Repair of scalp defects is often challenging, because without careful planning, excision of the defect may leave unsatisfactory cosmesis. Contemporary techniques in hair restoration surgery allow creation of natural and undetectable results, but these techniques are often unsuitable for repairing large scarred areas of hair loss. However, by using older techniques of scalp reduction and tissue expansion, excision of many large scarring defects can be accomplished. Combining older methods with modern hair restoration surgery permits the satisfactory treatment of many previously untreatable conditions. This article focuses on tissue expansion as an adjunct to repairing large scalp defects.
Key points
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The stretching of human skin via tissue expansion occurs as a result of biological and mechanical creep.
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Surgical planning is critical with tissue expansion to ensure that the repositioned scalp retains a natural hair direction.
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Overestimation of the required expansion is appropriate, and the largest commercially available expander for managing the patient’s defect is usually required.
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Social factors like patient availability, distance from the surgeon, and pain tolerance determine how fast the expansion can be completed.
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Caution should prevail if the advancing flap proves incapable of resurfacing the entire scalp defect, because undue tension on the flap can increase the risk of flap necrosis.
Introduction
The most common cause of hair loss is androgenetic alopecia (AGA). Although not a scalp defect, understanding the cosmetic treatment of AGA greatly enhances our ability to treat severe hair loss deformities, allowing normal and natural-appearing results. Treating a large scalp scar that results in a different kind of scalp deformity often leads to dissatisfied patients and physicians, regardless of the success the procedure.
The various deformities and degree of deformity generally determine the treatment choice. The significant developments in hair restoration surgery (HRS) in the past 2 decades now yield natural and almost undetectable results. By using these cosmetic and reconstructive techniques, most scalp deformities can be treated effectively. It is important to understand the anatomy, physiology, and cosmetic treatments of AGA and that subject has been treated effectively by other investigators in this monograph.
This article concentrates on the treatment of large deformities of the scalp and hair by combining advanced techniques of scalp reduction and tissue expansion with contemporary hair transplantation.
Introduction
The most common cause of hair loss is androgenetic alopecia (AGA). Although not a scalp defect, understanding the cosmetic treatment of AGA greatly enhances our ability to treat severe hair loss deformities, allowing normal and natural-appearing results. Treating a large scalp scar that results in a different kind of scalp deformity often leads to dissatisfied patients and physicians, regardless of the success the procedure.
The various deformities and degree of deformity generally determine the treatment choice. The significant developments in hair restoration surgery (HRS) in the past 2 decades now yield natural and almost undetectable results. By using these cosmetic and reconstructive techniques, most scalp deformities can be treated effectively. It is important to understand the anatomy, physiology, and cosmetic treatments of AGA and that subject has been treated effectively by other investigators in this monograph.
This article concentrates on the treatment of large deformities of the scalp and hair by combining advanced techniques of scalp reduction and tissue expansion with contemporary hair transplantation.
Hairline design
Perhaps the most deceptively difficult task in any scalp surgery is planning and executing a normal hairline with natural hair direction. Simple scalp coverage is unsatisfactory if the final result is unnatural. This situation is true of all scalp procedures, including hair transplants, scalp excisions, flap rotation, and movement of expanded scalp flaps and applies to all areas of the scalp. In general, frontal scalp hair points forward, parietal scalp hair points lateral and inferior, and occipital scalp hair is oriented posteriorly and inferiorly.
Addressing these subtleties is critical to avoid unnatural results. Even the untrained eye that does not understand the details of a natural hairline can detect an unnatural result.
Alopecia reduction procedures
These techniques are acknowledged because some form of them is required in virtually all scalp repairs. Alopecia reduction (AR) allows the surgeon to eliminate unwanted scar. Originally, innovated for HRS in the 1970s, its popularity waned as hair transplantation techniques improved and our understanding of the natural history of hair loss became more refined, but the techniques remain valuable tools for scalp repair.
The first AR procedures were simple and involved rapid excision of bald scalp from the central area of hair loss. Limitations of AR were identified, including widening the bald area (also known as stretch-back), slot deformity, and visible scarring.
The extensive scalp lift (ESL) is one of the more interesting and effective ARs in that the dissection was carried out beyond the limits of the galea aponeurotica, marked by the nuchal line, extending it down to the nape of the hairline. ESL permitted a greater reduction of bald scalp.
Tissue expanders
Basic Principles
Tissue expansion is an extraordinary adjunct for repairing large skin defects. Before tissue expansion techniques, repair of large defects was crude and ineffective. The original work on tissue expansion was not considered noteworthy and its significance remained unnoticed for almost 20 years, until a young surgeon showed its usefulness in breast reconstruction. Its simplicity and popularity grew exponentially as an expander manufacturer became involved in producing a commercially viable product.
The technique involves gradual expansion of a balloon prosthesis implanted under the skin immediately adjacent to the defect. The expander is incrementally filled with sterile saline through a series of percutaneous injections into a self-sealing fill-port. As the balloon increases in size, the tissue compensates by stretching, increasing its length and mass through mechanisms known as mechanical creep (stretching the collagen fibers) and biological creep (stimulating new tissue growth). Mechanical creep is subject to shrinkage when the balloon is removed as the collagen fibers attempt to return to normal resting length. Biological creep, on the other hand, is not stretching in the traditional sense, because cellular activation increases the amount of tissue present. Both properties are critical to successful tissue expansion.
Surgical Planning
Surgical planning is critical to ensure that the hair-bearing scalp to be moved retains a natural direction. Midline scalp reductions were effective in removing bald scalp but resulted in an obviously unnatural result, known as the slot deformity ( Fig. 1 ).
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Hair Restoration: A Sophisticated Art Form
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