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PPT

  1. 1. Management of Alopecia Elizabeth J. Rosen, MDElizabeth J. Rosen, MD Karen H. Calhoun, MDKaren H. Calhoun, MD 5/29/025/29/02
  2. 2. Management of Alopecia  Anatomy and PhysiologyAnatomy and Physiology  Androgenetic AlopeciaAndrogenetic Alopecia  Classification SystemsClassification Systems  Medical TherapyMedical Therapy  Surgical TherapySurgical Therapy
  3. 3. Hair
  4. 4. Scalp  S: SkinS: Skin  C: subCutaneousC: subCutaneous  A: galea AponeuroticaA: galea Aponeurotica  L: Loose connectiveL: Loose connective tissuetissue  P: PericraniumP: Pericranium
  5. 5. Blood and Nervous Supply  FrontalFrontal  SupratrochlearSupratrochlear  SupraorbitalSupraorbital  TemporalTemporal  Superficial temporalSuperficial temporal  ZygomaticotemporalZygomaticotemporal  ParietalParietal  RetroauricularRetroauricular  Auriculotemporal/GreatAuriculotemporal/Great Auricular/Lesser OccipitalAuricular/Lesser Occipital  OccipitalOccipital  OccipitalOccipital  Greater occipitalGreater occipital
  6. 6. Hair Follicles  Embryonic developmentEmbryonic development at 9-12 weeksat 9-12 weeks  EctodermEctoderm  Hair matrix cellsHair matrix cells  MelanocytesMelanocytes  MesodermMesoderm  Erector piliErector pili  Dermal papillaDermal papilla  Follicular SheathFollicular Sheath  Blood VesselsBlood Vessels
  7. 7. Hair Shaft  CuticleCuticle  MedullaMedulla  CortexCortex  SheathSheath
  8. 8. Hair Density  5 million follicles5 million follicles  100,000-150,000 on100,000-150,000 on the scalpthe scalp  Birth: 1135/cmBirth: 1135/cm22  1 year: 795/cm1 year: 795/cm22  20-30: 615/cm20-30: 615/cm22  30-50: 485/cm30-50: 485/cm22  80-90: 435/cm80-90: 435/cm22
  9. 9. Follicular Units  1-4 terminal hairs1-4 terminal hairs  1-2 vellus hairs1-2 vellus hairs  Sebaceous glandsSebaceous glands  Erector pili musclesErector pili muscles  Blood vesselsBlood vessels  NervesNerves  Connective tissueConnective tissue
  10. 10. Hair Growth Cycle
  11. 11. Types of Alopecia  Androgenetic AlopeciaAndrogenetic Alopecia  Alopecia AreataAlopecia Areata  Cicatricial AlopeciaCicatricial Alopecia  Traumatic AlopeciaTraumatic Alopecia  Diffuse AlopeciaDiffuse Alopecia
  12. 12. Androgenetic Alopecia  Male Pattern BaldingMale Pattern Balding  Female Pattern BaldingFemale Pattern Balding  PathophysiologyPathophysiology  Miniaturization ofMiniaturization of folliclesfollicles  Decreased anagen/Decreased anagen/ increased telogenincreased telogen  Increased latencyIncreased latency
  13. 13. Androgenetic Alopecia  Autosomal dominant –Autosomal dominant – variable penetrancevariable penetrance  30% of white men by30% of white men by age 30age 30  50% of white men by50% of white men by age 50age 50
  14. 14. Androgenetic Alopecia  Site-specific action of androgensSite-specific action of androgens Pubic/axillary/chest/beard: vellusPubic/axillary/chest/beard: vellusterminalterminal Scalp: terminalScalp: terminalvellusvellus  Men—testosteroneMen—testosterone Women—adrenal androgensWomen—adrenal androgens  5-alpha reductase5-alpha reductase TestosteroneTestosteronedihydrotestosteronedihydrotestosterone  Why the pattern of hair loss?Why the pattern of hair loss? Increased follicle susceptibilityIncreased follicle susceptibility
  15. 15. Norwood Classification
  16. 16. Ludwig Classification
  17. 17. Medical Therapy  MinoxidilMinoxidil  AntihypertensiveAntihypertensive  Side effect: hyper-Side effect: hyper- trichosistrichosis  Topical 2%, 5%Topical 2%, 5%  Stop progressionStop progression and reverse changesand reverse changes  Delayed onsetDelayed onset  Prolonged useProlonged use  FinasterideFinasteride  Specifically inhibitsSpecifically inhibits 5-alpha reductase,5-alpha reductase, type 2type 2  Lowers dihydro-Lowers dihydro- testosterone levelstestosterone levels  1mg/day1mg/day  Side effect: decreasedSide effect: decreased libidolibido  Not used in womenNot used in women
  18. 18. Why treat?  Lower self-esteemLower self-esteem  Mental distressMental distress  StereotypesStereotypes  OlderOlder  WeakerWeaker  Less productiveLess productive  Less attractiveLess attractive  Less virileLess virile
  19. 19. Patient evaluation for surgery  Expectations?Expectations?  Motivations?Motivations?
