|Year : 2019 | Volume
| Issue : 4 | Page : 160-166
Clinical experience with hair transplantation for secondary cicatricial alopecias
Ekrem Civas1, Hasan Mete Aksoy2, Berna Aksoy3, Muhitdin Eski4
1 Clinic of Dermatology, Civas Private Clinic, Ankara, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Bahcesehir University, Istanbul; Clinics of Plastic, Reconstructive and Aesthetic Srugery, VM Medicalpark Private Kocaeli Hospital, Kocaeli, Turkey
3 Department of Dermatology, Faculty of Medicine, Bahcesehir University, Istanbul; Clinic of Dermatology, VM Medicalpark Private Kocaeli Hospital, Kocaeli, Turkey
4 Clinic of Plastic, Reconstructive and Aesthetic Surgery, Private Practive, Ankara, Turkey
|Date of Submission||06-Nov-2018|
|Date of Acceptance||02-Jan-2019|
|Date of Web Publication||26-Sep-2019|
Dr. Berna Aksoy
Department of Dermatology, Bahcesehir University, Faculty of Medicine, Istanbul
Source of Support: None, Conflict of Interest: None
Background: Hair transplantation for the treatment of secondary cicatricial alopecia has recently become a more widely used technique. Objective: The aims of this study were to evaluate the results of use of hair transplantation surgery in patients with secondary cicatricial alopecia, to compare the results of the procedure with regard to different etiologies and to evaluate patient satisfaction. Patients and Methods: Forty-five patients with a definitive clinical diagnosis of secondary cicatricial alopecia were included in this retrospective study. Patients' characteristics were obtained retrospectively from medical records. The percentage of amelioration of cicatricial alopecia and patient satisfaction was obtained by interviewing patients. Results: Thirty-nine patients (86.7%) were satisfied and very satisfied with the procedure. While all patients who underwent hair transplantation for the treatment of facial cicatricial alopecic areas were satisfied, patients with hypertrophic scars were not satisfied significantly. Patient satisfaction was correlated to the percentage of amelioration of cicatricial alopecia. While patients with permanent alopecia as a result of developmental defects were satisfied the most, patients with postoperative and posttraumatic scars were satisfied the least. There was no difference between two different hair transplantation methods with regard to patient satisfaction. Conclusion: Hair transplantation done directly into scar tissue could be the first line treatment in selected cases with secondary cicatricial alopecia as this method is less traumatic and easier to perform in comparison with other surgical treatment methods.
Keywords: Cicatricial alopecia, follicular unit extraction, follicular unit transplantation, hair transplantation
|How to cite this article:|
Civas E, Aksoy HM, Aksoy B, Eski M. Clinical experience with hair transplantation for secondary cicatricial alopecias. Turk J Plast Surg 2019;27:160-6
| Introduction|| |
Cicatricial alopecias are a discrete group of hair disorders characterized by permanent destruction of follicular unit (FU) and irreversible hair loss. Follicular destruction can develop primarily as a result of folliculocentric disease (primary unstable cicatricial alopecia) or secondarily as a result of conditions affecting both hair follicles and structures outside hair follicles (secondary stable/permanent cicatricial alopecia).,
Hair pastiche and wigs could be used for the concealment of cicatricial alopecia. Surgical excisional treatment is a very effective method used for the treatment of secondary stable cicatricial alopecias. Complimentary hair transplantation to the resulting scars could be necessary in these cases. Hair transplantation for the esthetic correction of cicatricial alopecias of the face and scalp has been found to be a safe and predictable procedure with a high level of patient satisfaction. There are very little data on hair transplantation for the treatment of different secondary cicatricial alopecias in the literature.
In this study, we retrospectively evaluated the clinical results of hair transplantation used for the treatment of patients with secondary cicatricial alopecia in a single private hair transplantation clinic. We focused especially on comparing the clinical results of hair transplantation with regard to different etiologies of stable secondary cicatricial alopecia and perspectives of patients and on investigating patient satisfaction after a long follow-up period.
| Patients and Methods|| |
This study was performed retrospectively by evaluating the files of patients who underwent hair transplantation in a single private hair transplantation clinic owned by one of the authors (E. C.) between 2005 and 2008. Since the study is a retrospective case series evaluation, Ethics Committee approval was not obtained, but patients gave written and verbal consent. During the treatment of patients, the principles of the 1975 Declaration of Helsinki were followed. Forty-five patients with a definitive diagnosis of secondary cicatricial alopecia were included in this study. Some patients were not appropriate for primary or secondary excision of scar tissue and all treated patients in this study did not want to have excision of cicatricial alopecic area. Patients with primary cicatricial alopecia and noncicatricial alopecia were not included in this study.
