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

Nutrition for hair

Well our hair root is richly supplied with blood vessels but once the hair is formed and reaches the surface no nutrition reaches there in other words the hair once formed is not having life and it can not repair it self after injuries by any external agent of chemical, physical or thermal nature.


Although one must know that hair needs Protein ( Keratin) which is formed from Amino acids ( esp. L -Lysine), certain Vitamines ( Vit. A, Vit B6 B12, Biotin, Vit D and Vit E) and Minerals ( esp. Iron and Zink).

Dieting, Starving, Bariatric surgery ( for weight reduction) etc. can cause deficiency of one of these nutrients for the hair and can cause hair loss or growth problem. Although this is not common and esp. not in those who take regular balanced diet.

Deficiency should be diagnosed and can be treated by appropriate nutritional supplements. In females Iron deficiency is not uncommon due to monthly blood loss.

It takes 3-6 months before any change can be perceptible on regular treatment for deficiency correction.  The miracle cures should be looked at with suspicion. There is no overnight cure.

The kind of picture that you have should be investigated for miniaturization studies and other tests to rule out Pattern Loss or other causes instead of simply taking vitamins. In fact excess of Vit A can cause other problems besides increasing your hair loss.

Female Hair Loss

Female and Hair Loss:

Hair Loss in women can be Localized or Generalized Hair Loss:

Localized (patchy) Hair Loss (Alopecia)

The following are the more common causes of local alopecia. A dermatologist should be consulted if any of these conditions are suspected. Note: the term alopecia is synonymous with hair loss. Localized hair loss in women may be sub-divided into scarring and non-scarring types.
Alopecia areata is recognized by the sudden appearance of discrete, round patches that are completely devoid of hair. Occasionally, the entire scalp may be involved (alopecia totalis) and even the entire body hair including the eyebrows and eyelashes (alopecia universalis). When localized, the lesions respond well to injections of cortisone. Generalized alopecia is more difficult to treat. The prognosis is better the older the age of onset. Alopecia areata can occasionally be associated with other conditions such as thyroid disease. (more at:  http://goodbyehairloss.blogspot.com/2010/03/alopecia-areata.html)
Hairstyles that exert constant pull on the hair, such as Dread lock; . “corn rows” or tightly woven braids produce a characteristic pattern called “Traction Alopecia” that can be identified by a rim of thinning or baldness along the frontal hairline and at the temples. This is easily prevented by changing one’s daily hair-care habits, but once the hair loss occurs, it may be permanent. Fortunately, this condition is easily amenable to surgery ( usually by Hair Transplant) if the cause can be eliminated.
Trichotillomania is a condition seen more commonly in young females, where the person twists, tugs or pulls out her hair. This can be scalp hair, eyebrows or eyelashes. The diagnosis is made by observing short, broken hairs in the area of hair loss. The patient may deny having this habit.

Face-lift and brow-lift procedures can result in local hair loss in the vicinity of the incision. This may present as hair loss along the frontal hairline, in the temples, or adjacent to a surgical scar. If female patients do not have genetic hair loss, and have a good donor supply, they may make excellent candidates for a hair transplant.
Tinea Capitis

is a fungal infection of the scalp. It presents as irregular, red and scaly patches and/or small bald patches with broken hairs. The diagnosis is made by scraping a small piece of scale from the scalp and obtaining a bit of hair for testing. The specimens are sent for special fungal stains and cultures.
Pseudopalade is a non-specific scarring alopecia that generally starts on the top of the scalp and extends into the surrounding hair bearing areas with finger-like extensions. The areas look smooth and white due to the scarring and loss of hair follicles.
Lichen Plano-pilaris  is an inflammatory condition of the scalp that presents with redness, scale and localized areas of hair loss. There is a characteristic scaling at the edge of each balding patch.
Discoid Lupus Erythematosus (DLE) is the localized form of Systemic Lupus Erythematosus (SLE), a potentially serious autoimmune disease. The localized form presents with red, scaly, pigmented patches of scarred skin. The localized form of the disease is mostly a cosmetic problem, but patients must be evaluated for the systemic disease as well with specific blood tests such as an ANA. SLE can cause diffuse (generalized) hair loss and both the local and systemic forms of the disease may cause sensitivity to the sun.

Triangular Alopecia, Triangular alopecia refers to a thinning or complete patch of hair loss at the temples. The medical community does not know the cause of triangular alopecia, but it can be treated successfully with surgery. Triangular alopecia is permanent without treatment.

