------------------------------------------------------------------------------- TITLE: MANAGEMENT OF ALOPECIA SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: February 1, 1995 RESIDENT PHYSICIAN: Denise V. Guendert, M.D. FACULTY: Karen H. Calhoun, M.D., F.A.C.S. 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." History Before 1959 there were only sporadic reports on the surgical treatment of alopecia. Hunt, in 1926 reported on the use of scalp reductions in the treatment of alopecia areata. In 1931, Passot described the use of long temporoparietal transposition flaps for the treatment of male pattern baldness. Okuda in 1939, was the first to write about the use of punch grafts for hair transplantation in cicatricial alopecia, he also advocated the use of such grafts in the eyebrow and mustache areas. In 1959, Orentreich published "Autografts in Alopecias and Other Selected Dermatological Conditions", which launched the use of punch grafts by surgical dermatologists In 1964, Vallis described the use of punch grafts in combination with strip grafts. Recently developed microvascular techniques made the scalp free flaps of Harii, Ohmori, and Ohmori possible in 1974. Juri developed the long temporo-parieto-occipital flap in 1975. Finally, in 1976, Blanchard and Blanchard described a technique of scalp reduction called "scalp lifting", and Radovan reported on the use of tissue expansion in reconstruction, though it wasn't until 1984 that Manders and associates described the use of tissue expansion in the treatment of scalp defects. Anatomy Hair Shaft Composed of keratin, the hair shaft is essentially a collection of dead cells which are the product of the hair follicle. Hair Follicle The hair follicle is an invagination of the epidermis into the underlying dermis. The base of the follicle has an onion-shaped dilatation called the bulb which is hollow at its base and envelopes the dermal papilla. The follicle has two layers, the dermal layer which is composed of fibrous tissue and the epidermal layer. Each follicle has a single muscle, the arrectores pilorum which is inserted into the dermal layer below the entrance of the sebaceous gland duct. The action of the arrectore pilorus is to elevate the hair shaft and express sebum. Cycle of the hair consists of anagen phase which is the period of growth when the follicular cells are multiplying and keratinizing that lasts 2-6 years, the involutional phase when the follicle involutes and migrates closer to surface (club hair), and the telogen phase. The telogen phase is a resting period of lasts approximately 100 days during which the dermal papilla is released from the epidermal investment and no growth occurs. Hair growth occurs at the rate of 0.33mm/day. New hairs are produced following the formation of a new follicle and hair shaft that pushes out the club hair. Scalp Layers include skin, subcutaneous tissue, epicranium or gales aponeurotia, subaponeurosis, and pericranium. The subcutaneous layer is a fibrofatty layer that contains adnexal tissues, nerves, vessels and lymphatics. The epicranium is a continuation of the occipital and frontalis muscles. The subaponeurosis is a layer of loose connective tissue. The main blood supply to the scalp is derived from the following vessels: the superficial temporal artery, occipital artery, internal maxillary artery, posterior auricular artery (all branches of the external carotid artery), and the supratrochlear artery, supraorbital artery (branches of the ophthalmic artery which is off of the internal carotid artery). The veins of the scalp accompany the arteries and drain into the external jugular veins with the exception of the emissary veins which drain into the superior sagittal sinus. The frontal portion of the scalp receives sensory innervation via the supratrochlear and supraorbital nerves. Sensory innervation to the temporal region is provided by the zygomatic nerve which is a branch of the maxillary nerve. Sensation in the parietal scalp is supplied by the greater auricular nerve, this nerve in conjunction with the lesser occipital nerve also innervates the post-auricular scalp. The greater occipital nerve supplies the crown and occiput. Etiology Alopecia can be caused by injury to the living hair root or to the keratinized hair shaft. If only the hair shaft is damaged, the hair loss will be temporary. If the root is damaged,loss may be temporary or permanent. Congenital alopecia may be complete or patchy and may be associated with other adnexal disorders. Normal hair growth