Eyebrow Reconstruction in Craniofacial Clefts by Abnormal Hairline Extention

The absence of eyebrows, whether complete or partial, has been observed in specific types of craniofacial clefts, primarily occurring in Tessier clefts numbers 9 to 13. To address this defect, several techniques have been used to improve eyebrow appearance, such as the island scalp flap and scalp strip grafting technique. However, these methods did not yield satisfactory esthetic results. In this study, the authors present findings from 7 patients with craniofacial clefts, in whom the eyebrows were completely reconstructed through the rotation flap technique, using abnormal frontal hairline extension, in 1 or 2 stages. The result was natural-looking and highly satisfactory, with no associated morbidity.

The Role of Autologous Micrografts Injection from The Scalp Tissue in The Treatment of Covid-19 Associated Telogen Effluvium: Clinical and Trichoscopic Evaluation

The clinical presentation of severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2 COVID‐19) varies from asymptomatic infection to a life‐threatening, multiorgan disease. One of these manifestations is telogen effluvium (TE) which is characterized by diffuse hair loss occurring in patients previously infected with SARS‐CoV‐2 and lasts ~3 months, after which excessive hair loss follows. Hair follicles are known to contain a well‐characterized niche for adult stem cells which is the bulge containing epithelial and melanocytic stem cells. Stem cells in the hair bulge, a demarcated structure within the lower permanent portion of hair follicles, can generate the interfollicular epidermis, hair follicle structures, and sebaceous glands. This study aims to evaluate autologous micrografts from scalp tissues as a therapeutic modality in the management of TE caused by COVID‐19. Twenty patients of previous COVID‐19 infection suffered from TE were included in this study for human follicle stem cells micrograft scalp treatment and they were evaluated after 3 months of treatment and after 6 months. There was significant improvement of the hair thickness and density compared with the start of the treatment and 6 months of follow‐up. Autologous micrograft of the scalp showed marked improvement in the treatment of COVID‐19 TE.

Clinical Pearl: advantages of the scalp as a split-thickness skin graft donor site

Common challenges associated with split-thickness skin graft (STSG) donor site wounds include slow healing times and poor scar cosmesis. The technique described here improves these shortcomings by utilizing a Weck knife with adjustable thickness controls to harvest STSGs from the scalp.

Pentoxifylline intervention and drug action in scalping forehead flap for large temporal cutaneous defects

Pentoxifylline is widely used in the treatment of cerebrovascular disease, at present, there are a variety of drugs in the clinical expansion of the role of the skin flap, by improving or promoting blood circulation, to ensure the survival of the flap. We designed scalping forehead flap to reconstruct large temporal cutaneous defects. This flap is reliable and can give us excellent postoperative result. This design has several advantages and is worth to be promoted. The scalping forehead flap we designed is reliable. The posterior auricular artery and it branches provided enough blood supply to the scalp and forehead tissue of the flap. The frontal muscle also make the flap have a high survival rate. Large temporal cutaneous defects can be reconstructed by this novel scalping forehead flap we described. This technique is useful especially for patients who suffered malignant tumor and can not choose free flap.

[Clinical study of repairing donor site of thickness from cicatricial skin with auto-scalp grafting]

OBJECTIVE

To study the effects of using auto-scalp for repairing donor site of thickness from cicatricial skin with auto-scalp grafting.

METHODS

A total of 13 cases with donor site of thickness from cicatricial skin from January 2011 to December 2011 were analyzed. Wounds of donor site from cicatricial skin were grafted with auto-scalp and scalp were fixation was applied with negative pressure. The survival rate of auto-scalp graft was observed at Day 7 post-operation. At Month 12, hyperplastic scars at these donor sites of cicatricial skin were assessed through Vancouver Scar Assessment Table, scar itch assessment and scar proliferation rate. Wounds in the other thirteen cases with donor site of thickness from cicatricial skin from January 2010 to December 2010 were covered with vaseline gauze as control.

RESULTS

No significant difference existed in the gender and age of the two groups patients (P > 0.05). The auto-scalp graft all survived. And the average healing time of donor-site wound in cicatricial skin in grafting group (7 days) was significantly decreased than that of control group (a mean of 20 days) (P < 0.01). After followed up for twelve months, the scar formation assessment value (1.5 ± 0.5), scar itch assessment (1.2 ± 0.4) and scar proliferation rate (14.6% ± 7.6%) in grafting group were significantly less than those of control group (6.7 ± 1.1, 2.0 ± 0.7, 55.8% ± 12.2%, all P < 0.01).

CONCLUSION

Auto-scalp grafting may greatly shorten the healing procedure and ameliorate the quality of donor-site of thickness from cicatricial skin.

[Scalp flaps pedicled with superficial temporal vessel and hair removal for reconstruction of facial skin defects]

OBJECTIVE

To investigate the therapeutic effect of scalp flaps pedicled with superficial temporal vessel and hair removal for reconstruction of facial skin defects.

METHODS

From Jan. 2010 to Dec. 2011, 6 cases with large facial skin defects were treated with scalp flaps pedicled with superficial temporal vessel and hair removal. At the first stage, the skin expanders were implanted subcutaneously at the homolateral side according to the defect size. After the expansion was finished, the expanded flaps pedicled with superficial temporal vessel were used to reconstruct the facial skin defects at the second stage. 2 weeks after operation, hair removal was performed to remove the hair on flaps. 4-6 treatments were needed.

RESULTS

Seven flaps in 6 cases were survived completely. The wounds at donor sites were closed directly. The effect of hair removal was reliable. The patients were followed up for 6 months to 1 year. The flap color, texture and thickness had a good match with surrounding skin tissue.

CONCLUSIONS

It is a good option to reconstruct facial skin defects with scalp flaps pedicled with superficial temporal vessel and hair removal.

