alopecia and hair restoration

7/31/2019 Alopecia and Hair Restoration

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Copyrighted by dr. Mohamed El Rouby


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Management of Alopecia

An Overview:

Anatomy and Physiology

Androgenetic Alopecia

Classification Systems

Medical Therapy

Surgical Therapy


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Hair


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Scalp Layers

S:skin

C: subcutaneoustissues, connectivetissue,

A: aponeurosis,

L: loose areolar

tissue,

P: periosteum.


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Blood and Nervous Supply

Frontal

Supratrochlear

Supraorbital

Temporal

Superficial temporal Zygomaticotemporal

Parietal

Retroauricular

Auriculotemporal/Great

Auricular/LesserOccipital

Occipital

Occipital

Greater occipital


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Hair Follicles

Embryonic development

at 9-12 weeks

Ectoderm

Hair matrix cells Melanocytes

Mesoderm

Erector pili

Dermal papilla

Follicular Sheath

Blood Vessels

C i h d b d M h d El R b


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Hair Shaft

Cuticle

Medulla

Cortex

Sheath

C i ht d b d M h d El R b


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Hair Density

5 million follicles

100,000-150,000 on thescalp

Birth: 1135/cm2

1 year: 795/cm2

20-30: 615/cm2

30-50: 485/cm2

80-90: 435/cm2



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Follicular Units

1-4 terminal hairs

1-2 vellus hairs

Sebaceous glands

Erector pili muscles

Blood vessels

Nerves

Connective tissue



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Hair Growth Cycle

C ight d b d M h m d El R b


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Types of Alopecia


Alopecia Areata

Cicatricial Alopecia

Traumatic Alopecia

Diffuse Alopecia

Copyrighted by dr Mohamed El Rouby


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Male Pattern Balding

Female Pattern Balding

PathophysiologyMiniaturization of

follicles

Decreased anagen/

increased telogen

Increased latency



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Autosomal dominantvariable penetrance

30% of white men by

age 3050% of white men by

age 50



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Site-specific action of androgensPubic/axillary/chest/beard:

vellus terminal

Scalp: terminal vellus

Mentestosterone

Womenadrenal androgens

5-alpha reductase

Testosterone dihydrotestosteroneWhy the pattern of hair loss?

Increased follicle susceptibility



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Norwood Classification (men)



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Ludwig Classification (Women)



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Medical Therapy

MinoxidilAntihypertensive

Side effect: hyper-

trichosis

Topical 2%, 5%

Stop progressionand reverse

changesDelayed onset

Prolonged use

FinasterideSpecifically inhibits

5-alpha reductase,type 2

Lowers dihydro-testosterone levels

1mg/day

Side effect:

decreased libidoNot used in women



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Why treat?

Lower self-esteem

Mental distress

Stereotypes

Older

Weaker

Less productive

Less attractive

Less virile



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Patient evaluation for surgery

Expectations?

Motivations?



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Donor Hair

Type I

Type II

Type III

Type IV



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Age

Is NOT a contra-

indication forsurgery

Established pattern

Hair color

Co-existing medicalconditions



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C py g by a by

Surgical Therapy

Scalp reduction

Scalp flaps

Hair grafting



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Scalp Reduction

Unger and Unger, 1978

Many patterns

Sagittal midline ellipse

Y Lateral pattern

Transverse ellipse

Crescent ellipse

S, J, C, U, T,I

Easy to perform



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Scalp Reduction--Pitfalls

TensionExcessive reduction

Tissue necrosis,widened scar

Raposio &Nordstrom

500-1,500 gr

Galeotomies

40% reduction intension

Stretch-back Tendency for the

remaining baldscalp to expand

after a reduction 10-50% of the

reduction

2 months



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Scalp extenders

Frechet, 1993

1mm thick silastic,

two rows titaniumhooks

200% stretch

Memory

Effect: negativestretch-back



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Anchoring Galeal Flaps

Raposio, et al., 1998

Leave galea attachedto one scalp flap

Create 3 2x3cmgaleal flaps

Suture flaps toundersurface of

opposite galea80-88% reduction instretch-back



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Nordstrom Suture

Nordstrom et al., 2001

Silicone polymersuture, 2mm

diameter, cuttingneedle

Running, buried,mattress suture

Negative stretch-back3x greater than withextenders



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Tissue Expanders

Increases total hair-bearing surface area

Placement/Incisions

Filling

Useful in conjunction

with scalp reductionsor scalp flaps



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Scalp Flaps

Lateral

Temporoparietal

Occipital (TPO),AKA Juri

Preauricular

Free flap



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Juri Flap

Uses: recreatefrontal hairline

Parietal branch of

superficialtemporal artery

Flap

Pedicle: 2-2.5cm

Width: 4-6cmLength: 23-25cm

Delay



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Juri Flap

Design hairline

Elevate flap

Close donor site

Inset flap

Resect bald scalp



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Free Juri Flap

Advantages

1. Avoid delay

2. Avoid revision

around pedicle

3. More naturalpattern of frontal hair

growth



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Hair grafting

Okura, 1939

Orentreich, 1959

Punch graft

Strip graft

Follicular-unit graft



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Punch grafting



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Punch grafting



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Strip Grafting

Vallis, 1964

Free composite graft

Reconstruct frontal

hairlineDimensions

Length

WidthUn-operated

Previousoperation



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Strip Grafting

Vallis, 1964

Free composite graft

Reconstruct frontal

hairlineDimensions

Length

WidthUn-operated

Previousoperation



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Follicular-unit Grafting

Minigrafts

3-4 hairs/graft

Micrografts

1-2 hairs/graft

Barreras technique



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Revision Surgery

Removal

Repositioning

Reduction

Addition

Scar revision



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Conclusion

Wide variety of methods for the correctionof alopecia

Dont forget medical management

Individualize treatment plans

Counseling, Counseling, Counseling


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alopecia and hair restoration

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