rarely occurs in congenital alopecia. Acquired alopecia can have several causes including autoimmune disease, burns, nutritional deficiencies, chemotherapeutics, dermatologic disorders such as psoriasis, fungal infections, radiation exposure, traction, and neoplasms. Space-occupying masses in the scalp cause hair loss secondary to the pressure effects causing atrophy of the follicles or by invasion and replacement of the follicle. Traumatic alopecia may occur secondary to acute injury and scarring, conscious or subconscious rubbing or pulling out of hair or because of chronic pressure as for example during prolonged anesthesia. Several hormonal entities may cause alopecia, these include: hyperpituitarism, hypopituitarism, hypoparathyroidism, hyperthyroidism, hypothyroidism, androgen- secreting tumors, pregnancy, menopause, and diabetes. Alopecia areata is of unknown etiology and has many variants. It occurs suddenly in the absence of above mentioned causative factors. The course of alopecia areata is unpredictable, with either regrowth over a few months or complete loss. Biopsy shows intense lymphocytic infiltrate around hair follicle. The most common type of hair loss by far in men and women is androgenetic alopecia. Those affected are genetically predisposed to this form of hair loss (multifactorial form of inheritance). Androgenetic alopecia affects those scalp follicles with a genetic predisposition to androgen inhibition, in men these exist in the frontal scalp and vertex primarily (male pattern baldness). The follicles in predisposed regions continue to produce hair of decreasing growth rate until static resulting in eventual baldness. There is no difference in testosterone levels in balding and non-balding men. 95% of normal adult men and 75% of women have some androgenetic hair loss. Women usually have the diffuse variant of androgenetic loss whereas men may have diffuse, patterned or both. Clinically apparent thinning requires 25% hair loss. Classification Juri System Degree I consists of loss in the frontal region, Degree II involves the fronto-parietal regions, and degree III the fronto- parieto-occipital. Hamilton Scale 1 - no loss 2 - mild bitemporal recession 2A- mild frontal recession 3 - moderate bitemporal recession 3A- moderate frontal recession 3V- moderate vertex baldness 4-6 worsening involvement of the vertex and bitemporal areas 7 - complete loss frontal and vertex regions Medical Treatment Hormonal therapy and or surgical correction of imbalance is helpful in obtaining hair regrowth in the above mentioned endocrinopathies. Hair regrowth may not occur for several months after therapy is initiated. In some cases, the adrenogenital syndrome for example, treatment merely prevents further hair loss. Treatment of fungal infections is best done with oral griseofulvin until fungal cultures, Wood's light fluorescence, and the microscopic exam of hairs are negative. Response to steroids is both diagnostic and therapeutic for alopecia areata. Intralesional injections of aqueous corticosteroids are the treatment of choice. Triamcinolone suspension 0.05 to 0.1 ml at intervals of 1 to 2 cm of 5 mg/ml is best. Hair regrowth at the site of injection should be present in 4-6 weeks. Injected sites should not be reinjected for 3 months. Discomfort of injections can be minimized with Freon freezing or injections with local. In children, application of topical steroids (0.5% triamcinolone acetonide cream) under impervious occlusion may be helpful. Surgery is contraindicated in alopecia areata. A six month observation period following medical therapy and or surgical therapy of underlying cause is highly recommended prior to hair replacement surgery in alopecia caused by traction, masses, infection, hormonal imbalance, etc... The reason behind this is that follicles are thrown into telogen phase where hair growth ceases. In 1979, the FDA approved the use of Minoxidil as an antihypertensive agent. A side effect of this drug was the development of generalized body hair. In 1983, studies using Minoxidil topically were initiated and have since determined the efficacy and safety of topical Minoxidil. Minoxidil 2% twice a day may be beneficial for patients who are recently balding with areas <10 cm in diameter especially if area to be treated is not completely free of hair. 32% will have good result. Minoxidil may also retard androgenic loss in areas where it is likely to occur. Minoxidil acts as a vasodilator resulting in increased blood flow to the follicles. Histologically a