--------------------------------------------------------------------------- TITLE: MANAGING ALOPECIA SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: November 6, 1991 RESIDENT PHYSICIAN: Bruce A. Scott, M.D. FACULTY: Karen Calhoun, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. --------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. Anatomy of Hair and Hair Loss A. Hair follicle 1. Basic structure - Hair shaft - Surrounding shafts (x2) - Germinative bulb 2. Growth cycle a. Anagen phase (Growing) - 2-6 years - Control emanates from papilla b. Involutional Phase - Follicle involutes and moves closer to surface (club hair) c. Telogen Phase (Resting) - 3-4 months d. New hair cycle - Formation of new follicle and shaft pushes club hair out e. Grows approximately 0.35 mm/day B. Scalp Anatomy 1. Skin - Thickest in body 2. Subcutaneous - Contains adnexal tissues, nerves, lymphatics, vessels 3. Epicranium (Gales aponeurotia) - Continuation of occipital and frontalis muscles - Musculofascial layer - Strongest layer 4. Subaponeurosis - Loose connective tissue plane 5. Pericranium - Firmly attached to skull C. Hairline Anatomy 1. Curved anterior hairline with bilateral elevation in the widow peak areas - Don't want to restore line of youth, but of normal male with some recession 2. Kabaker - Midpoint of hairline to root of nose = nasolabial junction to menton 3. Transplants shouldn't be placed anterior to temporal hair D. Hair loss 1. Diffuse loss vs. patterned - 75% of women have diffuse loss - Clinically apparent thinning requires 25% hair loss 2. Damage to hair shaft => temporary loss 3. Damage to follicle: a. Immediate regrowth b. Delayed regrowth c. Permanent loss II. Classification of Alopecias by Etiology A. Androgenic 1. Induced by androgens 2. Only in persons genetically predisposed (Multifactoral mode of inheritance) 3. Male pattern baldness is classic form - Bitemporal and vertex 4. Most hair loss in men and women is androgenic - 95% of men have some loss of this type - 60 - 80% of Caucasian population with advancing age 5. Each hair follicle is genetically predisposed to respond or remain insensitive to androgens 6. Relation to androgens a. If castrated before puberty => no hair loss - Giving testosterone later in life => hair loss - (Hippocrates 400BC) b. No difference in testosterone levels of balding and non-balding c. May be difference in receptors (? at what level) d. Estrogen and progesterone topically, systemically and locally not effective in preventing or reversing loss or presence of testosterone that matters. B. Associated with neoplastic disorders 1. Space occupying masses in the scalp can cause loss by pressure effect or by direct invasion 2. Loss may be temporary C. Traumatic 1. Externally applied traction or pressure a. Acute i. With laceration or sudden traction - if scarring occurs - Loss most likely permanent ii. Self-induced - plucking, combing, etc. b. Chronic i. Positioning with comatose patients, GETA, infants ii. Chronic traction - pony tails, braids, etc. 2. Thermal injury a. Heat b. Cold 3. Chemical injury a. Associated with dermatitis b. Sodium sulfide, calcium sulfide, dimethylamine => temporary loss 4. Radiation (x-ray, radioisotopes, radium, etc.) a. Short exposure - surface effect damages epithelial component with temporary loss (3-5 weeks loss complete, 10 weeks regrowth) b. Prolonged exposure - dermal papillae destroyed => permanent loss E. Hormonal shifts 1. Hyperpituitarism 2. Hypopituitarism 3. Hyperthyroidism 4. Hypothyroidism 5. Hypocorticoidism 6. Adrenogenital syndrome 7. Pregnancy, postpartum 8. Menopause 9. Diabetes F. Infectious 1. Viruses (Herpes simplex, varicella, zoster) 2. Bacterial (M. tuberculosis, M. leprae) 3. Fungal (Usually temporary) 4. Systemic a. Sepsis b. Typhoid fever c. Scarlet fever d. Malaria e. Syphilis f. Erysipelas G. Neurogenic / Psychiatric 1. Trichotillomania - conscious or subconscious pulling out of hair 2. Lichen chronicus circumscriptus - chronic scratching and rubbing => hair loss 3. Stress related (?) H. Toxic / Pharmacologic 1. Non-specific alopecia - Heavy metals 2. Follicle - specific alopecia (typically permanent) - Antineoplastic drugs - Intense metabolic activity makes hair very susceptible H. Nutritional 1. Deprivation must be severe to result in hair loss 2. Kwashiokor, sprue, celiac disease (Diabetes, hypervitaminosis A, anemia may rarely produce alopecia) I. Alopecia Areata 1. Sudden hair loss 2. Otherwise asymptomatic 3. Unpredictable course 4. Biopsy of area shows intense lymphatic infiltrate around hair follicle which suggests immune etiology - Some progress to total loss - Others - regrowth may occur with no residual 5. Treat with topical or intralesional steroids III. Classification of Alopecia by Severity A. Juri System 1. Degree I - Frontal region 2. Degree II - Frontoparietal 3. Degree III - Fronto-parieto-occipital B. Hamilton Scale 1 No loss 2 Mild bitemporal recession - isolated 2A Mild frontal recession - isolated 3 Moderate bitemporal recession 3A Moderate frontal recession 3V Moderate vertex baldness 4-6 Worsening involvement of vertex and bitemporal areas 7 Complete frontal and vertex IV. Non-surgical Treatment A. Endocrine therapy 1. Estrogens stimulate and androgens inhibit growth of predisposed follicles 2. Treatment of endocrine abnormalities 3. Otherwise slows loss, not efficacious B. Infection therapy - Treat local viral, bacterial or fungal infection C. Intralesional steroids - Therapy of choice for areata D. Minoxidil - 2%, twice daily, lotion base 1. Efficacy a. DeVillez i. 32% with good cosmetic result and increased number of hairs ii. Characteristics of responders - Recently balding - Smaller area of baldness (< 10 cm diameter) - Higher initial hair count, not completely bald areas b. May retard androgenic loss - Treat areas where loss is predicted 2. Mechanism - unknown a. Increased blood flow to follicles - vasodilator b. Direct effect on keratinocytes c. Other unknown mechanism 3. Side effects (topical use) a. Low to no systemic absorption b. No major systemic side effects reported c. Local dermatitis, pruritus 4. Limitations a. Stopping daily treatment exacerbates loss b. Slow effect (4-12 months) c. Efficacy declines with long-term use d. Monetary cost and time 5. May be useful as adjunct in transplantation to improve and speed up regrowth V. Surgical Therapy A. Poor candidates for surgical therapy 1. Diffuse hair loss 2. Scalp disease, dermatitis 3. Non-pattern baldness 4. Family history of continued balding 5. Emotionally unstable 6. Medically ill 7. Insufficient donor area B. Good candidates for surgical therapy 1. Stable hair loss 2. Recession of anterior line is major component 3. Lateral donor sites without diffuse loss 4. Dense, dark hair 5. Age < 50 6. No previous scalp scars, surgery 7. No family history of complete baldness C. Punch Grafts 1. Donor dominance - Transplanted hairs maintain original characteristics 2. Technique a. Donor hair clipped to 2 mm (Allow visualization of hair orientation) b. Local anesthesia - Freon and Lidocaine c. Punches of various diameters (2.0, 2.5, 3.0, 3.5, 4.0 mm) - Choose donor site to match color and density - Donor punch .5 mm larger - 4 mm = 12-20 hairs - Smaller punches placed between 4.0 mm grafts to create better appearance. (Grafts > 4.0 mm don't take as well) d. Separate placements by approximately 4 mm - Additional plugs placed later - between cut at 90 degree for 1 mm, then angle direction of hair - Orient in graft site with normal lines - Donor cuts parallel to hairs - Keep plugs moist with saline e Pressure for hemostasis, wrap head, suture donor site PRN - Plugs may be stored at 10oC (< 3 weeks) - Fibrin clot holds plugs in place - Antibiotic ointment, gauze, ace wraps f. Allow 2-6 weeks before repeating - 3rd session - approximately 4 months 3. Post-op care a. No shampooing for 5 days b. Comb gently c. Hairs will fall out, regrowth in approximately 3 months d. Continue to grow as long as donor site. e. Avoid wearing hair piece (sweat and decreased ventilation) 4. Advantages a. Local procedure/ less risk b. high yield of transplanted hairs -Nordstrom 1989: 90% follicle survival 5. Complications a. Keloid/hypertropic scar at donor area b. Infection/osteo c. Numbness d. Hematomas/bleeding e. AV fistula 6. Disadvantages a. Abnormal appearing clusters of hairs i. Cornfield appearance ii. Density problems b. Time consuming for surgeon and patient - Sessions, total course c. Delay to hair bearing (months) d. Decreased yield in scarred areas e. Scarring in donor area 7. Micrographs and minigrafts a. contain 1 to several hairs each b. technique i. harvest from other plugs ii. recipient hole made with 20 gauge needle iii. dilators placed(hemostasis,ease) iv. 15 - 20 graphs per transplant session c. Advantage helps blur the unnatural hairline d. disadvantages time consuming and tedious D. Strip Grafts 1. For creation of new frontal hairline 2. Used in combination with punches 3. Avoids tufted appearance anteriorly 4. Punches must avoid area of planned strip 5. Technique a. 7 mm strip b. Horizontal orientation in parietal area c. Initial incision parallel - 1 mm deep d. Deeper incisions follow follicles down to galea e. Graft placed in two pieces - overlap in middle f. Single incision along frontal hairline Primary closure of donor site g. Graft placed with hair pointing anteriorly Sutured in place 6. Running "W" variation a. Avoids unnatural straight hair line b. Instrument (Razor blade with 4 mm sides of 90o "W" shapes) to create graft and recipient incisions ("Cookie cutters") c. Running suture through apex and valley of each d. Often used for central portion only e. Disadvantages i. Decreased density of hair ii. Time consuming 7. False growth in 3 - 4 weeks - Shed in 2 - 3 months - Permanent regrowth (1 cm/month) 8. Complications a. Difference in wound depth of graft and recipient - unlevel result b. Poorly positioned graft c. Numbness behind graft (usually temporary) d. Loss of graft E. Excision (Alopecia Reduction) 1. Excision of area of bald or balding scalp 2. Technique a. Multiple incision designs - U shaped - Crescent shaped - Midline ellipse (most popular) - Inverted "Y" (Less distortion of vertex fringe) - "I" shaped advancement (brings posterior hair forward) b. Beveled incision c. Wide undermining at subgalea level d. Galeotomies (if necessary) to decrease tension e. Two layer closure (galea and skin) f. Best to excise less and have less tension g. May repeat 8-12 weeks 3. Advantages a. Technically easy (local anesthesia) b. Rapid result c. Good for use in vertex d. Very good if baldness not involving frontal area 4. Complications a. Bleeding/hematoma b. Infection c. Wound dehiscence d. Numbness e. Necrosis (too much tension) f. Scarring 5. Disadvantages a. Stretch back i. Estimated by Nordstrom studies that 30-50% (2/3 stretch within 1 cm. of scar) ii. Bald skin stretches most a. Hair bearing skin is more resistant to stretch b. Bald skin closest to closure and tension decreased geometrically from around edge b. Scar in midline i. Visible ii. Affects hair styling even if edges come together iii. Unnatural part - hair divergence c. Worsens frontal recession, narrows hairline, and pulls occiput up d. Limited potential by scalp laxity and undermining e. Limits future therapy (Remember baldness may continue to advance) 6. Variations a. Mini reductions - used for removal of small areas with flaps or grafting - Less complications b. Parmedian scalp reduction i. Technique - Excision placed lateraly and extends across midline posterior, not beyond frontal hairline anterior. - Curvilinear design ii. Advantages a. Less distortion of hairline b. Greater area