[Donor supply of scalp and specificities of hair transplantation in Asians]

In 2005--2007 in a hair transplantation clinic 'Talizi' the flow of international patients increased dramatically, including those from Central and Eastern Asia. During this period 211 ethnic Asian patients underwent operations, including 146 patients from South Korea, 2--from China, 62-- from Kazakhstan and 1--from Philippines. Black and straight hair give impact of low density due to considerable contrast with characteristic for Asians light color scalp; therefore, from the very beginning we tried to transplant as many grafts (follicular units - FU) as possible. For the operation we chose strip version (FUSS) that enables to receive large number of grafts. The scale of transplantation varied in a range of 1200-3800 FU, on average--2500-3000 FU. Though, even from the very first cases we faced specificities of ethnic Asian scalp that significantly complicated our work: low density and low hair/graft ratio in donor zone in contrast to information from special literature, and low laxity (flexibility) of the scalp. We set an objective to specify indicators of donor density (number of FU on a sq.cm and hair/FU ratio), to study bio-mechanical specificities of ethnic Asian scalp and develop optimal surgical tactics for these patients after the evaluation of transplantation results. Observation group was composed of 211 patients from abovementioned countries and a sub-group--50 Korean patients for medium-scale hair transplantation (2000-3000 FU) by strip version. Study of donor characteristics of these patients revealed low density--74 FU/cm2; on 1 cm2 grow only 121 hairs, whereas hair/FU ration was 1,63. Strength required to close would edges (scalp tension power) varied from 1,4 kg-f to 2,6 kg-f depending on scalp flexibility and number of transplanted grafts (strip width), and amounted on average to 2,16 +/- 0,02 kg-f, p < 0,001%. This indicator is about 1,5 times exceeding the one of ethnic Caucasian patient group (1,47 +/- 0,02 kg-f, p < 0,001%). Low donor density of our Korean patients compelled us to increase width of the obtained skin strip (sometimes to 2,5 cm) in order to get required number of grafts (FU). In case of low flexibility of the scalps this resulted in high percentage (10-15%) of wide (4-10 mm) scar formation in donor area. In order to find the way out from this situation (restrict the width of the strip to 1,5 cm without affecting FU to be transplanted in one operation), we proposed the combination of the strip version (FUSS) with FU extraction (FUE). While this solution increased the duration and price of the operation, we believe that it is the most optimal version in case of large-scale hair transplantation for the ethnic Asian patients.

Scalp as a donor site for split thickness skin grafts

BACKGROUND

Use of scalp as a donor site was reported for the first time in 1964. Since then, authors have described scalp as a donor site, which heals rapidly and re-growth of hair conceals the donor site. This study was aimed at evaluation of scalp as donor site by calculating the healing time, and frequency of post-operative complications.

METHODS

This was a descriptive study and was conducted at Plastic Surgery Department Jinnah Hospital, Lahore, from October, 2006 to December 2007. Thirty patients requiring split skin grafting for small to moderate sized defects (requiring up to 4 sheets) were included in this study. After taking informed consent skin graft were taken from the scalp using Zimmer Electric Dermatome. Donor site was covered with occlusive dressing. Donor site healing time and complications were recorded. Patients having scalp lesions were excluded from the study.

RESULTS

All the patients in this study achieved healing of the donor site. None of them required grafting. 26 (86.67%) patients achieved healing by 6th post-op day 3 (10.0%) patients achieved healing by 10th post-op day and the remaining 1 (3.33%) patients achieved healing by 20 days. Complications noted were folliculitis in 2 patients and scab formation in 1 patient. Alopecia, hair transplant to recipient site and hypertrophic scarring was not encountered in our study. Patients were discharged by 6th post operative day and complications were managed on outpatient basis. Overall patients' compliance and satisfaction was excellent.

CONCLUSION

scalp is an excellent donor site for taking split skin graft. It has shown to be very useful in terms of quick healing, convenient post-op care and negligible complications. It should be given preference when donor site for taking skin graft is to be selected.

Expansion cutanée dans les alopécies cicatricielles du cuir chevelu: 18 cas

INTRODUCTION

Skin expansion technique used to increase the hair surface available at the scalp level was a major breakthrough in the surgical treatment of important cicatricial alopecia. This article had for aim to define the importance and limits of this technique in the treatment of alopecia and to highlight its relevance compared to other methods.

PATIENTS AND METHODS

Between November 1998 and April 2006, 18 patients (7 women and 11 men) presenting with one or many cicatricial alopecia areas were treated by skin expansion. The age of patients ranged between 14 and 68 years, with an average of 33 years. The indications were related to burn sequels in 44% of all cases. The average area of alopecia was 167 cm2. This technique combines two operating phases. In the first phase, the expansion balloon is inserted and then gradually filled. In the second phase, it is removed and the alopecic area is covered by the expanded flaps.

RESULTS

Thirty-nine expansion prostheses were used, with an average volume of 292 cc. Their number varied between 1 and 6 (two on average) for each patient. The average duration of expansion was 77 days. The tissue gained with this technique allowed the use of 38 flaps. The transposition flaps was the most frequently used (39.4%). The rate of major complications leading to total failure of the process reached 5.5%. The final result was considered good in 90% of the cases.

DISCUSSION

The results demonstrate that skin expansion technique is a simple, reliable, and efficient method in the healing of important cicatricial alopecia of scalp. It enables a wider use of the classical local flap technique, by expanding the surface and vascularization allowing for a direct suturing of the donor site. Skin expansion holds an important place in the treatment of significant skin cicatricial alopecia, since it represents the only surgical solution when the alopecia area exceeds 50 cm2.

Developing a Canine Model of Composite Facial/Scalp Allograft Transplantation

The study developed a model of composite facial and scalp allograft transplantation in canines. Dog cadavers were used for anatomy study. Three types of autotransplantations and 2 types of allotransplantations were performed. Cyclosporin A and methylprednisolone or prednisone were given for immunosuppression. Two long-term-surviving dogs with autologous facial transplantation developed leakage of salivary secretions. In the allotransplantation group (n = 5), 1 dog presented rejection at 28 postoperative days but was successfully treated and survived long term (>402 days); 1 dog died of pulmonary infection at 29 postoperative days; 3 dogs survived (>252, >222, and >201 days). Serial electromyelogram studies revealed progressive improvement of the function of the orbicularis oculi muscle. The study indicated that the unilateral superior half of the composite facial and scalp, including one third of the inferior tarsal plate and palpebral conjunctiva (type IV flap) allograft transplantation model, was an ideal model for the study of facial allotransplantation.

