You are on page 1of 19

Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233

Hair deformities
E. Antonio Mangubat, MD
Southcenter Cosmetic Surgery and Hair Restoration, 16400 Southcenter Parkway, Suite 101, Tukwila, WA 98188, USA

Hair deformities take many forms, including natural male- and female-pattern baldness,
trauma, cancer, and iatrogenic causes. The various deformities and degree of deformity
generally determine the treatment choice. The advancements in hair restoration surgery (HRS)
in the past two decades are signicant, yielding natural and almost undetectable results. Using
a combination of HRS and cosmetic and reconstructive techniques, most deformities can be
treated eectively by palliation or completely resolving the deformity. The purpose of this article
is to give the reader an overview of HRS cosmetic and reconstructive options and applications
for their use. The limited space prevents detailed discussion of technique; however, the
references provided oer signicant detailed information.
To treat many deformities, it is important to understand the basic concepts of HRS. Hair trans-
plantation has become more complex as we have identied the important variables in achieving
natural results, including the natural history of hair loss (androgenetic alopecia [AGA]), hairline
design, recipient site creation, graft preparation, and medical therapy for hair loss.

Androgenetic alopecia

Although AGA is not strictly considered a scalp deformity, the methods developed to treat
this problem underlie the same techniques used for treating signicant hair deformities. After
all, hair deformities are usually unsightly cosmetic problems; therefore, understanding the
development of cosmetic and reconstructive procedures are important aspects in treating these
deformities. Methods of treating all forms of hair deformities evolved from this early work and
contribute to our abilities to treat many modern complicated problems.
The exact mechanism of AGA is not clearly understood; however, the presence of the male
hormone dihydrotestosterone is required for men with a genetic predisposition for baldness to
demonstrate the trait. First recognized in 1942, the anatomist Hamilton [1] studied castrated
men who did not develop AGA until exogenous testosterone was administered. The men who
were genetically predisposed to AGA lost their hair, and Hamilton deduced that testosterone is
in some way responsible for phenotypic expression. The search for the genetic mechanism still
continues, but after six decades, the precise mechanism has not been elucidated. A major focus
of current medical therapy is based on blocking the synthesis of dihydrotestosterone with
nasteride [2,3]. A detailed discussion of nasteride therapy is beyond the scope of this article. It
is important to note, however, that chronic treatment with this medication will slow, prevent, or
even reverse the AGA process, which makes it an important tool is HRS. Finasteride therapy is
limited to men.
Another important medication that helps to slow or reverse AGA is minoxidil, which is
a topical formulation applied to the scalp twice daily. The exact mechanism for its eect is
unknown, but its ecacy in double-blinded, placebo-controlled studies is signicant. Unlike
nasteride, minoxidil may be used by men and women.

E-mail address:

1061-3315/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
216 E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233

Female AGA was rst described in the 1977 by Ludwig [4]. The mechanism does not seem to
be based on the presence of dihydrotestosterone, and the hair loss pattern is different from male
AGA. The mechanism is unclear, but there seems to be a genetic predisposition. Hair
transplantation can be successful if the occipital donor scalp contains sufcient hair density.
Medical therapy should include topical minoxidil [5,6].

