Scalp Expansion, Scalp Extender and Serial Excision

Serial Excision (Alopecia Reduction) 
In case of extensive baldness the door area at the back may not be sufficient to give the cover. This large area of baldness was commonly reduced by Serial Excision or Scalp Reduction (Alopecia Reduction) procedure. 

Various scalp reduction patterns have been designed to place the scar from the apparently more visible most convex area of mid line. But due to number of technical issues mid line reduction is commonly preferred. Every sitting at 3-4 months interval removes the 1.5 to 2.5 cm wide ellipse of scalp tissue and by necessary undermining of skin the closure is done. After few months this reduced area of baldness can then be transplanted with hair.

Disadvantages:  

1.      Pain for few days post operatively

2.      Tightness for few weeks ( increases by every sitting) due to tension closure

3.      Midline scar (unless some other style is used for reduction)

4.      Stretch back over next few months of scar due to elasticity of skin

5.      The unnatural balding pattern of  esp. crown area with change in natural whirl and direction of hairs

6.      Reduced donor density for the future requiring bigger size of strip for the same number of hairs from the back of the head ( perhaps FUE is a better option here than a strip surgery)

7.       Due to now tight donor skin (reduced laxity) the width of the strip has to be reduced and the donor density is less already therefore available donor hairs will reduce per strip.

8.      A large number of potential donor hairs have shifted to the margin of crown area and they now are not accessible by the strip harvest along with the already compromised density of donor with limited available width of strip all make things more difficult to cover ( this hairs can be accessible by FUE although)

9.      The donor skin tightness makes higher chances of donor complication for strip surgery

10.  Usually the priority of coverage is in the front and hair line area but at the same time the midline scar of the crown needs to be covered in this case. This reduces the available hairs for the front.

11.  The scalp reduction will also increase the number of procedure and the time required for the coverage.

The current method of Follicular hair Transplant unlike previous punch methods usually can cover the front and top of the scalp in majority of stage 6 or 7 baldness with limited donor hairs even without scalp reduction. With so many possible disadvantages once popular the procedure of scalp reduction has now taken the back seat.
If at all scalp reduction should be combined with FUE transplant rather than strip method

As during pregnancy if you gradually expand skin over a period of time, the pressure exerted on the skin actually stimulates new tissue to grow. This concept can be applied to treat bald areas of the scalp. There are currently 2 methods of Scalp Expansion:



 
1) Scalp expansion (Volumetric Expansion) pioneered at Hershey (Pennsylvania): In this surgery a balloon-type silicone device is implanted under the hair bearing scalp in subgaleal plane and over a period by inflating that device by injecting saline the scalp skin is expanded over few weeks. The expander is removed and the expanded hair-bearing scalp is used to cover the balding area or the skin defect. This is a 2 stages procedure and gives a period of temporary deformity due to expansion of balloon and does carry a chance of major skin loss or infection although for major scalp defects it is the great option available.

2) Scalp expansion (Non volumetric Expansion) using an implanted a device called Scalp extender which is called nonvolumetric scalp expansion or scalp extension. This procedure is pioneered by Dr. Patrick Frechet of Paris, France. The expansion and excision of bald scalp creates the conditions for subsequent approximation of hair-bearing scalp to cover the area of bald scalp excision. This procedure is useful for:

extensive hair loss where there are limited donor hairs are available. With scalp extension, the complete series of scalp reductions can be done within a 30- to 90-day period. In the past, some scalps could not be reduced at all and those that could be reduced often took as long as 1 1/2 years for the procedures to be completed. Scalp extension has some of the benefits of scalp expansion, although the amount of tissue stretch is less. Its great advantages are that it causes little or no discomfort and deformity. It is a relatively simple procedure, thereby adding little time and difficulty to the scalp reduction operation.


Advantages:
1) 50% increase in the amount of bald scalp removed in scalp reduction
2) Fewer procedures are needed to accomplish a final result
3) Reduced "stretch back" of scalp skin and subsequent scarring
4) Reduced postoperative hair loss
5) Early development of postoperative scalp laxity  

Complications and side effects:
1) Mild to severe pain during the first 24 hours after the scalp-expanding device is implanted
2) Occasional bruising or edema in scalp over the implanted device
3) Reduction in the number of donor grafts that can be harvested per session later for "fill-in"
4) Hair transplantation should this be needed to achieve the desired hair restoration goal
5) Postoperative scarring at the site where hair-bearing scalp is sutured together - most difficult to revise when the scar is a so-called "slot defect" the forms at the site where two previously non-adjacent scalp areas are now joined by suturing
6) Postoperative drainage and delayed wound healing for up to several weeks
7) Rarely, infection in the tissue around the implanted device