Use of Integra in a paediatric upper extremity degloving injury

Dermal substitutes such as Integra have been used in surgery since 1981. This product was developed to cover large skin burns but it may have a role in reconstructive upper limb surgery. In upper extremity avulsion, the choice of skin cover depends on many variables. Dermal substitute is an alternative when split-thickness skin grafting is appropriate. We present a case of severe upper limb avulsion, or 'degloving', in a child of 9 years old which was treated successfully with Integra. Integra is particulary useful in growing children to cover large skin losses.

The Scalp Is an Advantageous Donor Site for Thin-Skin Grafts: A Report on 945 Harvested Samples

BACKGROUND

Thin-skin grafts taken from the thigh or buttock take a long time to heal and leave permanent scars.

METHODS

The authors conducted a retrospective study based on their experience with 945 thin-skin grafts (0.2 mm) taken from the scalps of 757 adult patients between January of 1999 and December of 2003.

RESULTS

Of the 757 patients, 89 had grafts taken repeatedly from the scalp. The mean healing time was 6.2 days for a single harvest and 10.2 days for repeated (same hospitalization) harvests. During follow-up, eight patients had microalopecia and three developed "concrete scalp deformity." Of these 11 patients, eight had undergone repeated harvests. None of the other patients had any scarring; they were completely healed by day 15.

CONCLUSIONS

The results of this study confirm the rapidity of scalp healing compared with other donor sites. Providing patients with clear, detailed explanations helps minimize the psychological impact of having their heads shaved, and a rigorous technique can contain the two major potential risks: hemorrhage and alopecia. The adult scalp seems to be a donor site to be exploited whenever possible.

[Establishment of composite facial and scalp allograft transplantation model in canine]

OBJECTIVE

To develop an experimental model of composite facial and scalp allograft in canine in order to investigate technical and immunological aspects and functional recovery of facial muscles of this new approach to facial reconstruction.

METHODS

(1) Anatomic study: Four mongrel dogs were used for anatomical dissection of the head and neck region and for harvesting flap experiment. (2) Autologous transplantation (group I): Three types composite facial and scalp autologous transplantation were performed in five mongrel dogs. Type I composite tissue flap (group I a n = 2) included bilateral external ear and orbicularis oculi muscle. Type II (group I b n = 1) included single-lateral external ear, orbicularis oculi muscle, external nose upper and lower lip. Type III (group I c n = 2) included single - lateral external ear and orbicularis oculi muscle. (3) Allograft transplantation (group II): In group II a (n = 2), two allograft transplantation were performed with type III composite facial and scalp . In group II b (n = 4), four allograft transplantation were performed with the modified type III composite facial and scalp which included single - lateral external ear, orbicularis oculi muscle and one third of inferior tarsal plate and palpebral conjunctiva. To prevent allograft rejection, Cyclosporin A (CsA) and Methylprednisolone (MP) or Prednisone (PS ) were combined used as immunosuppressive protocol . Dose of CsA was adjusted depending on its blood drug level. Electromyogram (EMG) of orbicularis oculi muscle was carried out at 4 weeks, 6 weeks, 12 weeks and 6 months postoperation.

RESULTS

(1) The facial anatomic characteristic of dog is similar to that of human being, external carotid artery and external jugular vein afford good blood supply to composite facial and scalp. (2) The dogs in group I c were long-term surviving with leakage of salivary juice. (3) In group II a (n = 2), one dog presented rejection reaction at 28th day postoperation, the reversal of rejection was achieved by increasing the dose of CsA and prednisone and with topical clobetasol for 2 weeks, the dog survived indefinitely( > 309 days). In group II b (n = 4), there were three dogs survived indefinitely ( > 159 days, > 129 days, > 108 days) without complication, EMG showed the function of orbicularis oculi muscle was gradually improving.

CONCLUSION

The modified type III composite facial and scalp allograft transplantation model is an ideal model for facial allograft transplantation study.

[Induction of hair follicle regeneration in mice ear by microencapsulated human hair dermal papilla cells]

OBJECTIVE

To induce the hair follicle regeneration in mice ear by microencapsulated dermal papillae cells (DPs) and to investigate the permeability of fluorescein in APA microencapsulation to search the ideal diameter of microencapsulation.

METHODS

The DPs were encapsulated with alginate-polylysine-alginate by a high-voltage electric field droplet generator. The microencapsulated dermal papilla cells were xenotransplanted into the mice ears. After 6 week, the histological examination was made by microscopy. The diffusion way and speed of fluorescein into the microencapsulations were observed by confocal laser scanning microscopy. The comparison of fluorescein intensity was made in APA microencapsulations with different diameters.

RESULTS

Fully developed hair follicles could be easily identified in the skin of implanted site following xenotransplantation of microencapsulation DPs, which were different from the control groups in configuration, number, size and differentiation degree. The fluorescein was diffused gradually into the microencapsulations with a shape of concentric circularity. The fluorescein intensity inside three groups of APA microencapsulations was: small > middle > big.

CONCLUSIONS

The microencapsulated DPs retain the physiological function to induce the follicle regeneration. The APA microencapsulations with 400um diameter could ensure the nutrition and metabolite to pass in and out freely, and isolate the immunocompetent substance absolutely.

New Surgical Approach in Facial Transplantation Extends Survival of Allograft Recipients

We have previously developed a composite total face-scalp allotransplantation model based on bilateral common carotid arteries (CCA) and external jugular veins. To decrease the mortality rates, different modifications of arterial anastomoses in the facial allograft recipients are presented. Eighteen full face-scalp allograft transplantations were performed across major histocompatibility (MHC) barriers between ACI (RT1) donors and Lewis (RT1) recipients. Bilateral CCA and bilateral external carotid arteries of the recipients were used as recipient vessels to vascularize the flap in 5 and 4 transplants, respectively. In 9 transplants, unilateral CCA of the recipients were used to vascularize the face/scalp flap. All the animals received CsA 16 mg/kg/d Sc, which was tapered over 4 weeks to 2 mg/kg/d. In transplants utilizing bilateral CCA, the survival rate of the animals was very short. Transplants in which unilateral CCA were used yielded 100% survivals over 200 days posttransplant. These modifications of arterial anastomoses have significantly improved survival of facial allograft recipients.