Patients' gender and age, diagnosis, disease duration, operation date, donor and recipient areas, total alopecic surface area, total graft number, and mean graft number per cm 2 of recipient area were obtained retrospectively from the patients' medical records. The percentage of amelioration of cicatricial alopecia and patient satisfaction with the procedure was obtained from telephone or clinical interviews with all of the patients in August and September 2009 after about 1 year postoperatively. All of the patients are requested to answer two questions: “Could you give an estimated value for what percentage of your scar has been ameliorated by hair transplantation?” and “Are you satisfied with the result of your hair transplantation?” Percentage of amelioration of scar area was categorized as; 0%–25% fair, 26%–50% moderate, 51%–75% good, 76%–100% excellent. The answers for satisfaction were categorized according to 5 Likert scale as; 0 for unsatisfied, 1 for slightly satisfied, 2 for indecisive, 3 for satisfied, and 4 for very satisfied.
All patients were carefully evaluated and put the diagnosis of secondary cicatricial alopecia following thorough medical history and dermatological examination. Patients with a compromised vascular supply in the alopecic scar area were not operated as considering the risk of tissue necrosis following hair transplantation. Patients were evaluated before hair transplantation for the presence of any contraindication to the use of local anesthetics. All patients did not have any contraindication to surgical operation with regard to the scar area characteristics. None of the patients had any local anesthetic allergy in their medical history. Patients were informed about the treatment plan and other alternative surgical intervention methods. All patients preferred hair transplantation over other surgical intervention methods and informed consent is obtained for the treatment of their cicatricial alopecic areas.
Patients were examined preoperatively for their eligibility to undergo hair transplantation as following. Patients' scars were evaluated according to their size and skin characteristics. All patients were examined for the presence of androgenic alopecia signs. The donor site and the method of extraction of donor hairs were determined according to the patients' characteristics. If the patient had prior hair transplantation and had inadequate or limited donor hair in the occipital scalp, other alternative donor areas such as chest are used. Beard was used as donor area for the treatment of moustache scars. The occipital region was used as donor area in all other patients. Two methods of donor harvesting FU transplantation (FUT) and FU extraction (FUE) were used. FUT method is the preferred method in patients with a need for graft counts equal to or more than 1000. In one female patient with frontal scars resulting from prior rhytidectomy, FUT method was also used. FUE was preferred in all male patients with postoperative secondary cicatricial alopecia and especially in those patients who had hair transplantation for the treatment of androgenic alopecia to prevent the development of new scars. FUE method was also used in conditions of the presence of scalp skin tension in occipital area, predisposition to abnormal scar development, and usage of alternative donor areas. Transplantation density was determined according to the size of alopecic area, recipient skin condition, and donor hair density. Vascular supply of recipient scar was determined by pricking a 19 gauge needle into the scar and observing the amount of bleeding afterward. We got an idea of vascular supply of the scar tissue by pricking it several times and observing the presence of bleeding afterward. To avoid the development of postoperative complications, transplantation density of 30 grafts/cm 2 or fewer was planned for the correction of scars instead of using 40 grafts/cm 2 that is usually used in androgenic alopecia.
Anesthesia and premedication
Oral cephalexin was used for surgical prophylaxis; 2 g p. o. 1 h prior to and 1 g p. o. just after completion of the operation. When performing local anesthesia in skin surgery, dosages are usually performed by taking the maximum allowed safe doses of the local anesthetic used. We have used lidocaine in all patients for local anesthesia. Safe doses of lidocaine are 7 mg/kg when it contains adrenaline. A total of 480 mg can be given safely. We used two different techniques to perform anesthesia: A total scalp ring block anesthesia (usually over 50 cm 2 scar area and again 50 cm 2 donor area) was used for graft needs of 1000 and more. For the lower number of graft needs, regional infiltration anesthesia was used for anesthesia of the scarred area and donor region. The dose of lidocaine used was 300–350 mg maximum. Peripheral ring block anesthesia was performed in each donor site and recipient area by using 1% lidocaine containing 1: 100,000 adrenaline. Tumescence was performed by using serum physiologic containing 1: 100,000 adrenalin to obtain hemostasis in the donor site following local anesthesia. Tissue expansion by tumescence was performed by pure serum physiologic without adrenalin in the recipient area to protect subcutaneous vascular structures thus protecting perfusion of scar tissue.
