Transplanting into Areas of Cicatricial Alopecia

76 Transplanting into Areas of Cicatricial Alopecia

Robin Unger

Summary

The surgical correction of areas of cicatricial alopecia involves an intricate balance of achieving a good cosmetic result and respecting the tissue characteristics unique to scars. If possible, excision of the scar tissue is the preferred method of correction. The results are immediate and precious donor hair reserves are not used. When excision is not possible, hair transplantation can be used to correct the defect. The density of recipient sites can rarely be higher than 20 to 25/cm² in the first surgery and often a second correction is needed. The hair restoration surgeon needs to recognize the difference between stable and unstable cicatricial alopecias. The latter category includes lichen planopilaris and frontal fibrosing alopecia, which are on the rise in the general population and may be unrecognized and difficult to diagnose. Prompt medical treatment is necessary for these patients once a diagnosis is determined. Ideally, surgery should be delayed after at least 2 years of quiescence, and medical surveillance and treatment is continued even after the surgery.

Keywords: alopecia cicatricial lichen planopilaris frontal fibrosing alopecia unstable cicatricial alopecia stable cicatricial alopecia PRP fat grafting microneedling follicular family

Key Points

•Stable cicatricial alopecias are secondary to isolated events that cause permanent scarring in a hair-bearing region. Surgery can produce long-lasting excellent results.

•“Unstable” cicatricial alopecias are secondary to disorders that have a tendency to progress and recur intermittently over the course of time. Surgery should only be performed if the disease has been in remission for at least 2 years, and the patient remains on medical therapy and under medical surveillance.

•Surgery in an area of cicatricial alopecia needs to be performed with special regard for the vascular supply in the area. The size and density of sites may be limited and a second surgery is often necessary to achieve excellent cosmetic results.

•There are five interdependent factors to be respected when contemplating surgery for cicatricial alopecia: (1) the donor-to-recipient ratio over the patient’s lifetime, (2) scalp laxity, (3) the patient’s healing characteristics, (4) vascular supply, and (5) the location of the subsequent scar.

76.1 Introduction

Cicatricial alopecias are clearly on the rise. Hair restoration practices are seeing increasing numbers of patients with frontal fibrosing alopecia (FFA) and lichen planopilaris (LPP).1 These conditions, when active, are absolute contraindications to surgery. In some cases, quiescent cicatricial alopecias may be successfully treated with hair transplantation. Alternative approaches include medical treatment alone and alopecia reductions (ARs) and/or flap procedures, alone or together with hair transplanting. This chapter will be limited to a discussion of the techniques of hair transplantation and excision. The latter is, in fact, the preferable method of correction where appropriate. For purposes of clarity in this discussion, cicatricial alopecia will be referred to as “unstable” cicatricial alopecia (UCA) and “stable” cicatricial alopecia (SCA; Table 76.1).² The distinction is extremely important with respect to the treatment choice and the possibility of surgical correction.

Table 76.1 Causes of stable and unstable cicatricial alopecia

Stable cicatricial alopecia (SCA)	Unstable cicatricial alopecia (UCA)
Trauma	Lymphocytic
Burns cutaneous	Discoid lupus erythematosus
Radiation-induced alopecia	Classic lichen planopilaris
Prior hair transplantation	Frontal fibrosing alopecia
Prior rhytidectomy and browlift	Graham–Little syndrome
Traction alopecia	Classic pseudopelade (Brocq)
Trichotillomania	Alopecia mucinosa
Pressure alopecia	Keratosis follicularis spinulosa decalvans
Congenital	Neutrophilic
Aplasia cutis congenital	Folliculitis decalvans
Lymphocytic	Dissecting folliculitis
Central centrifugal cicatricial alopecia	Congenital
	Conradi–Hünermann chondrodysplasia punctate
	Incontinentia pigmenti
	Ankyloblepharon
	Hallermann–Streiff syndrome
	Generalized atrophic benign epidermolysis bullosa
	Other
	Acne keloidalis/acne necrotica
	Erosive pustular dermatosis
	Infection (deep fungal infections, zoster, massive bacterial folliculitis, tinea capitis with keratosis)
	Metastatic/primary neoplasm
	Graft vs. host disease

