Scalp Reduction Surgery - Factors, Techniques, and Complications

Introduction

Hair loss from the scalp is also called alopecia. Blanchard and Blanchard, in 1976, explained the scalp reduction surgical technique. Newer techniques are evolving to meet patients' expectations. Scalp reduction is also called alopecia reduction (AR). It involves the removal and replacement of the hairless scalp.

What Are the Factors Involving Scalp Reduction Surgery?

AR is done for male pattern hair loss (MPHL) and cicatrical alopecia. Cicatricial alopecia is a group of conditions with hair follicle destruction. It leads to scarring. Hence, all patients are not ideal candidates for AR. The success of the procedure depends upon the following factors.

1. Patient’s General Condition: The patient must have good health. Any underlying medical conditions, such as uncontrolled diabetes mellitus and hypertension, negate the surgery.

2. Degree and Pattern of Hair Loss: Candidates with a large area of hair loss and dense hair on the scalp sides and back (donor hair) are a good choice. The ideal patient is above age 40 and has stable hair loss. Hair loss due to age and genetics is considered. Alopecia areata is an autoimmune disorder with patchy hair loss. Scalp reduction surgery is indicated in this condition.

3. Scalp Laxity: Laxity is the ability to stretch. Scalp laxity is the basis of alopecia reduction surgery. The property exploited in this surgery is the scalp’s ability to stretch. The bald scalp is surgically removed, followed by stretching of the hair-bearing area. When the scalp skin is stretched for a long time, tissue growth occurs. Therefore, a good amount of scalp laxity is required.

4. Patient’s Expectations: Discussion with the surgeon is very important. A young patient with progressing hair loss and high expectations is unsuitable for the surgery. Therefore, surgeons must counsel patients about some hair loss near the incision following the surgery.

5. Timing of the Surgery: AR is most effective when combined with hair transplantation. It is especially true in the front areas of the scalp. Also, AR can be planned before, during, or after the hair transplant. However, AR done before hair transplantation ensures a good blood supply and scalp flexibility.

What Are the Different Techniques of Scalp Reduction?

Preoperative preparation involves a scalp massage started about two months before the procedure. The scalp massage gives good scalp laxity. The type of anesthesia depends on the procedure. For major AR, general anesthesia (GA) is recommended. However, a small hair loss repair can be done under local anesthesia. Various techniques employed for AR are:

1. Simple AR: Simple AR is done with an ellipse, inverted- Y, a flat S- shape, or an M design. These patterns warrant preservation of the hair-containing area and most bald scalp removal. The design choice depends on the individual and hair loss pattern. An incision is made in a sloping manner on the scalp side up to the connective tissue (galea aponeurotica). Dissection is done to create flaps that result in minimal bleeding. The flaps are overlapped, and a two-layer closure is done with sutures. Two-layer suture involves the closure of the connective tissue followed by the skin.

2. Major AR: It is also called an extensive scalp lift. Patients require a hospital stay for a day or two after the procedure. A major AR reduces the number of procedures for bald scalp excision. It involves cutting the nerves and vessels. Hence, increased scalp flap mobility is attained. Major AR is done in two stages. The first stage creates a flap on the scalp's front, top, and back sides. About three months later, the second stage of surgery is done. The previous scar is traced, and flaps are raised on the sides (temporal). The closure is similar to the simple AR.

3. AR With Prior Scalp Extension: Frechet, in 1993, devised a scalp extension procedure. Scalp extension uses an extender sheet. The scalp extender comprises a thin material made of silicone and plastic (bioplastic) with hooks. This technique is useful in extensive hair loss and the limited availability of donor hair. The scalp extender is an implantable device. Following a midline incision, the extender is attached to the connective tissue of the hair-bearing area on one side. After stretching it to 100 percent of the original size, it is hooked to the fibrous tissue on the opposite side. It is left for about one month. The principle is reducing the distance between the two hooks due to scalp laxity. Using extenders also decreases the number of ARs.

4. AR With Prior Tissue Expansion: Tissue expanders are silicone balloons inserted under the skin, followed by their expansion. The expansion increases the surface area of the overlying skin. The expander technique is carried out approximately three months before the AR. The expanders are inflated with normal saline at weekly intervals. The procedure is stopped if pain and blanching of the skin occur. The advantage of AR with prior tissue expansion is the one-time excision of about 10 to 12 centimeters (cm) of bald area. The disadvantage is a cosmetic deformity that has limited the use of tissue expander AR to cicatricial alopecia.

5. AR With Intraoperative Stretching: Dr. Unger devised the PATE (prolonged acute tissue expansion) procedure to overcome the disadvantages of tissue expansion. After the incision, the flaps are created. The tissue expander is inserted under the flaps and the connective tissue, and sutured. Finally, rapid inflation and deflation of the expander with distilled water are done on the same day. The advantage of the PATE procedure is that more tissue can be removed in one procedure. Moreover, frequent visits are not required. Miami STAR (suture tension adjustment reel) is a skin-stretching device patented by Dr. Cohen. It is a new device for skin closure.

What Are the Complications of Scalp Reduction Surgery?

Meticulous planning and expert surgical skills are important for the surgery’s success. Hence, a lack of experience and poor patient selection are problems. The complications are divided into surgical and cosmetic.

1. Surgical: Pain, bleeding, infection, non-closure of the wound, hematoma (blood collection), and numbness in the surgical area can happen. Stretch-back is the bald area re-expansion after AR. About 10 to 50 percent of stretch-back always occurs.

2. Cosmetic: A common cosmetic complication is slot formation. The slot is a midline scar seen about six to eight months after the surgery. Hair is seen growing in different directions due to the scar. Scars occur due to tight wound closure, improper suturing, and incorrect tissue fixation.

Conclusion

Surgical hair restoration has evolved dramatically. However, AR is a lesser-used technique than hair transplantation due to its invasive nature. Also, the patients have high expectations of the results. They want fewer risks and more benefits. Hence, the surgeon practicing AR must have superior knowledge of the procedure.