Scalp lifting. An 8-year experience with over 1,230 cases

BACKGROUND

This article reviews the author's 8-year experience with extensive scalp-lifting, which includes 1,230 cases.

OBJECTIVE

To overview extensive scalp-lifting paying particular attention to the areas of complications and the ways to reduce them.

METHOD

Retrospective analysis of 1,230 cases was done. Necrosis, infection, hematoma, numbness, and scarring were evaluated.

RESULTS

1) Vertical incision occipital artery ligatory should be performed 4 to 8 weeks prior to a scalp lift. 2) Use a delay procedure prior to a frontoparietal advancement flap. 3) Use only lateral lifts on patients with prior punch-grafting. 4) Locate the temporal arteries preoperatively with Doppler ultrasonography. 5) Do not perform frontoparietal advancement flaps on patients with prior punch-grafts.

CONCLUSION

Scalp lifting is an extremely effective and expedient method to treat alopecia; however, certain precautionary measures must be taken to obtain excellent, consistent results.

The expanded "BAT" flap for treatment of male pattern baldness

A new combination of expanded simultaneous transposition and advancement flaps is reported for the treatment of extensive male pattern baldness. Although vertical transposition and parieto-occipital advancement flaps in themselves are not new, their combination and simultaneous bilateral use combined with the use of expansion is new. The advantages of the expanded bilateral advancement transposition flap procedure are presented, along with the technique and results. The results are predictable, providing a more pleasing result, with a natural immediate temporal recession, avoidance of temporal dog-ears, and desirable anterior-superior direction of hair growth. Although flaps do require surgical skill and training, and there are risks and possible complications involved, the results are achieved in a relatively short time compared with grafting techniques. Flaps also provide the advantages of a full and natural hairline contrasted with the sparse look afforded by multiple grafts. The described procedures are very effective and reliable when properly planned and properly executed.

A preliminary report on a strategy for treatment of male pattern baldness: bilateral vertical flaps plus tissue expansion

A strategy of surgical treatment for male pattern baldness has been conceived using a combination of flaps and tissue expansion. This strategy has been tested on ten cases and the results presented herein. Based on the early experience guidelines have been formulated which allow reliability and predictability of results, as well as selection of appropriate patients.

Advanced use of tissue adhesive in hair transplantation

BACKGROUND

Cobblestoning is an unsightly result of graft elevation in the recipient site after hair transplantation.

OBJECTIVE

To describe the use of tissue adhesives for the avoidance of cobblestoning.

RESULTS

The long-term cosmetic appearance of hair transplants may be improved through the use of cyanoacrylate adhesives is the virtual elimination of the common problem of graft elevation or cobblestoning, which produces an unsightly bumpiness in the recipient area. The choice of type of adhesive and the method of application are central to successful use of this technique.

CONCLUSION

The indirect benefits of elimination of the need for postoperative bandages and restrictions in activities couple with the cosmetic results to produce a high degree of patient satisfaction.

Two new retractors for hair replacement surgery

BACKGROUND

Two new retractors that facilitate scalp reduction and scalp-lifting surgery are introduced.

OBJECTIVE

To improve the accuracy, visibility and speed of alopecia reducing procedures.

METHODS

These retractors were developed through trial and error in cooperation with the Robbins Instrument Corporation.

RESULTS

The suction retractor has been found to clear the field, elevate the scalp flap, and put the skin on stretch simultaneously. The serrated hook retractor has been found to greatly improve visibility for the cauterization of bleeders. The hook and serrated surface of this retractor prevents intraoperative slippage.

CONCLUSION

The two new retractors introduced in this article have been found to improve greatly the accuracy, visibility, and speed of alopecia reducing procedures.

Tissue expansion in the pediatric patient

Although tissue expansion has many advantages over other reconstructive options, potential complications require consideration. The purpose of this study was to evaluate the experience of tissue expansion in the infant and child. During the 6-year period from 1985 to 1990, a total of 147 expanders were placed in 76 patients. Age of the patients at the time of insertion of the expanders ranged from 1 to 18 years (median, 8 yr). Twenty of the 76 patients studied suffered from complications, a rate of 26%. Despite the high complication rate, complications did not compromise the final result because they occurred near the end of the expansion period and usually involved one of the many implanted expanders. With the appropriate selection of patients, tissue expansion has proved extremely valuable as a reconstructive option in the pediatric patient.

Scalp extension

BACKGROUND

Surgery to correct extensive alopecia requires increasing the surface of hair-bearing scalp and removing bald scalp. Two commonly used methods, scalp expansion and scalp reduction, have disadvantages.

OBJECTIVE

To describe a new method, scalp extension, that employs a thin sheet of bioplastic (an extender) stretched and attached with hooks to the galea after scalp reduction.

METHODS

The surgical technique is described and the results compared with those of patients who have undergone scalp reduction and scalp expansion. A study of the first fifteen cases treated is presented.

RESULTS

During the few weeks that the extender is implanted, the constant tension it exerts on the galea causes a progressive stretching of the scalp. Data from the first fifteen cases treated reveal eradication of more extensive bald areas than with scalp reduction, making it possible to cut the number of operations necessary in half while considerably shortening total treatment time. The absence of major side effects, along with the absence of any deformation of the scalp (unlike scalp expansion), explains the excellent acceptability of the instrument by patients.

CONCLUSION

Scalp extension appears to be a useful adjunctive technique in hair replacement and reconstructive surgery, and has distinct advantages over standard scalp reduction and tissue expansion techniques.