Hair restoration surgery techniques

The modern surgical treatment of AGA is attributed to Norman Orentreich with the
publication of his landmark article explaining donor dominance [7] in 1959. He postulated that
the reason autografted hair follicles grow in bald scalp is because the donor hair-bearing tissue
retained its dominant expression despite being transplanted into bald scalp. Thus the modern
hair transplant was born. Autologous hair transplantation had been described decades before
by Japanese dermatologists Sasgawa (1930), Okuda (1939), Tamura (1943), and Fugita (1953)
[8]. Because of language barriers and geopolitical obstacles, their work was not immediately
recognized; however, it is important to acknowledge their contributions.
The essence of hair transplantation is the movement of hair-bearing donor tissue from the
permanent occipital scalp to the balding frontal scalp in the same patient. This can be thought
of as a rotation of current hair inventory. More hair is not produced, just simply rearranged.
This was originally accomplished by taking 4-mm round punch biopsies of occipital scalp and
placing them in the bald frontal scalp. The skin graft would take, and hair would grow in
previously barren scalp. For most balding men and women, this was a miracle and an answer to
their hair loss concerns. Essentially any hair was good hair regardless of appearance.
For two decades, the process of hair transplantation remained fundamentally unchanged
from the original process described by Orentreich. Innovations such as powered hand tools
improved the round grafts that were produced and increased hair survival. The focus was
primarily on increasing hair survival rather than creating a natural appearance. Ayres was one
of the pioneers in HRS who systematically investigated ways to improve esthetic outcome [9].
Others followed [1012], which eventually led to the realization that a large number of small
grafts is necessary to reproduce that which is seen in nature. The current concept of follicular
unit transplantation was developed by Limmer [13,14] and expounded by Bernstein and
Rassman [15] as a challenging but plausible method of producing a natural and almost
undetectable hair transplant result.
Another signicant innovation was the alopecia reduction procedure rst reported by Sparkuhl
(1975), Blanchard [16], and Unger [17], which allowed HRS surgeons to eliminate or reduce the
amount of bald scalp and present less area that required transplantation. Larger reductions were
made possible with the development of extensive scalp lifting [18]. This method permitted much
larger alopecia excisions but with some increased risk of devascularization injury because of
acute occipital ligation injury during the procedure. Brandy [19] subsequently advocated ligating
the occipital artery as a ap delay 4 weeks before the scalping procedure. Mangubat [20]
developed a procedure to preserve the occipital artery during scalp lifting, which eliminated the
need for preoperative ligation and virtually eliminated the risk for vascular compromise.
Although challenging, this procedure has permitted the safe excision of large scalp scars.
Also important in the evolution of correcting hair deformities is the innovation of tissue
expansion [21], which also has found numerous applications in other areas. Tissue expansion
opens up the possibilities of excising large scalp deformities by safely creating more length in
tissue and allowing the hair-bearing scalp to be reapproximated. The resulting scars are often
covered by hair, which makes tissue expansion an ideal procedure for treating these deformities.
The array of scalp surgery has expanded considerably. The combination of these innovations
provides a set of tools that allow the reliable treatment of many scalp deformities.

Hair transplantation

Factors that aect the success of a hair transplantation procedure are numerous and must be
considered in the treatment of any hair deformity. A complete discussion of this topic is not
E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233 217

possible within the limited context of this article; however, a new textbook edited by Walter
Unger, MD, will likely be in print by the time that this article is published [22]. It will provide an
exhaustive source of information on contemporary hair restoration techniques. Natural
cosmetic results depend highly on the following factors:
 Extent of hair loss. This determines the amount of work required to cover the defect.
 Age of the patient. Bear in mind that the extent of hair loss increases with age. Young men
with AGA have less hair to transplant and more bald area to cover as they grow older.
 Adequate donor tissue. There must be sucient donor hair density and tissue to provide
enough grafts to cover the hair defect. Hair transplantation does not produce more hair but
rather relocates existing hair on a patients scalp. Unfortunately for most patients, the more
they hair they need, the less donor tissue they have.
 Hair color aects perceived coverage. The darker the color, the greater the apparent
coverage per graft. Dark hair also tends to create a more unnatural appearance, however.
 Hair curl increases the apparent volume of hair because curly hair covers more area as it
bunches up on itself.
 Hair contrast plays an important role in naturalness. The greater the contrast (eg, black hair
on white skin), the more unnatural the appearance. Care must be taken to use the nest
single hair grafts in the most exposed area (ie, the hairline).
 Hair shaft diameter is an important determinant is how much hair is moved in a graft. The
thicker the diameter, the more prominent the hair and the more contrast it provides. Thick
hair shaft diameters make producing a ne natural hairline challenging.
 Hair direction of the grafted hair must be matched to the existing naturally occurring hair
follicles of area being transplanted.
 Hairline considerations. A natural hairline is actually a misnomer. A natural hairline is
actually a zone of ne irregular hairs that create the feathering zone as the bald scalp
gradually yields to hair-bearing scalp.
 Ethnic dierences are wide and varied and usually can be described as a combination of the
previously mentioned characteristics. For example, Asian hair is less dense than hair on
caucasians, but the hair shaft diameters are typically thicker. The converse is also true:
caucasians typically have greater density (hair follicles/mm2) but smaller shaft diameters.
Several factors must be considered when contemplating any hair restoration procedure. The
state-of-the-art in HRS changes rapidly, so if the reader plans to add this procedure to his or her
surgical armamentarium, the author suggests attending several available live surgery workshops
and meetings dedicated to HRS [23,24].