Loose anagen syndrome

Loose-anagen syndrome is a condition easily extractable anagen hairs and is an Inherited autosomal dominant condition seen most often in younger people that is evidenced by excessive hair caught in hair brushes or in the bathtub drain. The condition is caused by hair follicles that are not set firmly enough in the scalp. This condition normally becomes less of a problem as we age.

Diffuse Hair Loss (Alopecia)

1.      AGA (Female Patterned Hair Loss, FPHL)

In case of Pattern Loss (AGA) there is usually a Family history of Hair loss it can have Female pattern of Ludwig or Christmas Tree type or occasionally that of Male pattern type. But females rarely have as sever hair loss as that of males. AGA in women is not usually accompanied by increased shedding. However, in some instances, an episode of telogen effluvium following childbirth, major illness or other causes may uncover a latent predisposition to AGA. Both young women and young men with AGA have higher levels of 5 reductase and androgen receptor in frontal hair follicles compared to occipital follicles. At the same time, young women have much higher levels of cytochrome p-450 aromatase in frontal follicles than men who have minimal aromatase, and women have even higher aromatase levels in occipital follicles. The diagnosis of AGA in women is supported by Family history, early age of onset, the pattern of increased thinning over the frontal/parietal scalp with greater density over the occipital scalp, retention of the frontal hairline, and the presence of miniaturized hairs. Most women with AGA have normal menses and pregnancies.

Common or “hereditary” baldness in women, also called female pattern alopecia, is genetic and can come either the mother’s or father’s side of the family. It is caused by the actions of two enzymes; aromatase (which is found predominantly in women) and 5-a reductase (which is found in both women and men).

The action of 5-a reductase is the main cause of androgenetic alopecia in men, as this enzyme converts the hormone testosterone to DHT. DHT is responsible for the miniaturization (shrinking) and gradual disappearance of affected hair follicles.
Women have half the amount of 5-a reductase compared to men, but have higher levels of the enzyme aromatase, especially at their frontal hairline. Aromatase is responsible for the formation of the female hormones estrone and estradiol. It also decreases the formation of DHT. Therefore female AGA is less severe and Estrogen is a protection against this type of loss in females*  Its presence in women may help to explain why the presentation of female hair loss is so different than in males, particularly with respect to the preservation of the frontal hairline. It may also explain why women have a poor response to the drug finasteride a medication widely used to treat hair loss in men that works by blocking the formation of DHT.

The Ludwig Classification uses three stages to describe female pattern genetic hair loss:

• Type I (mild)
• Type II (moderate)
• Type III (extensive)

In all three Ludwig stages, there is hair loss on the front and top of the scalp with relative preservation of the frontal hairline. The back and sides may or may not be involved. Regardless of the extent of hair loss, only women with stable hair on the back and sides of the scalp are candidates for hair transplant surgery.

	Type I: Early thinning that can be easily camouflaged with proper grooming. Type I patients have too little hair loss to consider surgical hair restoration Type II: Significant widening of the midline part and noticeably decreased volume. Hair transplantation may be indicated if the donor area in the back and sides of the scalp is stable. Type III: A thin, see-through look on the top of the scalp. This is often associated with generalized thinning.

2. CTE (Chronic Telogen Effluvium),   

Women’s hair seems to be particularly sensitive to underlying medical conditions. Since “systemic” problems often cause a diffuse type of hair loss pattern that can be confused with genetic balding, it is important that women with undiagnosed hair loss, be properly evaluated. Medical conditions that produce a diffuse pattern include:

Medical conditions that can cause diffuse hair loss in women:

• Obstetric and gynecologic conditions such as post-partum and post-menopausal states or ovarian tumors
• Iron deficiency- rather than Anemia
• Thyroid disease ( both Hyper and Hypo Thyroid State can cause hair loss and dry thin hairs-However, your head is not the only place you might lose hair due to thyroid disease. A symptom unique to hypothroidism is hair loss on the outer edge of the eyebrows and a thinning or loss of body hair is also possible.) even the medications to treat both states can also cause Hair loss.
• *During pregnancy and in early phase of OC pills/ HRT usage female can have good growth of hairs due to higher estrogen levels; during post partum and lactation phase, OC pills/HRT  withdrawal and menopause there is increase loss of hair due to low estrogen levels). Higher free testosterone (PCOD)  Androgens (CAH, Adrenocortical Tumours, Androgen Secereting tumours of Ovaries) , Progesterone (some OC pills) , Corticosteroids(cushing’s syndrome/ stress )  and Prolactine ( Hyperprolactenemia) can also cause hair loss. 