excised c. Avoids midline scar d. Better visualization e. Hairbearing skin on fringe of excision (stretch) c. Multiple Z-plasties for reorientation of hair prevent unnatural divergence 7. Tissue expanders a. Expand the hair bearing skin preferentially with proper design and placement of expander b. Technique 1. Incision for placement designed with excision or flap in mind - U shaped - Crescent shaped - Rectangular x 2 2. Undermine area of placement - Subgaleal 3. Absolute hemostasis and sterility 4. Placement - placed in temporal, occipital, or parietal area 5. Healing x 2 weeks 6. Gradual expansion, twice weekly - Cosmetically acceptable until final 2 weeks - Complete at approximately 52-54 cm ear to ear (6 - 8 wks) - Option of daytime deflation c. Advantages 1. Increase in hair bearing surface area 2. Allows excision of more bald area without tension 3. Increases vascularity of expanded area (?) d. Disadvantages 1. Requires highly motivated patient 2. Cosmetically deforming 3. Time consuming / multiple office visits e. Complications 1. Infection 2. Hematoma 3. Bone resorption 4. Necrosis 5. Expander failure 6. Wound breakdown with exposure of expander 7. Hair loss above expander F. Flaps 1. Small transposition flaps - small area of alopecia to close 2. Large transposition flaps a. Juri 1972 - Temporoparietooccipital (TPO) - Twice delayed (7:1 length/width) - 4.0 cm wide - Extends across entire frontal hairline b. Temporoparietal flaps - Other designs with better length/width ratio that don't require delay i. Inferior based - Nondelayed - Narrow (2.5 cm) - Rotated extends beyond midpoint of forehead - Second flap (2 weeks later) from opposite side for completion ii. Patients with anterior baldness iii. Patients with heavily punch-grafted donor sites iv. Patients without intact superficial temporal artery 3. Technique a. Let hair grow long b. Local vs GETA c. Donor 1. Superior incision parallel to permanent fringe - Flap approximately 3-4 cm wide - Based on superficial temporal artery (lesser degree on post-auricular artery) 2. First delay (Juri) - Incise and elevate 2/3 of desired length 3. Second delay (Juri) - Incise and elevate distal 1/3 4. Bevel cuts away (avoid damage to hair follicles and hide scar with regrowth) d. Recipient Incision 1. Anterior hairline incisions to frontalis muscle 2. Undermine equivalent to flap 3. Back cut after placement of flap 4. Drains and pressure dressing e. Sliding rotational/advancement closure of donor site 4. Advantages a. Dense hair b. Uniformity of hair c. Rapid result d. Natural hairline 5. Disadvantages a. Limited width of flaps (5.0 cm maximum) b. Potential for further loss c. Posterior orientation of hair d. Abrupt hairline e. Delays/major surgery 6. Complications a. Scarring (donor and recipient) b. Hair loss c. Necrosis of flap d. Hemorrhage/hematoma e. Infection 7. Variations a. Bilateral/smaller flaps - Narrower/shorter flap (2.5 cm wide and taper) - No delay - 1 side at a time - Overlap tips b. Tissue expander - Incision for placement along planned superior incision - Increase vascularity, increase survival of flap - Easier donor site closure - Useful in patients with tight scalps --------------------------------------------------------------------------- BIBLIOGRAPHY 1. Alt TH. "Advantages of the Paramedian Scalp Reduction." J. Dermatol. Surg. Oncol. March 1988;14(3):257-267. 2. Anderson RD. "Expansion-Assisted Treatment of Male Pattern Baldness." Clinics in Plastics Surgery. July 1987;14(3):477-490. 3. Dardour J-C. "Treatment of Male Baldness." Annals of Plastic Surgery. Oct. 1986:17(4):267-273. 4. Kabaker SS et al. "Expanded Pedicle Scalp Flaps for Baldness: Is a Delay Necessary?" Facial Plastic Surgery International Quarterly Monographs. July 1988;5(4):356-361. 5. Kulick MI. "Topical Minoxidil: Its Use in Treatment of Male Pattern Baldness." 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