Hairline design

The most important area that presents the greatest challenge to HRS surgeons is the hairline,
which is the transition from bald skin to hair-bearing skin. Hairline is actually a misnomer
because it is not a line at all. The natural hairline is more of a zone at the bald skinhair
perimeter that exhibits the characteristics of an uneven undulation of the hairs along the border
of the bald skinhairline interface and a gradually increasing hair density gradient. Fig. 1A
shows a 17-year-old boy with no hair loss. Note the large numbers of ne vellus hairs present in
the anterior border that eventually will be lost as he ages. Fig. 1B shows a 15-year-old boy who
lacks any vellus hairs. Note the strikingly nomadic hairline. Fig. 1C shows the hairline of a 50-
year-old man. Note the loss in density in the hairline with a more gradual density gradient.
These examples are not transplanted hairlines, and they exhibit an uneven undulating zone of
hair. Also note the important variations in hair direction. The vellus hair gives clues as to the
true natural hair direction that the transplant must simulate to achieve a natural result. In
general, frontal scalp hair points forward, parietal scalp hair points lateral and inferior, and
occipital scalp hair is oriented posteriorly and inferiorly.
When designing a hairline for transplantation, the surgeon must be aware of these subtleties
to avoid drawing attention to the transplantation. Most lay persons do not understand what
a natural hairline is, but they can usually detect an unnatural hairline. The results produced with
218 E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233

Fig. 1. (A) 17-year-old boy with no hair loss displays numerous vellus hairs that may be early AGA. Note the uneven
hairline. (B) 15-year-old boy has no vellus hairs, but the natural hairline is irregular. (C) 50-year-old man
demonstrates thinning but no AGA. Note that the hairline is actually a zone with an increasing hair density gradient.

contemporary techniques go virtually undetected (Fig. 2). Unfortunately, the old pluggy results
(Fig. 3) still exist as a constant reminder of our struggle to perfect the technique and the reason
why the lay public hesitates to seek out a surgical treatment for hair loss until they have
exhausted all other possibilities.

Alopecia reduction procedures

Alopecia reduction allows the surgeon to eliminate unwanted bald tissue. Originally
innovated for HRS in the 1970s, it is a procedure that became popular because of its simplicity
and eectiveness in reducing the amount of bald scalp that required hair transplantation. Its
popularity waned as hair transplantation techniques improved and our understanding of the
natural history of hair loss became more rened. The techniques remain valuable tools for
reconstructive purposes, however.
The rst alopecia reduction procedures were simple excisions of bald scalp from the central
area of hair loss (Fig. 4). Scalp was undermined to the nuchal line, which is a prominent ridge on
the parietal and occipital scalp at which several muscles attach to the skull. Undermining in the
subgaleal plane was easy, bloodless, and fast, which allowed the surgeon to remove a signicant
area of bald scalp, often in less than 30 minutes. Limitations and disadvantages of alopecia
reduction were soon discovered, including widening the bald area (also known as stretch-back
[25], slot deformity [26], and visible scarring), and many technique variations were developed to
improve further the method to enhance bald scalp removal and minimize hair deformities.
The extensive scalp lift is one of the more interesting and eective alopecia reductions
because the dissection is performed beyond the limits of the galea aponeurotica marked by the
nuchal line and extending it down to the nape of the hairline [18]. Brandy determined that most
of the tissue stretch occurred in the tissue beyond the thick and less elastic galeal layer; thus,
extensive scalp lift permitted a much greater reduction of bald scalp. This greater efciency was
not without greater complications, however, because an incidence of occipital hair-bearing scalp
necrosis was noted. Mangubat developed the procedure to preserve the occipital artery of the
posterior scalp and eliminated the incidence of necrosis [20] (Fig. 5).
E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233 219

Fig. 2. (A) 50-year-old man had 2500 grafts transplanted. Results were excellent. (B) Close-up of the virtually
undetectable transplanted hairline. (C) 48-year-old man with 2700 grafts transplanted. (D) Close-up of the transplanted
hairline. Note that the increased contrast between the skin and hair color make the transplant more noticeable, but the
results are acceptable.