Cicatricial eyebrow reconstruction with a dense-packing one- to two-hair grafting technique

Scarring eyebrow loss is usually repaired with a hair-bearing island scalp flap or scalp strip grafting technique. The results, however, are usually not desirable with regard to appearance. In this article, a one- or two-hair graft with a dense-packing technique was developed for cicatricial eyebrow reconstruction. It was carried out by harvesting a scalp strip close to the hairline of the back, then dividing it into a series of one- or two-hair grafts, and finally implanting the grafts into the prepared recipient holes of the eyebrow with a desired hair direction. With the authors' experience in treating 96 patients (154 eyebrows) in cases of burn, skin grafting, traumatic scarring, and chemical peeling scar after tattoo removal, the eyebrows could be restored in only one session. In general, 150 to 200 grafts with 200 to 250 hairs were needed for a complete male eyebrow reconstruction and 100 to 150 grafts with 150 to 200 hairs were needed for a complete female eyebrow reconstruction. The maximal hair density was 91.5 hairs/cm per session. Over a 6-month follow-up period, the mean graft survival rate reached 98.1 percent. All of the patients achieved satisfactory results, with a very natural appearance. These results indicate that the above-mentioned technique could be a practical, effective, and probably ideal method for cicatricial eyebrow reconstruction.

Allotransplantation of the Face: How Close Are We?

Reconstruction of patients with severe facial disfigurements due to burns, trauma, or cancer is a challenging task for plastic surgeons. Currently, available reconstructive options rarely result in satisfactory functional and aesthetic outcomes. In this article the authors present the rationale and experimental basis for the introduction of composite facial allograft transplantation in humans. They outline the ethical, social, and media-related issues in facial allograft transplantation.

Vascular Anatomy of the Anteriorly Based Pericranial Flap

OBJECTIVE:

The purpose of this study was to examine the vascular supply of the anteriorly based frontal pericranial flap to determine whether separating the pericranium from the galea above the orbital rim would devascularize the pericranial flap.

METHODS:

The arteries supplying and the veins draining the frontal pericranial flap were examined in 17 adult cadavers using ×3 to ×30 magnification. The arteries were examined on 25 sides and the veins on 16 sides.

RESULTS:

The main trunk and superficial branches of the supraorbital and supratrochlear arteries, which course in the galea-frontalis muscle layer, give rise to the deep branches that supply the pericranium. These pericranial branches may arise in the orbit or at the level of or above the orbital rim. Pericranial arteries that arose above the level of the orbital rim and would be divided in separating the galea and pericranium were found in 28% of the sides examined. Pericranial veins that coursed above the orbital rim and would be divided in separating the galea-frontalis muscle layer from the pericranial layer were found in 43.8% of the sides examined.

CONCLUSION:

In preparing a pericranial flap based anteriorly on the supraorbital rim, the separation of the galea-frontalis muscle layer from the pericranium layer should not extend into the 10 mm above the supraorbital rim if the arterial and venous pedicle of the pericranial flap is to be preserved.

Eyebrow reconstruction following burn injury

Facial burns represent between one-fourth and one-third of all burns. Absence of the eyebrows or distortions in their position alter the character of the face. Thus, eyebrow repair or reconstruction can be an important "finishing touch" in the overall reconstruction of a burned face. Generally, there are three ways to reconstruct the eyebrow: use of superficial temporal artery island flap; composite graft from scalp; and mini or micrografts from scalp. This report presents 20 patients reconstructed with the above techniques. Eleven patients (eight male and three female) with superficial temporal artery island flaps; seven patients (two male and five female) with composite grafts from scalp; and two patients (female) with minigrafts. The results suggest that superficial temporal artery island flaps were more suitable for males and composite graft for females who generally require thinner and less dense eyebrows. Our experience with minigrafts for burn alopecia has not been adequate. Here in this article, different methods of eyebrow reconstruction are presented with the greater emphasis on superficial temporal artery flap.

A New Composite Facial and Scalp Transplantation Model in Rats

There are limited sources of autogenous tissue available for reconstruction of severe facial and scalp deformities caused by extensive tumor ablation, burns, or trauma. Allografts from cadaveric sources may serve as a reconstructive alternative. However, technical and immunological aspects of harvesting and transplanting face and scalp flaps limit the routine use of such procedures. For evaluation of the feasibility of composite-tissue reconstruction, an experimental model of composite face/scalp flap transplantation in rats was designed. Technical aspects of the model, survival rates, and the complications encountered during development of the model are presented. A total of 64 animals, in three experimental groups, were studied. In group I, the anatomical study group (n = 6), the anatomical features of the face and scalp region in rats were explored. Groups II and III were the transplantation groups. Isograft transplantations were performed between identical Lewis rats (RT11 to RT11), and allografts were transplanted, across major histocompatibility complex barriers, between Lewis-Brown Norway rats (RT1l/n) and Lewis rats (RT11). In group II (the control group, n = 8), transplantation of nonvascularized composite face/scalp isografts and allografts was performed. In group III (the transplantation group, n = 50), vascularized face/scalp isografts (n = 36) and allografts (n = 14) were transplanted. Complications included partial or total flap necrosis, death attributable to food aspiration, and poor general condition. To prevent acute and chronic allograft rejection, cyclosporine A (16 mg/kg per day) therapy was initiated 24 hours after transplantation; the dose was tapered to 2 mg/kg per day within 4 weeks and was maintained at that level thereafter. Long-term survival (>170 days) was achieved, without any signs of rejection, with low-dose (2 mg/kg per day) cyclosporine A therapy. This is the first report documenting successful composite face/scalp flap transplantation in the rat model.

Total upper lip reconstruction with a free temporal scalp flap: long-term follow-up

BACKGROUND

In men, reconstruction of large full-thickness defects of the upper lip requires both an inner layer to replace the mucosal lining and an outer hair-bearing layer.