larger hair follicle and thicker hair shaft can be seen. There is no to very minimal absorption and therefore few side effects outside of local dermatitis. The limitations of Minoxidil include: exacerbation of loss when treatment discontinued, delayed effect after initiating treatment (4-12 mos), decline in efficacy with long-term use. Patient Selection and Surgical Planning Important to inquire about general health of patient, presence of bleeding disorders, and wound healing ability. It is also important to determine what the patients expectations are and if they are realistic. The patient must be counseled on the cost of procedure from start to finish, the length of time before he/she can expect hair regrowth, and possible complications. The donor and recipient sites must be thoroughly evaluated to assess for pathology as well as hair availability with regards to recipient bed need. Also important to assess the classification of baldness, hair color, amount of curl (wavy or curly hair covers better but is more difficult to style), texture (thick hair grows in direction it is transplanted despite styling and has more contrast with skin), density (high density growth often requires micrografts to conceal implants), skin color. The patient should be questioned regarding planned hair style following surgery. If punch grafting is to be performed, potential keloid formers should have a small number of trial plugs prior to complete procedure. Patients with diffuse hair loss, non-pattern baldness, and/or young patients with a family history of continued balding are not good candidates for hair transplant surgery. Good candidates include those patients under 50 years with stable hair loss in the frontal region, light skinned patients with dense grey hair or dark skinned patients with dark hair, and no history of scalp surgery. Patients with types III, IV, and V will usually be good candidates for transplant surgery, and planning and hair styling are rarely a problem. Techniques for advanced V and VI rely more on hair/skin color, style, texture etc... The best design for advanced VI and VII is the diffuse thinning look, with avoidance of flaps and standard punch grafts. Surgical options 1. Free composite hair-bearing scalp grafts a. punch grafts b. strip grafts 2. Scalp flaps a. rotation flaps b. transposition flaps 1. lateral scalp flap 2. temporal vertical flap 3. Juri flap c. bipedicle flap d. free scalp flap 3. Scalp reduction a. fractional excision of alopecia b. excision of alopecia with the aid of scalp expanders c. excision of alopecia with the aid of scalp extenders Punch Grafts General guidelines include: attaining a natural look by careful planning of the design and location of the frontal hairline, transplanted hair should grow in normal forward direction if possible, there should be an even distribution of hair throughout, and there should be a good color match between donor and recipient grafts. All forms of hair transplantation are possible because when hairs are redistributed from a region of scalp possessing hairs of high longevity to the balding regions, the hair follicles maintain there inherent longevity. Good candidates for this procedure include highly motivated patients with moderate recession and with adequate dense hair of good quality in the lower occipital and parietal areas. Those patients with Norwood Type VII alopecia may also benefit from mini and micrografting with the goal being to achieve the appearance of moderate thinning. Advantages of this procedure are that it is performed under local and there is a 90% follicle survival as reported by Nordstrom. Disadvantages are the "cornfield" appearance especially if micrografts not used in frontal hairline, total course is time consuming, and there is a several month delay for the development of hair within the grafts The donor and recipient sites are cleansed and the donor hair is clipped to a length of 2mm in a narrow band to ensure coverage of site with surrounding hair during healing. Clipping as opposed to shaving allows for visualization of the direction of hair growth for proper orientation in recipient site. The donor and recipient sites are then sprayed with Freon and anesthetized with injections of 1 or 2 % lidocaine with 1 to 100,000 epinephrine. May use hand driven or motorized punches. Donor punches should be far enough apart to be easily covered by surrounding hair. Grafts should be harvested in the direction of hair growth. The punch sizes most commonly used are 3.5, 3.75 and 4.0mm diameter. Grafts