Hair-bearing aps

Transposition of hair-bearing aps was rst reported by Juri [27], in which a long hair-bearing
ap of scalp was transposed from the parieto-occipital scalp to the frontal hairline. Variations of
this technique were developed with signicant success by various authors. Although the failure
rates of the techniques were low, the potential complications and disgurement were signicant
even in the best of hands. Consider that devascularization of all or part of the pedicle ap would
result in the loss of a considerable amount of hair-bearing scalp and a large disguring iatrogenic
deformity (Fig. 6). Currently, the technique is not widely used.

Tissue expanders

Tissue expansion is an extraordinary tool for repairing large skin defects. Before the tissue
expansion techniques, repair of large defects was often crude and ineective. The history of the
technique is similarly extraordinary because it took more than 20 years to recognize its value to
reconstructive work. The original work [21] was not considered noteworthy, and its signicance
220 E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233

Fig. 2 (continued )

remained buried and unnoticed until another young surgeon demonstrated its usefulness in
breast reconstruction [28]. Its simplicity and popularity grew exponentially as an expander
manufacturer became involved in producing a commercially viable product.
The technique involves gradually expanding a balloon implanted under the skin immediately
adjacent to the defect through a series of percutaneous injections into a self-sealing lling port.
As the balloon increases in size, the tissue compensates by stretchingincreasing its length and
mass through mechanisms known as mechanical (stretching the collagen bers) creep [29] and

Fig. 3. Old technique used 4-mm punch grafts, which resulted in an unnatural appearance.
E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233 221

Fig. 4. Original midline alopecia reduction pattern.

biologic (stimulating new tissue growth) creep [30]. Mechanical creep is subject to shrinkage
when the balloon is removed as the collagen bers attempt to return to normal resting length.
Conversely, biologic creep is not stretching in the traditional sense, because cellular actually
increases the amount of tissue present. Both properties are critical to successful tissue expansion.
The use of tissue expansion in cosmetic procedures has been limited in part because of the
signicant deformity a patient must endure temporarily during the nal stages of the process
(Fig. 7). Conversely, candidates for reconstructive surgery are more tolerant because of the
unsightly defects they are trying to repair.
Surgical planning is critical to successful tissue expansion. The patient and family must be
counseled to expect a cosmetic deformity, especially near the end of the expansion process. The
size of the expander must be estimated preoperatively. Although there are many mathematical
methods, none is particularly exact. I believe that it is better to overestimate needed expansion,
and I choose the largest commercially available expander that ts a patients anatomy. In
general, I select an expander with a base dimension roughly equal to the dimension of the defect
that also has a large vertical expansion dimension. Most manufacturers have tables of expander
specications that ease the decision-making process.
The vertical dimension is the most important factor because the greatest gain in ap expansion
is in the vertical dimension. One should choose an expander that poses signicant rise, which
makes calculating the necessary expansion relatively easy. When the distance over the expanded
tissue is equal to 130% of the width of the defect, the expansion is complete (Fig. 8). I plan to
overexpand by this amount, because removing excess tissue is simpler and safer than attempting
to overextend an expanded ap that falls short of complete coverage. Overextending an expanded
ap could lead to ap necrosis; therefore, before excising the defect, the surgeon should attempt
a trial advancement to see the actual area of coverage. If complete excision is not accomplished
easily, it is advisable to leave some residual defect, excise what you can, and replace the same
expander under the ap so a second expansion can be undertaken safely.
Placement of the expander in general should be parallel to the longest side of the defect,
which gives greatest coverage. In hair-bearing scalp, paying attention to hair direction could be
important if the defect is adjacent to the hairline. In most cases, however, the hair can be trained
to style appropriately. Although there are no hard and fast rules, I attempt to match the shape
of the expander to the shape of the defect. If the defect is long and curvilinear, I choose
a crescent-shaped expander to prepare a ap for advancement. A round defect can be treated
with a round or crescent-shaped expander.
Filling the expander is also subject to much variation. Social factors, such as patient
availability, distance from the surgeon, and pain tolerance, often determine how fast the
222 E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233