The length of occipital skin strip varied between 8 and 20 cm and the width of the strip was 1 cm in FUT method. The resulting defect was closed by using trichophytic closure method  in all of the patients. The skin strip was separated into FUs under surgical microscope (Mantis Elite Stereo Inspection Magnifier, United Kingdom).
Titanium and Harris punches with sizes varying between 0.8 and 1 mm were used in the FUE technique. Harris punches were preferred to reduce the probability of FU transection, and three-step method was used.
Specifically produced scalpels with 1–1.3 mm width were used to prepare the graft recipient sites for transplanting grafts in the recipient area. Graft recipient site width and depth were determined in accordance to graft sizes. Transplantation was planned and performed by taking variations of hair growth direction and hair texture into consideration to mimic natural hair characteristics of the recipient area., Transplantation density was determined according to the nature (dermal recoil and laxity) and perfusion of the scar and anatomic location of the recipient area.,
The donor site was covered with a bandage. The recipient site was kept open. The bandage over the donor area was removed 24 h following the operation in all of the patients. The first donor site cleaning was performed in the clinic 48-h postoperatively. All patients were followed up clinically at 24 h and 48 h, on the 10th day and after completion of the 1st year following hair transplantation. All of the patients were instructed to establish contact with his or her doctor immediately in case of any problem.
Data were analyzed using IBM SPSS Statistics for Windows v. 20.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics are expressed as mean ± standard deviation, range, frequency, and percentage values. The normality of the distribution of variables was determined using the Kolmogorov–Smirnov test. Qualitative independent data were analyzed using the Chi-square test and Yates correction (if necessary). Spearman's correlation analysis was used to identify correlations. The level of statistical significance was set at P < 0.05.
| Results|| |
Forty-five patients with secondary cicatricial alopecia were included in this study. Patient characteristics are presented in [Table 1]. Patients' diagnosis were grouped according to Finner et al. classification  and presented in [Table 2]. Five patients had cicatricial alopecia secondary to prior hair transplantation treatment for androgenic alopecia and its operative complications as follows: Widening of the scar in two cases and hypertrophic scar formation in one case at the occipital donor scar after FUT application. Cicatricial alopecia formation secondary to the development of necrosis at the frontal-recipient area after hair transplantation surgery were seen in two cases. Other patients had cicatricial alopecia secondary to developmental defects, infections, other surgeries, accidents, and burns [Table 2].
Out of 45 patients, five had hypertrophic scars (two postoperative, two postaccidental, and one postinfectious). In other 40 patients, the nature of scar is normotrophic or atrophic. Eight scars were located in the face (three in moustache, one in beard, two in sideburn area, and two in brow). Other scars were located on the scalp. Scar area was 17.5 cm 2 in mean (1–80 cm 2) [Table 3]. In 41 patients, occipital scalp was used as donor area. In two occipital posttransplantation scars, that were secondary to FUT donor harvesting, the chest was used as donor area to protect occipital donor reserve for the treatment of ongoing androgenic alopecia. In two moustache scars, developed after burn injury and Leishmania infection respectively, beard area was used as donor site. FUT method was used in 10 patients, and FUE method was used in other 35 patients [Table 4]. Number of grafts transplanted varied according to the surface area of the scar. The average density of implanted grafts was 24.9 grafts/cm 2. In one patient with wide postinfectious scar, two sessions of FUT were used to increase hair density, to prevent overloading during graft transplantation and to prevent compromise of scar vascular supply. The mean postoperative follow-up period was 25.5 months (10–50 months). Twenty-one patients (46.7%) had more than 2 years of follow-up. There were not any postoperative complications such as infection, necrosis, postoperative telogen effluvium, and postoperative edema. In all of the patients with more than 1000 grafts transplanted, postoperative hypoesthesia in the recipient area lasting for 2–3 months was encountered.