METHODS

When locating the superficial temporal vessels, the design of the temporal flap is marked following the hairline needed. After meticulously dissecting the flap, it is inset and microanastomosed with the facial blood vessels. The internal mucosal layer of the flap is grafted on. During the follow-up period, the sensory recovery and motor functions are examined and recorded.

RESULTS

The postoperative courses were uneventful, and patients were satisfied with the results. One patient has a long follow-up period of 18 years.

CONCLUSIONS

The free temporal scalp hair-bearing flap offers a reasonable alternative to conventional techniques in the reconstruction of large defects of the male upper lip or even a total upper lip. It is a single-staged, relatively simple method of providing hair-bearing skin to the upper lip.

Transfer of alopecia areata in the human scalp graft/Prkdc(scid) (SCID) mouse system is characterized by a TH1 response

Alopecia areata is an autoimmune condition directed at hair follicles, which results in loss of hair. We have previously demonstrated that it is possible to transfer hair loss, along with the immunohistologic findings of alopecia areata, to human scalp grafts on Prkdc(scid) (SCID) mice by injection of autologous activated lesional T-cells. This study examines the cytokine profile of T-cells and follicular epithelium following transfer of hair loss. Two consistent findings significantly (P < 0.01) associated with hair loss were production of interferon-gamma-inducible protein-10 kDa (IP-10) by follicular epithelium (13/13), and production of INF-gamma by infiltrating T-cells (10/12). Noninjected control grafts regrew hair, and were generally negative for IP-10 (positive 2/9), and INF-gamma (positive 2/9), but expressed of IL-10 on the follicular epithelium (7/9). These data support an INF-gamma TH1 pathogenesis for hair loss in alopecia areata.

[Aplasia cutis congenita in 4 infants]

In 4 infants, 3 boys and 1 girl, the congenital absence of skull skin was diagnosed: aplasia cutis congenita, a rare congenital skin defect, which usually presents as a solitary defect over the vertex of the skull measuring a few to approximately 10 centimetres. All four patients were treated with a skin transplantation and more than a year later the skin covered the skull well. There is no consensus concerning the treatment of aplasia cutis congenita. Due to unfamiliarity with this condition, a conservative approach is often adopted. The management strategy indicated should depend on the size of the defect and the child's physical condition. In the case of large defects, an early operative treatment is desirable to prevent serious complications such as haemorrhages and infections. Sufficient skin coverage can be obtained by using rotation scalp flaps, and if necessary additional split-skin grafts. In some patients large rotation flaps are not reliable due to the abnormal vascularity of the skin (Adams-Oliver syndrome). Split-skin grafting is the treatment of choice in these patients.

Melanocyte-associated T cell epitopes can function as autoantigens for transfer of alopecia areata to human scalp explants on Prkdc(scid) mice

Alopecia areata is a tissue restricted autoimmune condition affecting the hair follicle, resulting in hair loss. The goal of this study was to test the hypothesis that the autoantigen of alopecia areata is melanocyte associated. Potential autoantigens were tested in the human scalp explant/Prkd(scid) CB-17 mouse transfer system. Scalp T cells from lesional (bald) alopecia areata scalp were cultured with antigen-presenting cells, and antigen, along with interleukin-2. The T cells were then injected into autologous lesional scalp grafts on SCID mice, and hair regrowth was measured. Hair follicle homogenate was used as an autoantigen control. T cells cultured with melanoma homogenate induced statistically significant reduction in hair growth (p <0.01 by ANOVA). HLA-A2-restricted melanocyte peptide epitopes were then tested with lesional scalp T cells from HLA-A2-positive alopecia areata patients. Melanocyte-peptide-activated T cells significantly reduced the number of hairs regrowing in two experiments with six patients (p <0.001 by ANOVA). Injected scalp grafts showed histologic and immunochemical changes of alopecia areata. The most consistent peptide autoantigens were the Gp100-derived G9-209 and G9-280 peptides, as well as MART-1 (27-35). Melanocyte peptide epitopes can function as autoantigens for alopecia areata. Multiple peptides were recognized, suggesting epitope spreading.

Prevention of chemotherapy-induced alopecia in rats by CDK inhibitors

Most traditional cytotoxic anticancer agents ablate the rapidly dividing epithelium of the hair follicle and induce alopecia (hair loss). Inhibition of cyclin-dependent kinase 2 (CDK2), a positive regulator of eukaryotic cell cycle progression, may represent a therapeutic strategy for prevention of chemotherapy-induced alopecia (CIA) by arresting the cell cycle and reducing the sensitivity of the epithelium to many cell cycle-active antitumor agents. Potent small-molecule inhibitors of CDK2 were developed using structure-based methods. Topical application of these compounds in a neonatal rat model of CIA reduced hair loss at the site of application in 33 to 50% of the animals. Thus, inhibition of CDK2 represents a potentially useful approach for the prevention of CIA in cancer patients.

Sideburn reconstruction with an arterial V-Y hair-bearing scalp flap after the excision of basal cell carcinoma

A new flap is presented for sideburn reconstruction. It has good vascularity and hair direction. There is some tension in the closure of the scalp donor site that can be associated with alopecia. The flap should be advanced only to the desired sideburn level, with a cervicofacial flap covering any remaining defect. Follow-up at 2 years 4 months confirmed the satisfactory result. This flap adds another option to those discussed in this article for sideburn reconstruction.

Posterior scalping flap revisited

OBJECTIVE

To report our experience in a case series of 5 posterior scalping flaps.

DESIGN

Retrospective review of a case series.

SETTING

A tertiary academic care otolaryngology-head and neck surgery referral center.

PATIENTS

Five patients having undergone posterior scalping flap reconstruction of cutaneous midface defects.

METHODS

Reconstruction was performed for 4 cheek defects, 1 of which included the lateral third of the upper and lower lips, and 1 combined midfacial and lateral nasal wall defect.

RESULTS

All 5 patients had excellent cosmetic and functional results. The only complication was a single case of partial-thickness distal flap necrosis.