Fig. 5. This series of intraoperative photos demonstrates the technique and the eectiveness of the extensive scalp lift
procedure with preservation of the axial blood supply of the ap. (A) Preoperative view shows operative plan. (B)
Exposure of occipitalis muscle, which is the landmark used to locate the artery. (C) Occipital artery is isolated and
dissected for length. (D) Dissection beyond retracted artery to nape of the neck. (E) Elevation of the central bald ap. (F)
Closure of the hair-bearing scalp to the midline. (G) Extensive bald tissue is excised. (H) Immediate postoperative top
view. (I) Immediate postoperative posterior view.
E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233 223

Fig. 5 (continued )

expansion can be achieved. Expansion usually begins intraoperatively by lling the expander with
5% to 10% of the total expected ll volume. This takes up dead space and tests the ll mechanism
to identify any obstructions before wound closure. I usually wait 10 to 14 days postoperatively
before beginning the expansion process. This time allows the wound to gain tensile strength and
the pain to subside, which makes the rst series of expansions more comfortable.
The goal is to expand as rapidly and as safely as possible, which allows faster treatment of the
defect. If a patient is local and available, expansion can occur two to three times weekly. If
a patient or family member is medically trained, expansion can occur at home with proper
training. The most common endpoint of each expansion is pain; however, the surgeon must be

Fig. 6. (A) Preoperative views of 42-year-old man disgured by complete necrosis of superiorly based transposition ap.
(B) Pre- and postoperative view of multiple repairs performed to date, including multiple hair transplants, brow lift,
excision of skin graft, renement of surviving ap. (C) Renement of surviving ap required elevating the temporal
hairline to a more acute angle using a brow lift and excision of excess hair-bearing scalp. The excised hair was recycled
by creating hair grafts and placing them posteriorly.
224 E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233

Fig. 6 (continued )

constantly aware of adequate capillary rell. If skin blanching does not resolve, uid should be
removed. More technical methods of monitoring ll volumes have been described, such as
transcutaneous oximetry over the expanded ap and intraluminal pressure measurements.
Clinical observation is adequate in most cases, however.
Once expansion is completed and the measured distance over the expanded ap is 130% the
width of the defect, the nal ap advancement is executed. The initial incision in an
advancement ap should be made immediately adjacent to the expander at the border of the
defect. This incision allows the expander to be removed immediately and the ap advancement
tested to ensure that the complete defect can be excised. If the entire defect cannot be removed,
a blood stain is left on the distal portion of the defect that the ap can cover to mark the
maximum tissue to be excised. Although the inability to close a defect with a fully expanded ap
is not a common problem when the ap is overexpanded, the surgeon and patient must be
prepared to accept the potential possibility. If the residual defect is signicant, one should leave
the expander in place for a second expansion that likely will result in complete excision.
E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233 225

Fig. 7. Tissue expansion is completed in 10 weeks. The signicant cosmetic deformity the patient must endure for 4 to 6
weeks makes this dicult for the cosmetic patient to accept.

Case presentations

Hair deformities fall into several categories. Iatrogenic deformities are the most common cause,
usually as a result of surgery. Deformities secondary to trauma and cancer are also challenging.
Several examples follow to demonstrate the use of HRS techniques when added to cosmetic and
reconstructive procedures in delivering excellent results when treating these dicult cases.

Fig. 8. (A) Calipers can be used to measure the width of the expanded ap, which is roughly equal to the width of the
defect to be excised. (B) The measured distance over the expanded ap minus the ap width yields the approximate
distance of ap advancement. The actual yield is usually less than the measurement because of contraction of the
collagen bers (mechanical creep) and thus a 130% overexpansion is planned. (From Nordstrom REA, editor. Tissue
expansion. St. Louis, MO: Butterworth-Heinemann (Elsevier); 1996; with permission.)
226 E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233

Fig. 9. Old transplant technique in a 40-year-old man. With continued hair loss, the grafts became obvious (top row).
After a simple brow lift, the rst two rows of plugs were removed and replanted posteriorly, which resulted in
considerable improvement (bottom row).

Iatrogenic deformities

Iatrogenic deformities take many forms, including old hair transplant techniques, failed ap
procedures, and wide scarring. Most hair deformities can be treated with a combination of the
reviewed procedures.