larger than 4mm do not heal as well. Recipient sites should be created with a punch .25 to .5mm smaller than graft. Smaller grafts (micro referring to grafts that contain 1-3 hairs and minigrafts which are a quarter of the standard graft) can be harvested from standard plugs are used to fill in space between frontal grafts to create a more natural hairline. Recipient sites for micro and minigrafts can be created with a 20 gauge needle. Individual hair placement with correct angulation of growth can be accomplished by retrograde dissection of hair with attached follicle followed by transplantation using a number 5 French eye cutting-edge needle. Plugs can usually be removed with forceps. If the grafts are attached to underlying tissue a small pair of scissors may be used to cut them below the follicles. Grafts should be placed in sterile saline immediately. Pressure is applied to donor and recipient graft sites with moistened gauze for hemostasis while the donor grafts are prepared. Preparation of donor plugs includes trimming of excess fat and galea. Some surgeons close each donor site with a single nylon suture for hemostasis and to reduce scarring Separate recipient sites except in the hairline by a width corresponding to the punch diameter to assure adequate blood supply. Intervening space can later be grafted. Place grafts in recipient bed so hairs are angled in correct direction. The fibrin clot is usually adequate to hold the plugs in place. "Cobblestoning" or lifting of the grafts can occur especially if hemostasis is inadequate, for this reason, some physicians recommend the use of tissue adhesive (Alkyl-2-cyanoacrylate). Tissue adhesive also eliminates the need for a dressing After completion, the grafts are covered with antibiotic ointment and gauze which is secured in place with an ace wrap. Ten to sixty plugs are usually transplanted at each visit. These are allowed to heal for 2 weeks prior to further intervention in same area longer time periods (3-4 months) should elapse prior to transplantation immediately between new grafts. Other sites may be grafted the next day. . Post-operative care includes limited activity for five days, no disruption of the grafts for ten days, no shampooing or showering for five days, no picking at the graft sites, and no hair pieces or hats as increased moisture may loosen grafts. Complications include: infection, keloid formation, scalp numbness,"cobblestoning" of grafts, and lack of hair growth. Strip Grafts The strip graft is a composite graft of hair-bearing skin limited in width but unlimited length. Specifically for reconstruction of the hairline. Usually performed in conjunction with punch grafts. Approximately one-third of patients undergoing punch grafts will require a hairline strip graft to improve the cosmetic result. Important to start punch grafting from the existing hairline so that a strip graft, is necessary is not placed to low on the forehead. It is imperative to create a natural hairline with a slight widow's peak, not one that runs straight across the frontal region. Kabaker recommends that the distance from the midpoint of the hairline to the root of the nose should not be less than the measured distance from the nasolabial junction to the lower border of the chin. The patient should be prepped as for punch grafts. The width of the graft can be no greater than 7mm and should be 5-6mm wide if placed directly in front of punch grafts, its length is only limited by availability and /or length of frontal hairline. The strip grafts should be harvested in a horizontal direction from the parieto-occipital regions There is a special instrument called the parallel double-bladed holder which requires two 15 blades designed for this procedure, this instrument cuts through the epidermis at which point a single 15 blade should be used in the direction of the follicles and to the depth of the galea. The frontal hairline can be reconstructed in single procedure by cutting graft into 2 segments, overlapping these segments in the midline by 1/8 inch or in two procedures where one side is completed at a time 2-4 weeks apart. Recipient site created by single incision through the galea which allows spreading of the wound to allow placement of the graft. The incision can be placed through the center of the punch grafts to create a less linear hairline. The graft is secured with running nylon and a light pressure dressing is applied. Many recommend prophylactic antibiotics for a week. A variation of the strip graft is the running -W strip graft. Designed to avoid the unnatural straight hairline of the standard strip graft. This form of transplant is based on the broken line closure used in scar revision. A special instrument has been designed to harvest a strip graft with a running W margin as well as create a recipient site. Post-operative care is the same as for punch grafts. Additional punch grafts can be done following a strip graft, but not for three months. Complications include those associated with punch grafts as well as the following: incomplete growth of hair, indentation of the strip graft secondary to creating a recipient wound deeper than the donor graft, poorly positioned frontal hairline. Scalp Flaps This form of treatment is useful in patients with a stable pattern of frontal baldness with excellent density in the temporal areas who desire a dense growth of hair in frontal hairline and in patients with fine and/or sparse hair since free grafts in the latter often result in insignificant growth of hair. Often used in patients with traumatic alopecia. Flaps for treatment of alopecia are very appealing to patients since they have immediate results. Men in their teens or twenties and those with a family history of eventual balding in the temporal regions, and those with scarring in the donor areas are not good candidates. Most patients are more comfortable undergoing flap surgery under general anesthesia, though local is an option. When there is recession of the entire frontal hairline, bilateral flaps should be used and transposed in separate operations four months apart, this is done to assure a continuous hairline if there should be partial loss of hair in one or both flaps distally. Also, it is much more difficult to close two verses one donor site. The flaps should be long enough to overlap a few centimeters in the midline (12.5 to 15 cm). If there is a residual forelock that is usable, shorter flaps can be used to overlap on the forelock except if the patient is under 40 yrs, in this case it is better to perform a unilateral flap and wait until hairline stabilizes before performing flap on other side. A sparse forelock should be ignored. Bald regions posterior to the new hairline can be treated with punch grafts or additional flaps. When performing flaps, it is important to remember that if the length to width ratio exceeds 5:1 they must be delayed. Rotation Flaps These flaps are useful for the treatment of small areas of cicatricial alopecia. These flaps are the same as would be used in local flap closure anywhere else except there is less elasticity within the scalp tissue and flaps larger than the area to be excised are required. Lateral Scalp Flap As designed by Elliott in 1982, the lateral scalp flap is shorter than other scalp flaps which allows for easy closure of the donor site and eliminates the need for delay. This flap is usually performed under local anesthesia with sedation. The hair is not shaved. The lateral flap is based at the anterior hairline in the temporal region, is directed posteriorly above the ear and across the parietal scalp, and has a width of 2.5cm to 3cm with a length of 12.5-16cm. The superficial temporal artery enters the base of the flap, but as it courses vertically it exits the flap shortly thereafter. This flap will survive even if the superficial temporal artery is ligated at its origin. All incisions are beveled in direction of the hairs and flap is raised in the subgaleal plane. A corresponding segment of recipient scalp is excised to base of flap. Important to avoid a dogear that may require excision since this will result in obvious lack of hairgrowth along the new hairline. A small suction drain can be used under flap if hemostasis is incomplete. A moderate pressure dressing is left in place for 2 days. Cautious grooming is allowed when the dressing removed, but no shampooing should occur for 6 days. Postoperative complications include: flap loss (rare), partial loss of hair at distal end of flap, infection, hematoma, and improperly placed hairline. Temporal Vertical Flap Designed by Nataf in 1984. This flap is based superiorly in the parietal scalp and extends inferiorly along either the pre- or postauricular region. It was designed to orient hair growth in the natural forward direction along the frontal hairline, but because of retrograde circulation there is a higher likelihood of flap demise than with other flaps. Nataf claimed that flaps measuring 20cm in length by 2-3cm in width were possible though this required delay times two. Perhaps