Scalp Reductions
This technique is not performed by NHI.
Also see Repairing Scalp Reductions for more information.
Scalp reductions, a technique to reduce the size of the bald area by essentially "cutting it out" was first described in 1977 by Dr's. Blanchard & Blanchard. In 1978, Dr's. Martin Unger and Walter Unger began using a combination of scalp reductions and hair transplantation to manage their balding patients and introduced scalp reductions to a large segment of the surgical community. The official term "Scalp Reduction" was first introduced by Sparkuhl that same year at the International Hair Transplant Symposium in Switzerland.
In 1979, Bosley Medical published the first large series on Male Pattern Reduction (their term for scalp reductions) and heavily marketed this procedure to the general public. In 1983, Dr. O'Tar Norwood (the creator of the famous Norwood Classification for male pattern alopecia), first warned of the potential complications of scalp reductions and the list has continued to grow longer and longer ever since.
The appearance of a person who is losing his hair is improved most by restoring the front part of the scalp. A completely natural frontal hairline (which frames the face) with good coverage on the front and top of the scalp, is the key to achieving the best aesthetic results. Since the crown is generally the least cosmetically important of the balding areas (and potentially the largest), crown coverage should not be a first priority. It should be addressed after the aesthetically more important areas have been satisfactorily transplanted and there is enough donor hair for any future needs in these regions.
In all hair restoration surgery, the potential cosmetic improvement is ultimately limited by a finite donor supply, which, in turn, is dependent upon the donor density and scalp laxity. Scalp reductions deplete this supply by simultaneously decreasing both the donor density and scalp laxity; a bad combination when the benefit is merely to reduce the size of a non-critical cosmetic area.
As a result of the scalp reduction, the donor density decreases, so that a larger donor area must now be harvested to yield the same amount of hair, but the larger strip becomes more difficult to remove due to a tighter scalp. When the strip is finally removed, some of the hair must then be placed back in the crown to cover the scar produced by the reduction, further limiting the amount of hair available for the front.
The scalp reduction scar eliminates the option of leaving the crown untreated, as well as the ability to reduplicate the normal delicate swirl of hair that characterizes this area. Since the scalp reduction scar is either linear or geometric, the hair used to cover it will necessarily be in this pattern. Although this may not produce a short-term problem, eventually, as the balding progresses, an isolated island of hair will remain in the same geometric pattern as the scar it originally served to cover. More hair will then be needed to follow this new expanding cosmetic defect.
The scarred scalp, the irregular balding pattern, and the abnormal direction of hair can preclude the crown from ever looking normal, and the decreased donor density and scalp tightness will compromise the ability to adequately cover the front and top of the scalp in any patient with significant balding.
Although scalp reductions may be performed with the best intentions, they can place patients in the precarious position of having more cosmetic problems than they started with and the lack of donor reserves to correct them. The Hippocratic oath implores physicians to "First, Do No Harm!" In light of the many new advances in hair restoration surgery, it is probably reasonable for everyone to take a more critical look at this once popular procedure for androgenetic balding.
Scalp Lifts
Scalp Lifts or "Major Scalp Reductions" are just what the term implies, more extensive scalp reductions where very large amounts of tissue are advanced in a single procedure. As is to be expected, the problems encountered with these "lifts" are also increased.
Problems can occur because of risk of damage to the major blood vessels and nerves in the back of the scalp, the occipital neuro-vascular bundles and from the extensive movement of scalp tissue. Although there are some doctors very skilled in this technique, it is our opinion that, even in the best of hands, these procedures are risky and create too many cosmetic problems for the patient in the long run.
For those interested, further information on scalp reductions and lifts may be found in the texts "Hair Transplantation" by Walter P. Unger (Dekker, 1995) and "Color Atlas of Hair Restoration" by James M. Swinehart (Appleton & Lange, 1996).
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