Case 1: old techniques

A 42-year-old man underwent hair transplantation 20 years ago to ll in the temporal

recessions. He continued to develop more extensive hair loss and is left with an unnatural
appearance (Fig. 9). This is an excellent example of many pitfalls in HRS, including (1) the
progressiveness of AGA, (2) a poor understanding of hairline reconstruction, and (3) how high
contrast of dark hair and light skin color leads to unnatural results. The primary treatments for
his problem are aimed at removing the unnatural hair density in the frontal hairline and replacing
it with bald scalp. A more natural hairline can be transplanted anterior to the scar to yield an
updated result. A pretrichial browlift was performed to allow the forehead skin to be elevated
and the front two rows of 4-mm punch grafts to be excised completely. The excised grafts were
dissected into smaller grafts and transplanted posteriorly. This simple procedure has tremen-
dously improved the patients appearance. He will return in the future for hairline reconstruction.

Case 3: necrosis of hair ap

This 42-year-old man underwent bilateral superiorly based hair ap rotations in an attempt
to reconstruct the hairline 10 years ago. The left ap underwent necrosis and was replaced with
a split-thickness skin graft, which left him with a severe iatrogenic deformity (see Fig. 6). The
most difcult part of this patients treatment was gaining his trust to perform a reconstruction.
As a result, his treatment plan has taken several years and is still in progress.
E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233 227

Fig. 10. (A) 8-year-old boy who had a nevus removed as an infant. The defect was repaired with a skin graft (top left).
The expansion is complete (top right). 3 months later, the scalp defect is closed (bottom). (B) 3 years postoperatively, the
results are satisfactory despite the aberrant hair direction.

The plan used hair transplantation behind the scar in a preliminary step to provide hair that
would help cover the skin graft. Once the patient felt condent to continue, a pretrichial browlift
was performed to elevate the brow skin and excise the split-thickness skin graft. At the same
time, the surviving ap on the right side was tailored to a more appropriate shape. The excised
hair from the right ap was dissected into micrografts and added to the left hairline. The
signicant improvement has motivated him to begin removing his hair piece and exposing his
natural hair, and he plans more transplantation to ll the left side and complete the hairline.
Case 4: scalp defect from excision of skin neoplasm

This 7-year-old boy was referred for HRS after having a large giant congenital nevus (at
signicant risk for developing melanoma) excised as an infant (Fig. 10). He is in grade school,
and classmates have begun teasing him and he wishes to have the defect repaired.
Treatment was undertaken during summer vacation with a large tissue expander placed over
the scalp vertex in such a position as to maximize movement of hair-bearing scalp. The expander
was gradually inated over a period of 2 months. Before the end of the summer vacation,
expansion was sucient so that complete excision of the defect was possible. Note that the hair
direction is somewhat distorted but easily covered when his hair is longer. The future potential
for AGA was discussed with the family is. If he were to develop male-pattern hair loss during his
young adult life, more HRS would be required. It may be more complicated as a result of the
unusual hair distribution. Currently, however, he is free from teasing that could aect his social


Scalp burns are relatively common causes of hair deformities. If a burn is deep enough to
destroy the hair follicles, traumatic alopecia results regardless of burn depth. Burns are typically
228 E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233

Fig. 11. (A) Large defect left by full-thickness burn as a child. Multiple attempts at excision and hair transplants were not
successful. (B) Expansion completed after 9 months because of rigid tissue. (C) Incision was made along the expanded ap
border. (D) 1.3-L expander was exposed and ll port dissected free. (E) Expander was removed. (F) Trial advancement of the
ap to ensure complete coverage of defect before excision. (G) Complete excision of large defect. (H) Immediate
postoperative results. (I) 9-month postoperative result. Note stretch back phenomenon and slight widening of scar.
E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233 229

Fig. 11 (continued )

irregular, scarred, and often large, and the resultant tissue is inelastic, which makes
reconstruction dicultif not impossibleusing standard excisions. Tissue expansion is ideal
for these dicult patients. Often tissue expansion is prolonged because of the rigidity of the scar.
The expansion can be accomplished with little risk as long as patient compliance in follow-up is

Case 5: large burn defect presenting after multiple failed treatment attempts

A 35-year-old woman presented after having ve prior procedures to repair a grease burn she
suered on her scalp as a child (Fig. 11). The procedures included two scalp reductions and
three hair transplants using 4-mm punch grafts. She has had to wear her hair long to camouage
the defect. The scar and surrounding tissue is thick and rigid, which allows little, if any,
movement that would permit excising the 25  8 cm defect.

