extensive scalp lifting are discussed.

METHODS

The performance of extensive scalp lift surgery must be preceded by a thorough understanding of the specific goals, anatomic considerations, surgical techniques, and specific methods for successful completion of this operation. A knowledge of preoperative preparation, anesthesia, intraoperative methods, undermining, hemostasis, means of scalp advancement, and proper closure are essential for minimizing side effects and complications of this beneficial procedure. One must understand the dynamics of scalp stretching and lifting in order to achieve optimum removal of baldness and to successfully predict the outcome of the operation.

CONCLUSION

Present and future advantages of scalp lifting over traditional scalp reduction have been enumerated and discussed.

The paramedian scalp reduction with posterior Z-plasty. A technique to minimize the "slot" defect

BACKGROUND

One consistent and undesired sequela resulting from scalp reductions has been the "slot" or "trough" defect, referring to the scar following the final reduction. Attempts to correct this have not been entirely satisfactory.

OBJECTIVE

To present an approach to minimize the "slot" defect that consists of staged modified paramedian scalp reductions combined with a large posterior Z-plasty during the final reduction.

METHODS

A paramedian crescent-shaped ellipse was marked onto the patient's scalp parallel and adjacent to the existing fringe hair. Subsequent reductions were performed in a similar manner approximately 2 months apart. The final reduction consisted of mobilization and transposition of the large flaps used in the posterior Z-plasty.

RESULTS

Patients who underwent the staged modified paramedian reductions combined with a posterior Z-plasty had significant minimization and adequate camouflage of the undesirable "slot."

CONCLUSION

Combining a large posterior Z-plasty with a paramedian reduction minimizes the slot defect.

The pulley suture. Utilization in scalp reduction surgery

A suture variation not commonly utilized in dermatologic surgery is helpful in approximating wound edges without the complications of excessive undermining or the scarring of conventional retention sutures. It is especially useful in scalp reduction surgery.

Adjuncts to scalp reduction surgery. Intraoperative tissue expanders and hyaluronidase

Scalp reduction has become an important part of the cosmetic surgeon's armamentarium in the treatment of male pattern alopecia. Recently, the use of two-stage tissue expansion has been advocated for scalp reduction. Intraoperative tissue expansion obviates many of the disadvantages of delayed expansion and increases the yield of excised scalp by 20-30% over standard reduction techniques in the 20 patients studied. The addition of hyaluronidase to the local anesthetic facilitates its diffusion, enhancing anesthesia and the ease of dissection. Therefore, the use of intraoperative tissue expansion and the addition of hyaluronidase to the local anesthetic are two separate adjuncts to scalp reduction surgery.

A new technique for curvilinear scalp reduction

A technique of alopecia reduction utilizing a curvilinear ellipse employing a sequential excision and suture technique is described. Advantages of the technique over previously described procedures are presented. Measurements of individual scalp elasticity and alternating suture tension vectors help to produce an excellent cosmetic result with minimal complications.

Aids to scalp reduction surgery

Utilizing certain surgical techniques during scalp reduction surgery will assist the surgeon in achieving a carefully planned and more efficient result. Measurement of scalp depth will assist in predicting the amount of skin to be excised. A simple method of safe identification of the periosteum is described along with the description of an elevator which assists in rapid, safe, and extensive undermining in the galeal-periosteal plane. An accessory supra-auricular scalp incision can be employed to allow for extensive scalp undermining. A transverse incision into the skin flap to be advanced, allows the surgeon to safely approximate the amount of skin to be excised. When skin closure becomes impossible due to overzealous excision of bald skin, galeotomies can provide closure. A special order suture is described which allows for easier galeal closure. Surgical skin staples are recommended to provide a faster skin closure.

The modified major scalp reduction

A new procedure for reducing the area of baldness, the modified major scalp reduction, is presented. This operation provides an important alternative to either standard or major scalp reductions. The surgical technique is described in detail, and comparisons are made with regard to advantages and disadvantages.

How to avoid the principal complication of scalp reduction in the management of extensive alopecia

Instead of risking the esthetic complication sometimes observed with the development of a vertical alopecic strip crossing the posterior aspect of the scalp, another method can be used to replace this. A small, round alopecic area similar to a small developing bald spot is created and eventually grafted later.

Midline alopecia reduction combined with hair transplantation

The advantages gained by incorporating alopecia reduction (AR) in patients undergoing hair transplantation, or with patients who have previously had hair transplantation, are delineated. The specific advantages of the midline elliptical pattern are discussed. Clinical considerations that determine whether ARs are necessary are the degree of baldness, laxity of the scalp, age of the patient, and ultimate goal of the individual. The advantages and disadvantages of performing ARs or hair transplantation first are discussed and the new concept of minireductions also outlined.

The Y-shaped pattern of alopecia reduction and its variations

The Y-shaped alopecia reduction is used less frequently than indicated. This article outlines the advantages of this pattern, describes the technique of excision in detail, discusses the many variations possible, and advocates greater utilization of this procedure.

Complications of scalp reductions

Early problems with central sagittal scalp reductions are primarily medical and surgical. As they resolve with surgical experience, the cosmetic problems become more apparent. These problems and complications are outlined along with suggestions for prevention and correction.

Scalp reduction as an adjunct to hair transplantation. Review of relevant literature and presentation of an improved technique

The literature on scalp reduction is reviewed and an improved technique of scalp reduction is presented. The amount of bald skin that can be excised by the author's technique exceeds that previously reported by two to three times. The technique rests on tried principles of wide undermining in the galeal-periosteal plane, use of serial relaxing incisions in the galea, closure of specifically designed flap edges under increased tension, and the administration of adrenocorticosteroids postoperatively.

Reduction of male pattern baldness in multiple stages: a retrospective study

Seven hundred and forty-nine reductions of male pattern baldness were reviewed retrospectively with respect to selection of patients, operative techniques, complications, benefit obtained during successive stages of reduction, optimum intervals between operations, ages of patients, and prior operations on the scalp. A classification of mobility of the scalp is also given.

Scalp reduction for alopecia

A 17-year-old boy had a large, scarred area of alopecia from a thermal burn. Forty square centimeters of scarred scalp skin were excised in six sessions. The cosmetic result was excellent. Neither hypertrophic nor keloidal scarring supervened. The technique of scalp reduction and its procedure as an adjunct to hair transplantation is discussed.

Planning in hair transplantation

The size of an area to receive hair transplants can be minimized by designing a conservative hairline and by surgical reduction of the area of alopecia. A pattern of dispersion of grafts for optimal aesthetic effect is presented together will suggestions about frequency of sessions and amount of transplantation done each time. Hair transplanting begun prior to complete alopecia has advantages that are explained.