Repairing Scalp Reductions
Also see Scalp Reductions for more information.
Scalp reductions can pose such a complex array of cosmetic problems that a full discussion of their repair is way beyond the scope of this section. The most common issue is that of a diminished, or depleted, donor supply in conjunction with decreased scalp laxity, minimizing the amount of "movable hair" available for the correction. Click on Scalp Reductions.
This can be partially addressed by the "hair conserving" powers of microscopic dissection, but with multiple scalp reductions full correction with even the best techniques are often not possible. Specific patterns of repair, such as the "Hockey Stick," used for treating patients who have low donor supply in general, would be especially useful for patients with low donor supply as a result of scalp reductions and scalp lifts.
Another problem created by scalp reductions and lifts is the scar in the crown. This can be camouflaged, but it requires a considerable amount of hair. In addition, the scar tissue limits the amount of hair that can be used in one session, so that multiple sessions are often required. When the scar is covered with hair, the patient then runs the future risk of having an abnormal pattern if the hair loss continues and the hair loss in the crown progresses.
In general, correcting scalp reductions and the associated defects can be approached similar to the way one would approach plugs and a depleted donor supply. That is, to correct the front as much as possible and allow that hair to grow and camouflage problems in the back with either light coverage or tacking hair. "Weighting" of the hair to the part side will also add to the fullness that can be achieved when the donor supply is low and at the same time produced a very natural look. The following figure illustrates the concepts of side weighting and layering. When the patient combs his hair to the side and diagonally backwards, it provides good frontal coverage, takes advantage of layering and gives coverage in the back of the scalp using only a modest amount of hair.
The patient pictured below had "Y-Shaped" scalp reductions that left significant scarring. This was camouflaged with a single procedure of 1,825 follicular unit grafts. A second procedure is planned to create greater density and increase the fullness. If the patient had not had the scalp reductions, more hair would have been available and even greater fullness would have been possible. In addition, there would be no scarring (limiting how close grafts could be placed) and the hair direction in the top and back of his scalp would have been far more natural. The three photos below show a top view of the patient before, during, and after a camouflage repair of an extensive scalp reduction.
The photos below show the dramatic changes in the frontal presentation of the same patient after just one corrective session with Follicular Unit Transplantation.
Sometimes the cosmetic problems are so significant that camouflage alone is insufficient and a specific repair of the defect must be performed first. A "dog-ear" deformity (puckering of excesses tissues in the corners) caused by a poorly planned scalp reduction can be corrected by excision, and the hair in the excised tissue can be dissected into follicular units and re-implanted. On the other hand, significantly altered hair direction from a scalp reduction is an extremely difficult problem to correct and sometimes requires further tissue movement to undo the defect.
In the above photos, the elevated dog-ear section was removed so that the area now lies flat. The hair in the excised dog-ear tissue was transplanted into the front part of the scalp in individual follicular units. In subsequent procedures, hair will be added to the area where the dog-ear was, completely camouflaging it.
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