Consecutive transposition flaps for the management of slot formation after alopecia-reducing surgery

Alopecia-reducing procedures were first introduced to the field of cosmetic hair restoration surgery in 1977 and have advanced to the point that large areas of baldness can be treated very effectively and expeditiously (Fig. 1). The most aggressive of the alopecia-reducing procedures is called scalp-lifting (undermining down to the hairline of the nape) (Fig. 2) and consists of the lateral lift (Fig. 3a), the bilateral occipitoparietal lift (Fig. 3b), and the bitemporal lift (Fig. 3c). These procedures are usually used to correct posterior baldness while hair grafts are used for frontal hairline restoration (Fig. 3d). Although incredible results can occur with this methodology, it is not without its difficulties. One of the most formidable of these problems is slot formation with divergent hair direction. This problem can develop after multiple alopeciareducing procedures are carried through (Fig. 4). In an excellent study performed by Nordstrom in 1983, he demonstrated that the total length of the bald area increases by approximately 10% of its total length with each progressive operation. This increased length in the posterior region can cause a severe cosmetic deformity, especially in patients who are extensively bald and have had several of these procedures.