Six patients (13.3%) were unsatisfied, slightly satisfied or indecisive with the procedure (3 of them had hypertrophic scars). Thirty-nine patients (86.7%) were satisfied or very satisfied with the procedure [Table 5]. There was not any significant difference in terms of satisfaction among genders (P > 0.05). There was not any patient who was dissatisfied with the procedure when hair transplantation was performed in facial areas (moustache, beard, sideburn, and brow). Patient satisfaction with the procedure correlated with the percentage of amelioration of cicatricial alopecia which varied from 20% to 95% [Table 5] (r = 0.776, P= 0.000). Good to excellent amelioration (51%–100%) of scar area was achieved in 86.7% of patients. Patients with developmental defects and resulting permanent alopecia were all satisfied with the procedure. However, patients with postoperative scars were less satisfied with the procedure [Table 5]. Satisfaction of patients with postoperative scars due to prior hair transplantation for androgenic alopecia (one dissatisfied, two satisfied, and two very satisfied) seems to correlate with scar amelioration percentage. None of our patients with hypertrophic scars were satisfied with the procedure (P = 0.11). There was no difference between two different hair transplantation methods (FUT and FUE) with regard to patient satisfaction from the procedure (P > 0.05). One of our patients was dissatisfied with the procedure as a consequence of graft popping and sticking of transplanted hair grafts to the pillow at first postoperative night. Hence, transplanted hairs did not re-grow in this patient.
Clinical examination of the patients revealed that the most important factors were the alopecia amelioration percentage and density, although they were not the sole factor in determining the satisfaction of patients. In patients with an adequate density, the factors related to dissatisfaction were the difference in hair character (diameter and color of occipital and temporal hairs were not the same in some patients) and the structural characteristics of the scar (hypertrophic and severely atrophic scars continued to appear as hypertrophic or atrophic underneath transplanted hairs).
A 25-year-old male patient with congenital developmental alopecia applied to the private hair transplantation clinic. The patient was diagnosed to have aplasia cutis congenita located in the temporal area with a size of 6 cm 2. He had hair transplantation of 170 grafts by using FUE method and occipital region served as donor site. He noted a 90% amelioration of alopecia 37 months after hair transplantation and had excellent satisfaction with the procedure [Figure 1].
|Figure 1: Aplasia cutis congenita in the right temporal area of case 1 prior to and following hair transplantation by using the FUE technique, postoperative photograph taken at postoperative 37 months|
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A 29-year-old male patient applied with a scar located on the left side of his moustache present for 6 years. The scar developed following cutaneous Leishmania infection. This postinfectious scar was treated by using hair transplantation with hairs obtained from the beard area, and FUE technique was employed. A total of 85 grafts were transplanted. At postoperative 25 months, he declared that the scar amelioration percentage was 80% and he was satisfied with the procedure [Figure 2].
|Figure 2: Cicatricial alopecia resulting from cutaneous Leishmania infection 6 years previously and at postoperative 25 months following hair transplantation by using the FUE technique in case 2|
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A 26-year-old male patient applied to the clinic with the complaint of hair loss affecting left frontotemporal hairline present for 20 years. He had a burn injury when he was a child. He was operated by using FUT technique and transplanted 800 hair grafts harvested from the occipital area. He had 70% amelioration of cicatricial alopecia at 22 months following the operation and was satisfied with the procedure [Figure 3].
|Figure 3: Burn alopecia with a duration of 20 years before hair transplantation and at postoperative 22 months following hair transplantation by using FUT technique in case 3|
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A 23-year-old male patient applied with a donor scar located in the occipital region present for 4 years. He had one session of FUT hair transplantation for androgenetic alopecia when he was 19-year-old. Later, he developed a hypertrophic and wide scar measuring 1–1.5 cm in width and 7–8 cm in length with an area of 13 cm 2. We applied hair transplantation with FUE because his cicatricial alopecic area was a FUT donor area, there is tension on the scar, and the excision of the scalp scars usually heals with re-expansion of the scar. He had signs of miniaturization of hairs in androgenic alopecia prone areas and a family history of type VII androgenic alopecia. His postoperative occipital donor scar was treated by using hair transplantation with hairs obtained from chest area and FUE technique was employed. A total of 230 grafts were transplanted. At the postoperative 30 months, he declared that the scar amelioration percentage was 60% and he was satisfied with the procedure [Figure 4].
|Figure 4: Postoperative donor scar with a duration of 4 years in case 4. The chest was used as donor area and the appearance of chest immediately after donor harvestingis shown. At postoperative 30 months, treatment result following hair transplantation by using FUE technique in occipital postoperative donor scar area is satisfactory|
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| Discussion|| |
The success and satisfaction with hair transplantation depend on the degree of obtaining a natural result (e.g., consistency of hair direction and diameter could be obtained by choosing a similar donor area to the recipient area) and density of the regrown hairs.