• Connective tissue diseases such as Lupus
• Nutritional – crash diets, bulimia, protein/calorie deficiency, essential fatty acid or zinc deficiency, malabsorbtion, hypervitaminosis A
• Stress – surgical procedures, general anesthesia, and severe emotional problems

A relatively large number of drugs can cause “telogen effluvium,” a condition where hair is shifted into a resting stage and then several months later shed. Fortunately, this shedding is reversible if the medication is stopped, but the reaction can be confused with genetic female hair loss if not properly diagnosed. Drugs that can cause diffuse hair loss in women:
Cardiology:

1. Blood thinners (anti-coagulants), such as warfarin and heparin
2. Blood pressure medication, particularly the b-blockers (such as Inderal) or diuretics
3. cholesterol Lowering Medications:

Neurological:

Antidepressents: drugs – lithium, tri-cyclics, Elavil, Prozac

Antoconvulsants: , most commonly dilantin

Endocrinology:

Thyroid medications: for Hypo and Hyper thyroidism

Oral contraceptive agents, particularly those high in progestins

Orthopedics:

Medication for gout, colchicines and alopurinol (Xyloprim)

Anti-inflammatory drugs such as prednisone, Indomethacine, Ibugesic etc

Oncology:

Chemotherapy

Others:

Misc. – diet pills, high doses of Vitamin A, street drugs (cocaine)

Chronic Telogen Effluvium is a condition whose diagnosis is often missed, so it is worth mentioning briefly. Chronic TE affects women age 30-60. It starts abruptly with or without an initiating factor. Chronic TE presents with diffuse thinning with accentuation at the temples – often more apparent to the patient than to others. It has a long fluctuating course and patients can lose up to 50-400 hairs/day. There is increased shedding of telogen (club) hairs with a positive hair pull. Fortunately, the condition does not lead to complete baldness. Chronic TE can be expected to resolve spontaneously in 6 months to 6-7 years.
When the cause of the hair loss is still uncertain, further diagnostic information can be obtained from a scraping and culture for fungus and a scalp biopsy (sent for regular and special tissue stains and examined under both horizontal and vertical sections

In CTE, women in the fourth to sixth decade, with above average hair density, describe sudden onset of marked shedding from the entire scalp. Excess hair fall, diffuse hair loss with < 10% miniaturization, pull test positive for bulbed hair, reduced Anagen / Telogen ratio on trichogram/ trichoscan or Biopsy. Post pregnancy and post menopausal  effluvium is common. Hair pull test may extract increased numbers of telogen hairs easily, yet scalp hair density appears normal or minimally decreased even though the shedding may be prolonged. Miniaturized hairs are not seen. Horizontal sections of a scalp biopsy distinguish CTE from AGA: the ratio of terminal hairs to miniaturized hairs in CTE is 9: 1, in AGA is 2: 1, and in a normal scalp is 7: 1.

Others causes of CTE needs special investigations: insulin resistant diabetes, obesity Exclusion of Adrenal or Ovarian androgen secreting tumor (increased 17 DHEAS)

, Cushings Syndrom (increased Cortisol), Hyperprolactenemia by pituitary tumor ( increased serum prolactin) , CAH-congenital adrenal hyperplasia, (increased 17 OHP)

17-hydroxyprogesterone to rule out 21-hydroxylase deficiency (CAH).

There is always a great diagnostic dilemma and therefore the line of the treatment between Pattern Loss (AGA) and CTE (Chronic Telogen Effluvium).

You must have clinical and trichoscopic examination and following tests to rule out common causes of effluvium (CTE) such as Thyroid problem, Low Iron, or POCS (Poly cystic ovarian Syndrome- symptoms and signs of androgen excess are present such as hirsutism, severe unresponsive cystic acne, virilization, or galactorrhea) or use of contraceptive pills.
1. T3, T4, TSH
2. Free  Serum Testosterone, LH/FSH ratio
3. Serum Prolactin
4. Serum Ferritin
5. trans vaginal sonography to rule out polycystic ovaries

3. ATE (Acute Telogen Effluvium),

A reversible type of female hair loss seen with stress, pregnancy, drug reactions and a variety of other conditions. Telogen effluvium generally occurs 2-3 months after a stressful event and affects 35-50% of one’s hair. Over 300 club hairs (telogen hairs that have rounded ends) can be shed per day shed. Acute telogen effluvium may occur in a woman with long-standing AGA or unmask latent AGA. A careful history will usually identify the cause of profuse hair shedding such as high fever, severe dietary protein deficiency, or chronic blood loss as in women with prolonged heavy menses. Relevant laboratory tests are noted above. Categories of drugs that may cause hair loss include anticancer drugs, anticoagulants, anticonvulsants, antithyroid drugs, beta blockers, tricyclic antidepressants, and progestins with androgenic effects (