CONCLUSION

The posterior scalping flap offers a reliable source of skin with appropriate color and texture and minimal donor-site morbidity.

New topical antiandrogenic formulations can stimulate hair growth in human bald scalp grafted onto mice

The purpose of this study was to test the ability of topical formulations of finasteride and flutamide to re-enlarge hair follicles in male-pattern baldness. This was evaluated by an experimental model of human scalp skin graft transplanted onto SCID mice. A comparison was made between formulations containing finasteride and flutamide, and a vehicle formulation in terms of the mean hairs per graft, length, diameter of the shafts, and structures of the growth stages of the hair. Flutamide and finasteride had a significantly higher effect (P<0.05) than the placebo in all the tested parameters, but flutamide demonstrated more hair per graft and longer hair shafts than finasteride (P<0.05). The number of hairs per graft for flutamide and finasteride groups were 1.22+/-0. 47 and 0.88+/-0.95 hairs/0.5 mm2 graft, respectively, versus 0. 35+/-0.6 hairs/graft for vehicle-treated graft. Similarly, hair lengths for flutamide and finasteride were 5.82+/-0.50 and 4.50+/-0. 32 mm, respectively, versus 2.83+/-0.18 mm for the vehicle-treated grafts. An in vitro diffusion study of flutamide gel using hairless mouse skin demonstrated the beneficial effect of the vehicle composition in comparison with a hydroalcoholic solution or a gel containing no penetration enhancer. It is therefore suggested that this topical composition containing flutamide or finasteride may effectively result in regression of male-pattern baldness.

Characterization of infiltrating T cells in human scalp explants from alopecia areata to SCID nude mice: possible role of the disappearance of CD8+ T lymphocytes in the process of hair regrowth

T cells may play a role in the pathogenesis of alopecia areata (AA). We attempted to elucidate the linkage between infiltrating T cells and hair regrowth processes by grafting scalp skin from the affected region of patients with AA onto severe combined immune deficiency (SCID) nude mice. When the AA scalp was grafted into the mice, the grafts were accepted, and normal hair regrowth was observed. Before grafting, CD4+ and CD8+ T cells had infiltrated into the peribulb area. After grafting, the telogen hair shifted to anagen hair, and the CD4+ and CD8+ T cell infiltrates in the bulb area decreased in all cases. CD8+ T cells had almost disappeared from all portions of the follicles. It has been suggested that CD8+ T cells play a crucial role in the pathogenesis of AA. The absence of CD8+ T lymphocytes that responded to follicular autoantigens may induce hair regrowth in the grafted skin. In addition, the CD4+ human T cells that had infiltrated or still remained in the upper-middle portions including the bulge area accompanied the HLA-DR expression after grafting. Infiltrating or surviving T cell phenotypes and locations changed during the hair cycle in the grafts. These results indicate that the location of infiltrated T cells and their phenotypes may participate not only in hair loss but also in regrowth of hair in AA.

Deepithelialization prior to onlay grafting using the UltraPulse carbon dioxide laser

When used in a defoeused mode, the UltraPulse carbon dioxide laser causes skin vaporization at a subepidermal level with minimal surrounding thermal destruction, allowing early reepithelialization from retained skin appendages. This attribute is of paramount importance if only skin resurfacing is desired. However, because the effect essentially is total removal of the epidermis, such a sequela can also be used advantageously to prepare a vascularized dermal bed prior to onlay of composite grafts or secondary overgrafting. This skin deepithelialization can be achieved in a bloodless field, permitting constant visualization of the depth of penetration, and an integrated computerized pattern generator scanner allows rapid, precise, and consistent desurfacing to the desired level. This preliminary investigation demonstrates that successful overgrafting is possible on a viable dermal plane exposed by the UltraPulse carbon dioxide laser, as another example of its role in skin deepithelialization.

An experience of pubic hair reconstruction using free temporoparietal fasciocutaneous flap with needle epilation

Lack of pubic hair may cause suffering for pubescent and adult patients; thus, rapid and precise reconstruction is required for their mental health. We reported pubic hair reconstruction for burn alopecia using a free temporoparietal fasciocutaneous flap transfer with needle epilation. Fourteen months after the reconstruction, an acceptable aesthetic result was obtained, and our patient is satisfied with her reconstructed pubic hair. We conclude that reconstruction using a free temporoparietal fasciocutaneous flap with needle epilation is a useful method for selected patients.

Outcome of scalp donor sites in 450 consecutive pediatric burn patients

The scalp is a useful and reliable donor site in pediatric burn patients that can be multiply harvested with minimal morbidity. Healing complications, however, may include alopecia and chronic folliculitis. To investigate scalp donor-site morbidity, a consecutive series of 2478 pediatric burn patients treated over a 10-year period were reviewed. A total of 450 of these patients had scalp donor sites for wound closure. Percent of total body surface area burned was 46+/-23 percent (mean+/-standard deviation), and the mean number of sequential scalp donor-site harvests was 2.2+/-2 (range, 1 to 10) with mean intervals between harvesting of 6+/-0.6 days. Ten patients (2.2 percent) had related complications. Eight patients developed scalp folliculitis, with Staphylococcus sp as the predominant organism (80 percent). Two patients were managed successfully with wound care alone; the other six patients required surgical debridement and split-thickness skin grafting to achieve wound healing. These eight patients developed varying degrees of alopecia. Two patients developed alopecia without previous folliculitis. Six patients required reconstructive surgery, which consisted of primary closure (3), staged excision (1), and tissue expansion (2). A number of variables were examined to determine any differences in the group that had complications compared with the group of patients that did not. No differences in age, sex, race, burn type, burn size, septic episodes, time to wound closure, or number of times the scalp was harvested were detected. Healed second-degree burns to the scalp that were subsequently taken as donor sites seemed to be a risk factor (p < 0.05) for folliculitis and alopecia. Our study confirms that scalp donor sites are reliable with low morbidity. Complications include alopecia and chronic folliculitis that can be avoided by meticulous technique and avoidance of previously burned areas.