the best use of these flaps is to augment the hairline created by Juri flaps contralateral to the Juri flap base. Juri Flap Allows reconstruction of the entire hairline with single flap. The Juri flap is a pedicled transposition flap based on the superficial temporal artery. In patients with more advanced stages of male pattern baldness, bilateral Juri flaps can be combined with scalp reduction. The Juri flap requires four stages. In the first stage, the flap is designed and incised in its proximal 3/4ths through the galea without elevation. The flap is based 3 cm above the helix with a 4cm base and the STA located centrally. The flap inclines 35-45 degrees in an anterior and superior direction into the temporal region and then gently arches into the parietal and occipital regions not past the midline. The flap length is measured as the length from the base to the distal extent of the hairline plus 4 cm. The second stage occurs one week after the first and consists of incising and elevating the distal 1/4th of the flap and ligating the occipital plexus prior to replacing the flap. The third stage is elevation of the entire flap in a subgaleal plane and transposition of the flap into the recipient incision one week after the second stage. Prior to securing the flap, a 1mm strip of epidermis is removed from the anterior aspect of the flap and buried beneath the forehead skin to allow hair growth from the dermis to later camouflage the scar. The final stage which occurs 6 weeks after transposition is excision of the dogear at the base of the flap and insetting of the proximal and distal ends to create a normal temporal hairline. The possible complications are the same as for the lateral scalp flap though flap loss is more common. Bipedicle flap This particular flap is useful in selected cases of cicatricial alopecia. Also known as the visor flap, it is based on both superficial temporal arteries and can replace hairbearing scalp in the central frontal region. Free Scalp Flap The above mentioned scalp flaps have similar disadvantages, these include: restricted positioning, limited control over the direction of hair growth, formation of dogears at the base. These disadvantages led to the use of microvascular free scalp flaps in the treatment of alopecia in 1974 by Harii, Ohmori, and Ohmori. Another advantage of the free scalp flap is the ability to transplant a large area of hairbearing scalp in one procedure. The occipital flap is based on the occipital artery which supplies the lateral half of the posterior scalp and has connections with the contralateral occipital artery across the midline, making the option of a complete posterior scalp flap a possibility. Because of the large, consistent vascular anatomy, there is significant variability allowed with this flap, Depending on the desired length, width, direction of the hair follicles, the flap can be based on a long vertical branch or a horizontal branch across the midline. When performing scalp free flaps, the flap is raised in a subgaleal plane beginning away from the pedicle. Greater pedicle length can be achieved by retracting the SCM laterally. The recipient vessel is the superficial temporal artery. Disadvantages include patient positioning, time consumption, morbidity associated with losing the flap. In 1980, Ohmori designed a temporo-parieto-occipital free flap (Juri flap transformed into a free flap) for reconstruction of the frontal and temporal areas in postburn alopecia. The flap is elevated from the intact side of the scalp and anastomosed to the contralateral superficial temporal vessels. The risks are the same as for the occipital flap. Scalp Reduction Scalp reduction is indicated for the treatment of partial or complete elimination of alopecia on the vertex of the scalp secondary to male pattern baldness and in the treatment of burn alopecia. The frontal region is best reconstructed with grafts. Scalp reduction will greatly reduce the number of grafts needed. The amount of scalp that can be excised is related to the elasticity of the individual patient's scalp and a good candidate has a loose scalp. Patients to undergo reduction should have adequate density of hair in the temporal and occipital regions, as stretching will lead to a reduction in density, which lessens the quality of future punch grafts.Peri-operative antibiotics should be given. The procedure is often done with local anesthesia and sedation. Paramedian excision is begun ~ 2cm behind the proposed hairline in an S-shaped or crescent fashion