 Besides densitometry, two other common diagnostic tests that can be performed in the physician’s office are the hair-pull and hair pluck. In the hair pull, the physician grabs on to 20-30 hairs with his fingers and gently pulls on them. If five or more come out in the pull then this is suggestive of the increased shedding associated with telogen effluvium
In the hair pluck, 20 to 30 hairs are forcibly plucked from the scalp with a small clamp. The hair bulbs are then examined under a microscope to determine the ratio of anagen (growing) hairs to telogen (resting) hairs. Normally, at least 80% of the follicles should be in the anagen stage. A lower ratio would suggest telogen effluvium. With the hair pluck, various abnormalities of the hair shaft may be observed that can contribute to hair breakage and poor growth.
Laboratory Evaluation for Androgen Excess
Occasionally, when a woman presents with female pattern hair loss, increased androgen production may be a contributing factor. The following signs and symptoms suggest that specific blood tests might be appropriate to rule out underlying sources of excess androgen:

1. Irregular periods – for an extended period of time
2. Cystic acne – severe acne which usually leaves scars
3. Hirsuitism – increased body hair that doesn’t normally run in your family
4. Virilization – appearance of secondary male sex characteristics such as a deepened voice
5. Infertility – inability to become pregnant
6. Galactorrahea – breast secretions when not pregnant (this is due to prolactin which is not actually an androgen)

It is important that when any of these symptoms are present, or these conditions are being considered, that you are under the care of a physician, to receive a proper evaluations and correct treatment if needed. Generally a gynecologist is the specialist most helpful for these problems.
Some of the tests that your doctor might order when considering androgen excess include:

• Total and Free Testosterone – the hormone that is mainly responsible for male secondary sex characteristics
• DHEA-Sulfate – a precursor to testosterone
• Prolactin – the hormone that enables the breast to secrete milk

Diagnostic Tests for Other Medical Conditions
Other test that are commonly ordered to screen for underlying medical conditions include:

• CBC (complete blood count) – for anemia, blood loss and certain vitamin deficiencies
• Serum iron and iron binding capacity – for anemia
• T3, T4, TSH – for thyroid disease
• ANA – for Lupus
• STS – for Syphilis

4. DUPA
5. Anagen  Effluvium
Anagen effluvium occurs when hair is shed in its growing phase and is characterized by large numbers of tapered or broken hairs (>80%). It can be caused by chemotherapy or radiation and can result in extensive hair loss in women. Chemotherapy causes a diffuse type of hair loss called “anagen effluvium” that can be very extensive, but often reversible when the medication is stopped. C.f. Loose Anagen Syndrome.
6. Hereditary Shaft Disease,
Rare condition where the hairs since childhood or birth are in poor quantity and quality. They may not grow in length and are thin and less in number all over the scalp. Usually there is no medical answer. Concealer,  Wig are the usual answer.

Medications:

1. Minoxidil 2 to 5% local application 

2.  use of 2% Nizoral shampoo thrice a week

3. Vitamins , Minerals, Nutrient, Iron pills as required

4. Low level Laser therapy (although of unproven value as now)
5. Estrogen Cream is often beneficial in Female Pattern Loss - to be applied on scalp 2-3 times a week.

This will help to prevent further loss and will help thicken the existing thin hairs.  The medications do not regrow the lost hairs.

Finasteride, Hormone Pills Aldectone etc. are prescribed by some practitioners but are of inadequate value and can have may possible serious side effects so are best avoided.

Finasteride is a competitive inhibitor of type II 5-reductase, and is contraindicated in women who are or may become pregnant, because 5-reductase inhibitors may cause abnormalities of the external genitalia of a male fetus. Finasteride was not effective in postmenopausal women in a placebo-controlled study

Cosmetics:

Use of Cosmetic Concealer like Toppik  ( visit www.toppik.com ) is useful to make the hair look thicker or gives a temporary cosmetic benefit.

Transplant:

Transplant may be useful in Pattern hair loss and not for CTE; therefore the accurate diagnosis is essential because the transplant in CTE will do more damage to your hairs then any help.

Females have usually less dense donor site at the back and side of the head unlike the males and the Post transplant Effluvium is more common in Females than in male.

Wig / Hair piece/ Hair Extension etc.

Some Results of Dr. Mahadevia

The results of transplant depend upon the transplanted number of hairs, the thickness of hairs, thhe colour contrast of scalp with hair, the length of hairs, the lighting effects. therefore every patient does not get the similar result. Click on the image to see enlaged image.