Non-anastomotic bypass surgery for childhood moyamoya disease using dural pedicle insertion over the brain surface combined with encephalogaleomyosynangiosis

BACKGROUND

Anastomotic bypass surgery for childhood moyamoya disease provides more rapid improvement of blood circulation than indirect non-anastomotic bypass surgery, but there are several problems, such as the technical difficulty of the operation, the extended period of anesthesia, and temporary occlusion of blood flow in the vessels of the brain surface.

METHODS

We describe a new non-anastomotic bypass procedure using dural pedicle insertion over the brain surface combined with encephalogaleomyosynangiosis and preservation of the superficial temporal artery (STA). We treated nine patients with childhood moyamoya disease admitted to our institution from 1989 through 1994. The operative field was determined based on the ischemic site identified by preoperative neuroimaging methods. Our procedure was performed in a total of 15 hemispheres, and the patients have been followed up for 5 months to 5 years after operation.

RESULTS

Cerebral angiography, cerebral blood flow measurements, and clinical symptoms and signs were improved at the operation site in all patients. Because the STA and the superficial portion of the temporal muscle attached to the skin flap were preserved, the skin at the operation site was not depressed and no necrosis, infection, or alopecia developed.

CONCLUSION

Childhood moyamoya disease is progressive, so repeated bypass surgery may be required. Therefore, non-anastomotic bypass surgery is better for the first operation because the STA is preserved. The present procedure using temporal muscle, galea, and dura can be extended over a wider brain surface than the operative field, and is suitable for establishing collateral circulation in the frontal lobe. Blood flow in the skin flap is maintained, so the cosmetic result is satisfactory.

Incidence of the concrete scalp deformity associated with deep scalp donor sites and management with the Unna cap

The scalp has become a popular donor site for split-thickness skin grafts. This donor site does, however, have complications, including the concrete scalp deformity, which consists of hairs embedded in a thick, desiccated, exudative crust. This article presents our burn unit's experience with this complication. Fifty-six patients underwent scalp skin graft harvesting between 1984 and 1996. All grafts were quite thick and were used for resurfacing facial burns. Thirty-eight donor sites were treated with medicated gauze, and 18 were treated with the Unna cap, which is an Unna dressing applied over Aquaphor gauze (Beiersdorf, Norwalk, Conn). Eighteen of the 38 patients (32%) treated with medicated gauze developed the concrete scalp deformity. None of the patients treated with the Unna cap developed the deformity. Although useful, the deep scalp donor site has complications, including the concrete scalp deformity. However, with use of the Unna cap dressing, we have had no occurrences of this problem.

The Unna "cap" as a scalp donor site dressing

Deep scalp donor sites can be difficult to manage because of the higher incidence of healing complications that can make daily wound care exquisitely painful. When faced with this problem, we prospectively studied the Unna "cap" dressing on the scalp. Group 1 received our standard treatment--Xeroform gauze (Sherwood Medical, St Louis, Mo) and daily wound care. Group 2 received the Unna cap--Aquaphor gauze (Beiersdorf, Norwalk, Conn) and Dome Paste gauze (Bayer Corp, West Haven, Conn) with wound care every 3 days. Pain, healing time, and costs were compared. Twelve patients between the age of 1 and 54 years were studied. A significant number of patients in Group 1 developed wound complications after initial healing, resulting in a longer length of stay and higher costs. Group 2 reported significantly less procedural pain, comparable healing (11 days +/- 2 SD), and fewer dressing changes, resulting in an institutional savings of $5.51 to $16.25 per patient up to postoperative day 13. This study supports use of the Unna cap as a less painful, safe, and cost-effective alternative to our standard deep scalp donor site dressing.

The C8/144B monoclonal antibody recognizes cytokeratin 15 and defines the location of human hair follicle stem cells

Stem cells are vital for the homeostasis of self-renewing tissues such as the hair follicle. Epithelial stem cells have been implicated in tumorigenesis and wound healing, and their manipulation may have wide ranging applications including gene therapy and tissue transplantation. Rodent hair follicle stem cells have been localized to an area of the follicle called the bulge, however, the identification and characterization of human hair follicle stem cells has been hampered by a lack of cellular markers for this area. We have determined that the C8/144B monoclonal antibody, originally generated against a short intracytoplasmic peptide of CD8, preferentially immunostains hair follicle bulge keratinocytes without staining the remaining hair follicle. Using expression cloning, we identified cytokeratin 15 as the keratinocyte protein recognized by the C8/144B monoclonal antibody. By delineating the bulge using this antibody, we demonstrated that bulge cells possess a stem cell phenotype characterized by their slowly-cycling nature, preferential proliferation at the onset of new hair follicle growth, high level of beta1 integrin expression, and expression of cytokeratin 19.

Scalp autografts and hair transfer to the face in the burned child

Hair transfer from split-thickness skin grafts harvested from the scalp is not a widely reported problem. The authors present their experience with hair transfer from scalp autografts in a pediatric burn population, with particular emphasis on hair transfer to the face. They retrospectively reviewed 3307 acute and reconstructive pediatric burn admissions over a 4-year period at a single institution and identified 109 cases in which the scalp had been used as a donor site and in which the patient survived the acute burn period. Data from 73 male and 36 female patients were analyzed with respect to age, race, sex, percent total body surface area burned, graft thickness, number of scalp harvests and time between harvests, and presence of donor site alopecia. Eighteen of the 109 patients had noticeable hair growth from their scalp grafts (17 percent). Fourteen of 18 cases of hair growth involved face or neck grafts (13 percent); the remaining 4 patients had hair growth elsewhere on the body. There was no difference between the two groups (hair growth versus no hair growth) when compared by age, sex, or graft thickness. There was a correlation between larger burn size and greater incidence of hair growth. Those who had multiple harvests of the same scalp donor site were more than twice as likely to have hair transfer (9 of 34 versus 9 of 75 patients), although time between harvests was not a significant variable. Caucasian children represented 77 percent of the study population yet 100 percent of the cases of problem hair growth. Thirty-three percent of the hair growth group (6 of 18 patients) and 4 percent of the remaining patients (4 of 91) had some degree of donor site alopecia. The scalp is a reliable and valuable donor site for skin grafting in children, particularly for facial burns. The authors note a moderate incidence of hair transfer (17 percent) and propose both suggestions for prevention and recommendations for management.

