[Plastic surgical management of large cicatricial scalp alopecia]

To investigate the proper ways to manage a large cicatricial scalp alopecia.

Based on the location, size and condition of the scarring lesions, 218 patients with 20 - 75% scarring alopecia were selected and treated with either dense-packing hair grafting technique (136 cases) or tissue expansion (82 cases). There were 209 in burn, 5 in avulsed injury and 4 in tumor excision. The lesions with thick, stable scars in the frontal or/and temporal areas undergoing either hair grafting or tissue expansion process as desired by the patients. In addition, the alopecia in an unstable scar on the skull, with skull defect under the lesion and the lesion involved in the back of the head was only treated with tissue expansion. The hair-grafting technique was carried out by harvesting a scalp strip from the back of the head, then dividing it into a series of 1 - 3 hair grafts and finally implanting them into the prepared recipient holes of the lesion with a desired hair direction. Ten areas with 1 cm(2) size in 10 patients were randomly selected to examine the hair survival over 8 months post-operation. Tissue expansion was performed by firstly positioning a tissue expander in the subgaleal pocket of the scalp and serially inflating it with normal saline in 5 - 7 days intervals for about 3 months. Thereafter, an expanded scalp flap was designed, with the combination of advancement and rotation flap transplantation principles, to be transferred to the recipient site after lesion removal.

In patients with hair-grafting technique, hair density reaching 60 - 80 hairs/cm(2) per session. Over 8-months following-up, the grafted hairs grew good with 98% hair survival. Forty-five patients with 20% - 30% scalp hair loss were reaching very satisfactory results with only one session while 91 patients with 31% - 50% hair loss were needed a second session to improve their appearance. In those with tissue expansion, 56 patients with 20% - 50% scalp loss were managed in one session and 26 patients with 51% - 75% scalp loss needed secondary tissue expansion. All of the expanded hair-bearing flaps survived well with only minimal complications (9.8%) of the infective dome explosion in 3, slight skull depression in 2, seroma in 5 and early infection in 1.

Either hair grafting or tissue expansion is proven as a safe and effective technique for restoration of large cicatricial scalp alopecia. The former technique could be of benefits to simple, mini-surgical procedure, natural hair growth and good for lesion size under 30%. And the letter technique shows wider clinical indications, especially for the patients with unstable scar, skull defect under lesion and lesion over 50%. But the obvious drawbacks are multi-clinic visiting, disfigurement and long-term procedures.