Fig. 12. (AE) Preoperative views. Note thin skin grafts that will break down as child grows. (F, G) Unilateral expansion
of the less scarred side is complete. (HJ) Bilateral expansion is completed. (K) Large bilateral scar excisions. (L)
Immediate postoperative results. (MP) 9-month postoperative bilateral expansion. Note stretch back over time.
Complete excision not possible because of cellulitis complication. Patient is still a work in progress. When he matures, he
may return to complete the procedure.
230 E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233

Fig. 12 (continued )
E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233 231

Fig. 12 (continued )

Treatment consisted of placing a large 1.3-L crescent-shaped expander in the occipital scalp
directly adjacent to the defect. The extreme rigidity of the tissue required more than 9 months to
complete the expansion process. The typical process takes 2 to 4 months in an adult with a defect
this size. In this young woman, however, the process was prolonged because of pain that
resulted from the excessive tissue rigidity. The result was particularly satisfying because with two
simple procedures, the entire defect was closed.
232 E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233

Case 6: extensive scalp loss in an 8-year-old boy

This young boy was brought to my oce by his mother, who stated that the plastic surgery
department at the local university felt there was nothing more they could do for her son (Fig. 12).
He was the victim of a house re as an infant, and he suffered burns over approximately 60% of
his body surface area. He survived after months of treatment and recovery at the regional
trauma center; however, he required numerous secondary procedures to manage the burns. Of
particular interest are the multiple skin grafts required in the scalp. As he began to grow, his
skull volume increased beyond the skin grafts elastic properties, which caused skin necrosis. He
also required regular skin-grafting procedures throughout his young life. The more skin grafting
he underwent, the greater the bald area he accumulated. The cosmetic appearance of a balding
little boy in grade school elicited much teasing and social turmoil. He was almost in need of
another skin graft when his mother sought help in my ofce. This case was a particular challenge
because the boy had lost more than 70% of his hair-bearing scalp. His calvarium was still
young, pliable, and moldable, which made rapid tissue expansion more challenging because of
possible deformity to the skull.
The treatment plan consisted of a two-stage expansion. Note that there is more hair-bearing
area in the right parietal scalp. I elected to expand the right side rst, which has the advantage of
eliminating a signicant amount of skin graft being overstretched by the childs growth
relatively quickly. It also gave us the opportunity to evaluate any signicant skull deformity that
resulted from the tissue expander and the childs ability to cope with the expansion process.
Stage one was successful, which gave us the opportunity to proceed with bilateral scalp
Stage two proceeded more slowly because the child developed a habit of picking at the skin
overlying the expander port. Unfortunately, he developed a cellulitis that required hospitali-
zation, intravenous antibiotics, and wound care before the expansion could be completed. After
resolution of the cellulitis, it was clear that the child was not going to tolerate much more
discomfort. With family input, we decided to take what we could get safely and delay any future
procedures until he was mature enough to participate in his care. We were able to remove all of
the skin grafting at risk for necrosis and replace it with expanded scalp. The scar was reduced
more than 90%. With appropriate hair styling, he is able to cover a signicant portion of the
disguring scar.
What lies in his future depends on his maturity and what develops with his existing hair. As
he approaches puberty, he may be subject to AGA, although most of the scalp vertex most
susceptible to AGA was burned in the re, and we hope that AGA eects will be limited.


To be able to treat the wide spectrum of hair deformities, a surgeon must possess a wide
spectrum of skills in HRS, cosmetic surgery, and reconstructive surgery. Specic education and
training in HRS is not a traditional part of formal surgical training, although much information
is available through several national and international organizations. Being sensitive to the
unique variables associated with HRS increases the chances of achieving a superior functional
and cosmetic result when treating signicant hair deformities.

Further readings

Nordstrom REA, editor. Tissue expansion. St. Louis, MO: Mosby (Elsevier); 1996.
Stough DB, Haber RS, editors. Hair replacement: surgical and medical. St. Louis: Mosby; 1996.
Unger W, Shapiro R, editors. Hair transplantation. 4th edition. New York: Marcel Dekker, Inc.; 2004.