Miniflap hair restoration

BACKGROUND

Flap reconstruction of the scalp has traditionally required multiple, delayed procedures, an extensive principle operation, and several minor revision surgeries to produce the optimal end result. The entire protocol had to be repeated for each subsequent flap. Flap reconstructions only covered a moderate portion of the bald scalp of the later-staged patient. This hair restoration process required considerable surgical skill on the part of the operator and tenacity on the part of the patient.

OBJECTIVE

A system of short, nondelayed flaps was developed to shorten this comparatively long, multi-staged process and reduce the risk of flap compromise.

METHODS

Initially, the patient underwent a two-step, scalp-lifting procedure to reduce the width of bald scalp to be spanned. At later sessions, anteriorly based flaps were outlined from the margin of the lifted scalp and rotated into the desired configuration.

RESULTS

In 29 flaps rotated to date in 13 patients, flap viability was excellent and interflap scarring acceptable. Hair direction was readily adapted to the patients' desires. Case examples are presented.

CONCLUSION

Staged scalp-lifting with miniflap reconstruction of the scalp is a preferred option for hair relocation in selected cases.

Autoimmune hair loss (alopecia areata) transferred by T lymphocytes to human scalp explants on SCID mice

Alopecia areata is a tissue-restricted autoimmune disease of the hair follicle, which results in hair loss and baldness. It is often psychologically devastating. The role of T lymphocytes in this disorder was investigated with cell transfer experiments. Scalp explants from patients were transplanted to severe combined immunodeficiency (SCID) mice and injected with autologous T lymphocytes isolated from involved scalp. T lymphocytes which had been cultured with hair follicle homogenate along with antigen-presenting cells were capable of inducing the changes of alopecia areata, including hair loss and perifollicular infiltrates of T cells, along with HLA-DR and ICAM-1 expression of the follicular epithelium. Similar changes were not noted in grafts injected with scalp-derived T cells that had not been cultured with follicular homogenate. These data indicate that alopecia areata is mediated by T cells which recognize a follicular autoantigen.

Design and development of a fascioperiosteal flap for use in experimental cranial surgery in a porcine model

As part of an ongoing program of research on reconstructive techniques applicable to the growing craniofacial skeleton, this study aimed to characterize a pedicled fasciocutaneous flap on the scalp of a porcine model. Twelve juvenile Yorkshire white pigs were used. The anatomy of the porcine scalp was determined by fresh cadaveric dissection, radiocontrast dye injection, and resin casting of the vascular supply. No direct analogue of the human superficial temporal artery, the key to the superficial and deep temporal fascial flaps in humans, could be demonstrated in the pig. Thus, a fascioperiosteal flap, pedicled on an occipital leash of vessels, was designed. After a 14-day surgical delay, this flap, which covered the entire cranial width, from the nuchal crest to the glabella (7-10 cm long x 3-4 cm wide), could be elevated and split into a periosteal and a fascial layer. A cartilage construct placed between these layers could be kept alive for 4 weeks with no evidence of necrosis. The flap would allow mobilization of the construct to distant sites on the head and neck. An extensive literature survey showed a dearth of suitable cranial flap options in animal models. Accordingly, the pig cranium was examined with a view to finding a fascial flap analogous to the human temporoparietal flap, suitable for use in ear reconstruction. Cadaver dissections of the pig scalp, examining both the fascial layers and blood supply, were performed in three pigs; in an additional three pigs, the vascular supply to the scalp and cranium was injected with a radiocontrast gel, and, after dissecting suitable flaps, x-ray exposure was used to demonstrate the microvascular supply of these flaps. In an additional two pigs, the cranial vascular tree was filled with a plastic resin, and the soft tissues were then removed by thermal and chemical digestion. Finally, a group of three pigs were used to test the functional efficacy of a bilayered, occipitally based fascioperiosteal flap, whose design evolved from the foregoing work. Fluoresceine and disulphine blue were used to demonstrate the vascularity of these flaps before and after a surgical delay procedure. Function of these flaps, as carriers of a reconstructive construct, was shown by implanting autologous cartilage for 3 weeks and then demonstrating complete survival of the implant by fine section and histology. No clinically useful equivalent of the superficial temporal artery in humans could be identified in pigs, thus rendering the porcine superficial temporal artery flap of little use. However, a useful flap, comprising the pericranium and the subgaleal fascia, based on the occipital vasculature, could be raised with relative ease.

A controlled study of the effects of RU58841, a non-steroidal antiandrogen, on human hair production by balding scalp grafts maintained on testosterone-conditioned nude mice

Human hair growth can be monitored for several months after the transplantation of scalp samples from men with androgen-dependent alopecia on to female nude mice. Hair production from balding sites has been shown to be inhibited in testosterone-conditioned nude mice. We used this recently reported model to study the effect of a new non-steroidal antiandrogen-RU58841-on human hair growth. Twenty productive scalp grafts from balding men were maintained for 8 months after grafting on to nude mice, and hair production was monitored monthly for 6 months. All mice were conditioned by the topical application of testosterone (testosterone propionate, 300 micrograms in 10 microL; 5 days/week) on the non-grafted flank. The scalp samples were divided equally according to the estimated hair production potential, which was based on the amount of hair present on the scalp samples before grafting. Each of the two equal groups of grafts was further allocated at random to be treated topically (5 days/week) with blinded solutions of either RU58841 1% in ethanol, or ethanol as a control. Twenty-eight active follicles appeared on the 10 control grafts. Among them only two follicles (7%) initiated a second hair cycle. However, the 10 RU58841-treated grafts bore a total of 29 active follicles, and eight of them (28%) showed a second cycle. The values for the linear hair growth rates (LHGR) were significantly (P < 0.04) higher in the RU58841-treated group. Recycling and increased LHGR indicate a positive action for RU58841 on human hair growth from balding samples grafted on to testosterone-conditioned nude mice, and encourage a clinical trial to evaluate its potential in the treatment of androgen-dependent alopecia.