Patient satisfaction in our study was very high (86.7%). Six patients (13.3%) were dissatisfied with the procedure. One of the explanations for dissatisfaction with the procedure was the scar character; hypertrophic scars were present in three dissatisfied patients. Reduction of hypertrophic scars by using prior surgical excisions, medical treatment, or intralesional steroid injection could have increased the satisfaction with hair transplantation procedure in these patients. The other explanation for patient dissatisfaction was low hair density in the scar tissue obtained after hair transplantation. The percentage of amelioration of alopecia varied between 20% and 60% in patients who were dissatisfied with the procedure. Desired amelioration percentage could have been obtained in these patients by increasing graft density to 30 FUs/cm 2 by paying more attention to the vascular supply of the scar area. Moreover, microskin pigmentation method may be advised to the patients for better concealing of cicatricial alopecia area. Patient satisfaction was also related to the scar size and available donor density. While all patients with developmental defects with resulting permanent alopecia were satisfied with the procedure, patients with postoperative and posttraumatic scars expressed less satisfaction with the procedure. When the etiologic factors of cicatricial alopecia in dissatisfied patients were evaluated it was determined that there were three postoperative scars, two posttraumatic scars and one postinfectious scar. We propose that satisfaction or dissatisfaction of the patients may also be related to the knowledge about the natural hair (i.e., quality, direction, and density) which had been present in the recipient scar area prior to the development of cicatricial alopecia. Another important factor increasing patient satisfaction with the hair transplantation treatment of cicatricial alopecia is the acquisition of thorough information about the treatment and having realistic expectations from the procedure before the operation.
In order to increase patient satisfaction, scar excision can be performed before transplantation. Topical treatments to improve the amount of collagen, circulation, and color of scar tissue such as ablative nonablative laser treatments, low-level laser therapy, intralesional therapies especially for hypertrophic lesions (corticosteroid, 5-fluorouracil, and interferon), camouflage (make-up, accessories such as scarves and tattooing), cryotherapy, dermal fillers (hyaluronic acid), autologous fat injection can be applied. Channels opened into scarred areas to put the grafts lead to loosening and softening of the scars. In addition, because the grafts are scarless tissues and also contain fat in their root parts, these also have positive effects on the quality of the scar. If the scar is adhered to the base, it may be an option to apply autologous fat injection before hair transplantation. As a result, scar quality increases with hair transplantation. Scar quality additionally increases with hair frequency when the second hair transplantation session is planned.
There are a few reports on successful use of hair transplantation for the treatment of temporal triangular alopecia by using punch hair grafting and FUT technique., However, we found that FUE technique was very effective in the treatment of developmental permanent alopecia cases. We found case reports or reports of case series on the use of hair transplantation for the treatment of both donor scars  and cleft lip moustache alopecia.,, Clinical results were reported to be satisfactory.,,, Radwanski et al. reported that 3 patients out of 31 were dissatisfied with the clinical results of hair transplantation used to correct stigmas caused by rhytidoplasty operation. We found that postoperative scars were not good candidates for hair transplantation as our patients with this problem were less satisfied with the procedure than other group of patients. It was recently reported that autologous fat grafting before hair transplantation yielded superior results than solely performing hair transplantation to treat postoperative scars. There is only one report of traction alopecia that we could find in the literature and this report contains successful FUT restoration in a female patient with traction alopecia. We found that posttraumatic alopecias were similar to postoperative scars with regard to the clinical results of hair transplantation. There are case reports and an extensive review article on the treatment of postburn alopecia by using hair transplantation.,, We found high satisfaction rates in cases with postburn and postinfectious alopecias in accordance with the literature. There may be unsatisfactory results following hair transplantation to postburn cicatricial alopecia. Shao et al. reported their experience in 37 patients with secondary cicatricial alopecia treated with FUT method. They found that survival of transplanted hairs was inversely correlated to operative time. Jung et al. reported their results in 23 patients with secondary cicatricial alopecia treated with FUE method. They obtained 83.3% good and excellent results and concluded that burn scars are better ameliorated in comparison with incision scars as we do. We found that satisfaction of our patients was similar to this former report  and success rates of incision scars were worse than those of postburn scars as in the latter report.
The limitations of our study include retrospective character; some patients could have been persuaded to undergo surgical scar excision before hair transplantation, and lack of scar biopsies to assess histological scar characteristics such as vascularity, collagen density, and thickness.
Hair transplantation into scar tissue has become an alternative or complementary method to surgical excision. Hair transplantation directly into the scar tissue could be the preferred method of treatment in selected secondary cicatricial alopecia cases because this method is less traumatic and easier to perform in comparison with surgical excision. There is also no need for general anesthesia in this procedure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]