Most dermatologists categorize alopecias as cicatricial or noncicatricial, and further distinction is made with regard to the type of inflammatory cells involved in the disease. Those who specialize in hair restoration surgery need a further type of categorization to help determine whether operative intervention will be of benefit. UCAs are secondary to disorders that have a tendency to progress and recur intermittently over the course of time. This is of particular importance currently, given the increase in incidence of both LPP and FFA. Additionally, the surgery itself may cause reactivation of the disease, and therefore it should only be considered after complete remission for a period of 2 years (previously, 1 year was thought to be sufficient).

It is very important to note that the patient may not have the disease at the time of presentation for surgery or it may be totally quiescent at that time. If the patient’s history and physical examination do not raise any suspicions, it is a possibility that a surgery would be done without recognizing the presence of the disease. In addition, hair restoration surgeons cannot predict the patient’s future, and a dermatopathology can present at any point in the patient’s lifetime.

If a hair transplant is performed knowing the patient has an UCA, the patient must understand the importance of continuing with medical surveillance and treatment—maintenance treatment may minimize or prevent recurrences. Case reports have been published showing disease reactivation within 6 years of hair transplantation if the patient is not on maintenance medical therapy.3 This is not a surprise. Patients need to be informed that if their disease becomes reactivated at any time, the success achieved with surgery would likely be compromised if the disorder is not promptly controlled (Box 76.1). It is possible to stop the insidious, intermittent progression of UCA with prompt appropriate medical therapy (see Chapter 9).

SCAs are secondary to isolated events that cause permanent scarring in a hair-bearing region. Surgery can produce excellent results in these cases and once successfully corrected there is no need for the constant vigilance that is required after treatment of UCA. Common inciting events resulting in SCA include trauma, burns, infection, radiation, and prior head and facial surgeries (Fig. 76.1).

Fig. 76.1 (a) A 58-year-old woman who came in for hair restoration after a brow lift and partial facelift done 10 years prior. A total of 1,766 follicular units were transplanted into the hairline, frontal area, and temporal area including the sideburns. (b) The patient at 18 months after surgery.

Box 76.1

Unstable cicatrici alopecias (UCAs) should not be treated with hair transplant surgery unless the patient’s disease has been inactive for 2 years and medical surveillance and treatment is continued. If the disease reveals itself after surgery, prompt medical therapy can help preserve the hair.

76.2 Important Considerations in Surgical Correction

As noted earlier, because the cause of UCA can be expected to be intermittently recurrent, with subsequent cicatricial hair loss in new areas, excision is often the best choice for UCA provided the pattern and size of the scarring lend itself to that option (Fig. 76.2). However, the decision as to whether hair transplantation, excision, or “AR” should be utilized requires consideration of not only whether one is dealing with UCA or SCA but also five additional interdependent factors: (1) the donor-to-recipient ratio over the patient’s lifetime, (2) scalp laxity, (3) the patient’s healing characteristics, (4) vascular supply, and (5) the location of the subsequent scar (Box 76.2).

Fig. 76.2 (a) A 15-year-old adolescent boy with cicatricial area in his temporoparietal area following an accident at the age of 2 years in which scalding coffee spilled on him. The area is totally alopecic and difficult to camouflage especially with the patient’s hair–skin color contrast. It was decided that the best approach would be to excise as much of the scar as possible and use follicular units to fill the irregular patchy inferior border of the scar. (b) Immediately after surgery, showing both the excision and the sites for follicular units to create a natural hairline border and fill the inferior irregular scars. (c) Four-month follow-up photograph of the patient.

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