towards the occipital scalp. Some use Y or U shaped incisions and some perform midline excision. The greatest width of reduction allowed is 3.5 to 4cm. Undermining is then performed in a subgaleal plane laterally and posteriorly. Incisions should be made in the galea perpendicular and parallel to the excision in a checkerboard pattern to allow for easier closure. The scalp should be advanced anteriorly and medially. Two penrose drains (some may use suction drains) should be placed, and a light pressure dressing applied. A series of reductions is usually required to excise entire area of alopecia. Z-plasties and/or punch grafts are helpful in camouflaging the resultant scar which tends to be quite obvious since the hair adjacent grows laterally. Additional reductions should be performed at intervals of 3 months. Possible complications include: infection, alopecia, flap ischemia, scarring, and hematoma. Another problem with reduction surgery is the phenomenon of "stretchback". This refers to the reappearance of alopecia 2-3 months after reduction secondary to the bald scalp stretching back to its original laxity. Over 50% of strectchback occurs within 1cm of the incision. The midline form of reduction therefore places the greatest amount of scalp at risk for stretchback, the paramedian form allows less, and the Ushaped excision the least. Retention sutures and silastic strips can help to eliminate the small amount of stretchback that occurs with the U-shaped excision and scalp lifting. A variant of scalp reduction is "scalp lifting", which is essentially extensive scalp reduction made possible by extensive undermining in the posterior and lateral directions. Ideal candidates should have a bald crown width less than 13cm and an occipital donor site height of 9-10cm at least. This requires two procedures, the first is bilateral occipito-parietal flaps that allows removal of a Ushaped section of scalp, and the second is a bitemporal flap which unites both parietal regions in the midline. The first procedure incision lies 1 cm posterior to the temporal hairline and in front of the dopplered STA, it the extends superiorly and posteriorly along the bald crown. The subsequent procedure uses the same incision. Undermining is then performed to the nape of the neck. The occipitalis and postauricular muscles must be transected. The potential for scalp necrosis can be reduced by occipital artery ligation 4-6 weeks before first scalp lift or by transecting one artery at a time with each lift. Scalp lifting allows greater reductions of scalp since undermining is performed in the more elastic regions ie those of the lower occipital and lower parietal scalp. Complications are the same as those of scalp reduction. Scalp Reduction With Expanders Expanders have allowed the completion of scalp reduction in two procedures. Unfortunately, most patients seeking surgical treatment of male pattern baldness are unlikely to proceed with expansion because they find this method cosmetically unappealing. Patients with alopecia secondary to burns or other trauma are less likely to refuse scalp expansion. The expanders used in reduction vary from 200 to 700cc (the size should be sufficient enough that most of the hairbearing scalp is expanded,, as this distributes the hair follicles evenly) and can be rectangular, crescent, or custom shape. Expanders are placed in a subgaleal plane through an incision at the border of the normal scalp and area of alopecia. For reduction of the crown, it is best to use either a crescent shaped expander or two rectangular expanders in the parieto-occipital regions. Inflation of the expander is begun 2 weeks after insertion and repeated weekly until adequate hairbearing scalp exists. Expanders also allow the creation of larger flaps such as the Juri flap (5cm by 23cm) by making closure of the donor site defect easier. In these patients, the tissue expander is positioned beneath the intended flap. synchronous bilateral Juri flaps are also possible following tissue expansion as is the combination of scalp reduction and creation of a frontal hairline with transposition flap. Potential complications are several and include: implant failure, implant extrusion, flap ischemia, scarring, infection, temporary or permanent alopecia within the flap, inappropriate flap placement. Intraoperative expansion theoretically allows for a single stage operation and cosmetic deformity secondary to expansion is limited to the OR, but usually two or three reductions are necessary since it allows less