Hair replacement surgery for male pattern alopecia

Male pattern alopecia is the most common type of hair loss encountered. Although this malady has no direct adverse consequences on physical health, physicians should be aware of the impact hair loss may have on a man's self-esteem. This type of hair loss and current hair replacement surgical techniques are discussed.

[Forum on tissue expansion. Conclusion. How to master expansion...]

The author presents several reflections based on more than ten years of experience with skin expansion. In order to master expansion, a number of rules must be respected at each step of the procedure:--start by defining the treatment plan,--choose appropriate material,--apply the expander(s) according to a rigorous approach,--prevent and treat all complications,--ensure sufficient expansion to eradicate the entire lesion. The authors views are illustrated by particular clinical examples using expanded transposition flaps: treatment of extensive baldness, ear reconstruction, repair of major sequelae of thoraco-abdominal burns.

The occipital artery flap for transfer of hair-bearing tissue

The posterior scalp is investigated as the donor site for the transfer of hair-bearing tissue based on the occipital artery. The dissection of fresh cadavers was performed and the occipital artery was noted to have three major branches including a vertical, transverse, and descending branch. The vessel connection across the midline allowed transfer of the posterior scalp to the desired recipient site. This vessel provides the possibility of transfer of large areas of hair-bearing tissue to a single stage. The variability of flap design is described as well as the technical considerations for a successful transfer.

The paramedian scalp reduction with posterior Z-plasty. A technique to minimize the "slot" defect

BACKGROUND

One consistent and undesired sequela resulting from scalp reductions has been the "slot" or "trough" defect, referring to the scar following the final reduction. Attempts to correct this have not been entirely satisfactory.

OBJECTIVE

To present an approach to minimize the "slot" defect that consists of staged modified paramedian scalp reductions combined with a large posterior Z-plasty during the final reduction.

METHODS

A paramedian crescent-shaped ellipse was marked onto the patient's scalp parallel and adjacent to the existing fringe hair. Subsequent reductions were performed in a similar manner approximately 2 months apart. The final reduction consisted of mobilization and transposition of the large flaps used in the posterior Z-plasty.

RESULTS

Patients who underwent the staged modified paramedian reductions combined with a posterior Z-plasty had significant minimization and adequate camouflage of the undesirable "slot."

CONCLUSION

Combining a large posterior Z-plasty with a paramedian reduction minimizes the slot defect.

Dissecting folliculitis of the scalp. A case report of combined treatment using tissue expansion, radical excision, and isotretinoin

Dissecting folliculitis of the scalp can develop into an extensive, hypertrophic scarred lesion that is unresponsive to routine treatment. In these situations, radical excision of the affected area and concurrent perioperative treatment with isotretinoin (13-cis-retinoic acid) may be effective. The authors describe a case, illustrating the successful clinical application of this technique.

Extensive scalp lifting as a reconstructive tool for a large scalp defect

Extensive scalp lifting is a relatively new technique for the treatment of alopecia. Because this technique involves the undermining of the entire occipitoparietal scalp down to the hairline of the nape, a significant anterior and medial advancement is accomplished with one operation. This case report describes a patient with a large surgically induced scalp defect that was reconstructed with the use of extensive scalp lifting in combination with coronal brow lifting--thus, the intermediate cosmetic deformity of the more commonly used tissue expansion technique was completely circumvented. Why this technique can be substituted for tissue expansion or multiple rotation-transposition flaps in certain cases in elaborated.

Extensive scalp lifting. Decrease in complications utilizing unilateral occipital artery ligation and other modifications

The superior yield from extensive scalp lifting has been detracted from by complications, including hemorrhage, scalp necrosis, and the need for greater anesthesia. Intraoperative unilateral occipital artery ligation, with extensive undermining to the nape of the neck on only one side, can minimize the risk of postoperative scalp necrosis or telogen effluvium. Careful hemostasis, extensive infusion of dilute anesthetic, and modifications in instrumentation can decrease the morbidity associated with this procedure. The advantages of the operation include removal of the large amounts of bald scalp, excellent intraoperative visualization, and lack of stretchback and asymmetry.

[Forum: dermopigmentation or medical tattooing. Dermopigmentation with an esthetic aim. Apropos of 420 cases]

420 cases of chromatic skin corrections for medical or aesthetic reasons have been documented over the last 1-5 years. The author analyses cases based on local anatomy classification, so that good and poor results of the technique are clearly revealed. Results are then regrouped in a synthetic study, without distinction of anatomical area. This synthesis establishes a check list of defects inherent in the technique: pain or discomfort, poor smoothing-out of skin defects, far from natural chromatic variations of the skin, dull lacklustre colours, short-lasting pigmentation, and chromatic instability of dyes. All these pigmentations were performed using basic techniques and medical pigments. The author suggests that in the future these defects should be corrected by: more systematic use of dyes used by tattoo artists, addition of a gloss in the dyes, transparent technique, anaesthetic skin cream.

[Forum: dermopigmentation or medical tattooing. In practice ... how to perform medical tattooing?]

Dermopigmentation is now part of the therapeutic armamentarium of plastic surgeons. In good indications and when applied according to a few simple rules, every surgeon can obtained reliable and reproducible results with medical dermography. This therapeutic procedure is performed on an outpatient basis, usually in several sessions; subsequent revisions are always possible provided certain basic errors are avoided. The authors describe each step of this technique.