[1] Hamilton JH. Male hormone stimulation is prerequisite and incitement in common baldness. Am J Anat 1942;71:
E.A. Mangubat / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 215233 233

[2] Kaufman KD. Androgen metabolism as it affects hair growth in androgenetic alopecia. Dermatol Clin 1996;14(4):
[3] Price VH, Menefee E, Sanchez M, Ruane P, Kaufman KD. Changes in hair weight and hair count in men with
androgenetic alopecia after treatment with nasteride, 1 mg, daily. J Am Acad Dermatol 2002;46(4):51723.
[4] Ludwig E. Classication of the types of androgenetic alopecia (common baldness) occurring in the female sex. Br
J Dermatol 1977;97(3):24754.
[5] Price VH. Androgenetic alopecia in women. J Investig Dermatol Symp Proc 2003;8(1):247.
[6] Price VH. Treatment of hair loss. N Engl J Med 1999;341(13):96473.
[7] Orentreich N. Autografts in alopecias and other selected dermatological conditions. Ann N Y Acad Sci 1959;83:
[8] Stough D. Presented at the International Society of Hair Restoration Surgery Live Surgery Workshop. The
evolution of hair transplantation. Orlando, Feb 21, 2001.
[9] Ayres S. Prevention and correction of unaesthetic results of hair transplantation for male pattern baldness. Cutis
[10] Nordstrom RE. Methods to improve old results of punch hair grafting. Plast Reconstr Surg 1983;72(6):8039.
[11] Marritt E. Transplantation of single hairs from the scalp as eyelashes: review of the literature and a case report.
J Dermatol Surg Oncol 1980;6(4):2713.
[12] Marritt E. Single-hair transplantation for hairline renement: a practical solution. J Dermatol Surg Oncol 1984;
[13] Limmer BL. Elliptical donor stereoscopically assisted micrografting as an approach to further renement in hair
transplantation. J Dermatol Surg Oncol 1994;20(12):78993.
[14] Marritt E. Follimmerlicular transplantation: giving credit where credit is due. Dermatol Surg 1998;24(8):9259;
discussion 92932.
[15] Bernstein RM, Rassman WR. Follicular transplantation: patient evaluation and surgical planning. Dermatol Surg
1997;23(9):77184; discussion 8015.
[16] Blanchard G, Blanchard B. Obliteration of alopecia by hair-lifting: a new concept and technique. J Natl Med Assoc
[17] Unger MG, Unger WP. Management of alopecia of the scalp by a combination of excisions and transplantations.
J Dermatol Surg Oncol 1978;4(9):6702.
[18] Brandy DA. The bilateral occipito-parietal ap. J Dermatol Surg Oncol 1986;12(10):10626.
[19] Brandy DA. The effectiveness of occipital artery ligations as a priming procedure for extensive scalp-lifting.
J Dermatol Surg Oncol 1991;17(12):9469.
[20] Mangubat EA. Preservation of the occipital artery during extensive scalp lifting. American Journal of Cosmetic
Surgery 1997;14(2):1616.
[21] Neumman CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon: use of the
method for securing skin for subtotal reconstruction of the ear. Plast Reconstr Surg 1957;19(2):12430.
[22] Unger WP. Hair transplantation. 4th edition. New York: Marcel Dekker. 2004.
[23] International Society of Hair Restoration Surgery/for hair restoration physicians/upcoming events. Available at: Accessed June 18, 2004.
[24] American Society of Hair Restoration Surgery Surgeons Center/Educational Courses. Available at: www. Accessed June 18, 2004.
[25] Nordstrom RE. Stretch-back in scalp reductions for male pattern baldness. Plast Reconstr Surg 1984;73(3):4226.
[26] Norwood OT, Shiell RC, Morrison ID. Complications of scalp reductions. J Dermatol Surg Oncol 1983;9(10):
[27] Juri J. Use of parieto-occipital aps in the surgical treatment of baldness. Plast Reconstr Surg 1975;55(4):45660.
[28] Radovan C. Reconstruction of the breast after mastectomy using a temporary expander. Plast Reconstr Surg 1982;
[29] Mustoe TA, Bartell TH, Garner WL. Physical, biomechanical, histologic, and biochemical effects of rapid versus
conventional tissue expansion. Plast Reconstr Surg 1989;83(4):68791.
[30] van Rappard JH, Sonneveld GJ, Borghouts JM. Histologic changes in soft tissues due to tissue expansion (in animal
studies and humans). Facial Plast Surg 1988;5(4):2806.