stretching of the scalp. Many practitioners feel that intraoperative expansion yields no more tissue than circumferential undermining. The procedure for intraoperative expansion is as follows: An incision along the planned site of reduction is made to the subgaleal plane, a pocket is formed beneath the hair bearing scalp, a 125 to 250ml expander is placed, the skin is reaproximated with several towel clamps, the expander is then filled with saline in cycles of 1-2 minutes three or four times, the process is then repeated on the contralateral side, finally the redundant scalp is excised and the wound closed. The complications are similar to those of standard expansion. Scalp Reduction With Extenders This procedure was developed to avoid some of the pitfalls of both standard reduction and expansion with reduction. With reduction, both the bald scalp and the hairbearing scalp are stretched and therefore prolongs the time required to completely excise bald scalp and the density of hair along the crown is reduced secondary to stretchback. Expanders result in cosmetic deformity that most patients find unacceptable. Scalp extension is made possible by the placement, in the subgaleal plane, of a rectangular silastic sheet with a row of titanium hooks on either side following reduction. The extender allows continuous stretch of the hairbearing scalp for 30-40 days, after which the process is repeated until there is no remaining crown baldness. Comparisons of scalp extension to reduction and expansion have resulted in the following findings: Single extension results in an average width of excision of 9.4cm while for reduction alone to remove 9.6cm of scalp four operations are required. The risks of extension are similar to those of expansion, though the risk of extrusion and ischemia is less. ------------------------------------------------------------------------- Bibliography Anderson, R.D. The Expanded "BAT" Flap for Treatment of Male Pattern Baldness. Annals of Plastic Surgery Nov. 1993;31:385-391 Argenta, L.C. etal Treatment of Male Pattern Baldness by Tissue Expanders in Courtiss, E.H. ed Male Aesthetic Surgery, second edition:212-225 Brandy D.A. Circumferential Scalp Reduction.The Journal of Dermatology, Surgery, and Oncology April 1994;20:277-284 Brandy, D.A. The Use of Retention Sutures and Tensed Silastic- Dacron Strips for the Prevention of Stretch-Back After Alopecia- reducing Procedures. The Journal of Dermatology, Surgery, and Oncology Oct. 1994;20:666-672 Caputy, G.G. and Flowers, R.S. The "Pluck and Sew" Technique of Individual Hair Follicle Placement. Plastic and Reconstructive Surgery March 1994;93:615-620 Elliot, R.M. etal Advanced Use of Tissue Adhesive in Hair Transplantation. The Journal of Dermatology, Surgery, and Oncology Sept. 1993;19:853-860 Elliot, R.A. Lateral Scalp Flaps in Rees, T.D. ed Aesthetic Plastic Surgery, volume II, Philadelphia,W.B. Saunders :875-885 Frechet,P. Scalp Extension. The Journal of Dermatology, Surgery, and Oncology July 1993;19:616-622 Friedenthal,R.P. Treatment of Male Pattern Baldness by Alopecia Reduction, in Courtiss, E.H. ed Male Aesthetic Surgery, second edition, 201-211 Konior,R.J. and Kridel,R.W. Management of Alopecia, in Bailey,B.J ed Head and Neck Surgery-Otolaryngology, Vol. II, Philadelphia, J.B. Lippencott Co., 2338-2348 Mandy, S.H. Intraoperative Expander-Assisted Scalp Reduction. The Journal of Dermatology, Surgery, and Oncology Dec. 1993;19:1117- 1119 Matloub, H.S. etal The Occipital Artery Flap for Transfer of Hair- bearing Tissue. Annals of Plastic Surgery Dec. 1992;29:491-495 Nelson, B.R. etal Hair Transplantation in Advanced Male Pattern Alopecia. The Journal of Dermatology, Surgery, and Oncology July 1991;17:567-573 Nelson, B.R. etal The Paramedian Scalp Reduction With Posterior Z- Plasty. The Journal of Dermatology, Surgery, and Oncology Nov. 1992;18:996-998 Norwood, O.T. Patient Selection, Hair Transplant Design, and Hairstyle. The Journal of Dermatology, Surgery, and Oncology May 1992;18:386-394 Orentreich, N. Punch Grafts in ReesT.D. ed Aesthetic Plastic Surgery, volume II, Philadelphia, W.B. Saunders:865-875 Swinehart, J.M. and Brandy, D.A. Scalp Lifting. The Journal of Dermatology, Surgery, and Oncology Sept. 1994;20:600-612 Vallis, C.P. Strip Grafts in Rees, T.D. ed Aesthetic Plastic Surgery, volume II, Philadelphia, W.B. Saunders:885-889 Vallis, C.P. Hair Replacement Surgery in McCarthy, J.G. ed Plastic Surgery, 1990, volume 2 1514-1537 -----------------------------END-----------------------------------------