  20. 20. Patient evaluation for surgery  Donor HairDonor Hair  Type IType I  Type IIType II  Type IIIType III  Type IVType IV
  21. 21. Patient evaluation for surgery  AgeAge  NOT a contra-NOT a contra- indication for surgeryindication for surgery  Established patternEstablished pattern  Hair colorHair color  Co-existing medicalCo-existing medical conditionsconditions
  22. 22. Surgical Therapy  Scalp reductionScalp reduction  Scalp flapsScalp flaps  Hair graftingHair grafting
  23. 23. Scalp Reduction  Unger and Unger, 1978Unger and Unger, 1978  Many patternsMany patterns  Sagittal midline ellipseSagittal midline ellipse  ““Y”Y”  Lateral patternLateral pattern  Transverse ellipseTransverse ellipse  Crescent ellipseCrescent ellipse  ““S”, “J”, “C”, “U”, “T”,S”, “J”, “C”, “U”, “T”, “I”“I”  Easy to performEasy to perform
  24. 24. Scalp Reduction--Pitfalls  TensionTension  Excessive reductionExcessive reduction  Tissue necrosis,Tissue necrosis, widened scarwidened scar  Raposio & NordstromRaposio & Nordstrom 500-1,500 gr500-1,500 gr  GaleotomiesGaleotomies 40% reduction in40% reduction in tensiontension  ““Stretch-back”Stretch-back”  Tendency for theTendency for the remaining baldremaining bald scalp to expandscalp to expand after a reductionafter a reduction  10-50% of the10-50% of the reductionreduction  2 months2 months
  25. 25. Scalp extenders  Frechet, 1993Frechet, 1993  1mm thick silastic, two1mm thick silastic, two rows titanium hooksrows titanium hooks  200% stretch200% stretch  MemoryMemory  Effect: negativeEffect: negative stretch-backstretch-back
  26. 26. Anchoring Galeal Flaps  Raposio, et al., 1998Raposio, et al., 1998  Leave galea attachedLeave galea attached to one scalp flapto one scalp flap  Create 3 2x3cm galealCreate 3 2x3cm galeal flapsflaps  Suture flaps toSuture flaps to undersurface ofundersurface of opposite galeaopposite galea  80-88% reduction in80-88% reduction in stretch-backstretch-back
  27. 27. Nordstrom Suture  Nordstrom et al., 2001Nordstrom et al., 2001  Silicone polymerSilicone polymer suture, 2mm diameter,suture, 2mm diameter, cutting needlecutting needle  Running, buried,Running, buried, mattress suturemattress suture  Negative stretch-backNegative stretch-back 3x greater than with3x greater than with extendersextenders
  28. 28. Tissue Expanders  Increases total hair-Increases total hair- bearing surface areabearing surface area  Placement/IncisionsPlacement/Incisions  FillingFilling  Useful in conjunctionUseful in conjunction with scalp reductionswith scalp reductions or scalp flapsor scalp flaps
  29. 29. Scalp Flaps  LateralLateral  TemporoparietalTemporoparietal Occipital (TPO), AKAOccipital (TPO), AKA JuriJuri  PreauricularPreauricular  Free flapFree flap
  30. 30. Juri Flap  Uses: recreate frontalUses: recreate frontal hairlinehairline  Parietal branch ofParietal branch of superficial temporalsuperficial temporal arteryartery  FlapFlap  Pedicle: 2-2.5cmPedicle: 2-2.5cm  Width: 4-6cmWidth: 4-6cm  Length: 23-25cmLength: 23-25cm  DelayDelay
  31. 31. Juri Flap  Design hairlineDesign hairline  Elevate flapElevate flap  Close donor siteClose donor site  Inset flapInset flap  Resect bald scalpResect bald scalp
  32. 32. Free Juri Flap  AdvantagesAdvantages 1. Avoid delay1. Avoid delay 2. Avoid revision2. Avoid revision around pediclearound pedicle 3. More natural3. More natural pattern of frontal hairpattern of frontal hair growthgrowth
  33. 33. Hair grafting  Okura, 1939Okura, 1939  Orentreich, 1959Orentreich, 1959  Punch graftPunch graft  Strip graftStrip graft  Follicular-unit graftFollicular-unit graft
  34. 34. Punch grafting
  35. 35. Punch grafting
  36. 36. Strip Grafting  Vallis, 1964Vallis, 1964  Free composite graftFree composite graft  Reconstruct frontalReconstruct frontal hairlinehairline  DimensionsDimensions  LengthLength  WidthWidth Un-operatedUn-operated PreviousPrevious operationoperation
  37. 37. Strip Grafting  Vallis, 1964Vallis, 1964  Free composite graftFree composite graft  Reconstruct frontalReconstruct frontal hairlinehairline  DimensionsDimensions  LengthLength  WidthWidth Un-operatedUn-operated PreviousPrevious operationoperation
  38. 38. Follicular-unit Grafting  MinigraftsMinigrafts  3-4 hairs/graft3-4 hairs/graft  MicrograftsMicrografts  1-2 hairs/graft1-2 hairs/graft  Barrera’s techniqueBarrera’s technique
  39. 39. Follicular-unit Grafting
  40. 40. Follicular-unit Grafting
  41. 41. Follicular-unit Grafting
  42. 42. Follicular-unit Grafting
  43. 43. Follicular-unit Grafting
  44. 44. Follicular-unit Grafting
  45. 45. Follicular-unit Grafting
  46. 46. Follicular-unit Grafting
  47. 47. Follicular-unit Grafting
  48. 48. Follicular-unit Grafting
  49. 49. Revision Surgery  RemovalRemoval  RepositioningRepositioning  ReductionReduction  AdditionAddition  Scar revisionScar revision
  50. 50. Conclusion  Wide variety of methods for the correctionWide variety of methods for the correction of alopeciaof alopecia  Don’t forget medical managementDon’t forget medical management  Individualize treatment plansIndividualize treatment plans  Counseling, Counseling, CounselingCounseling, Counseling, Counseling
  51. 51. •Nordstrom, RE. Scalp, Hair, Baldness, and Surgery. Facial Plastic Surgery. 1985, 2 (3); 173-177. •Barrera, A. Hair Transplantation, The Art of Micrografting and Minigrafting. Quality Medical Publishing, Inc, St.Louis; 2002. •Abell, E. Embryology and Anatomy of the Hair Follicle. In, Disorders of Hair Growth, Diagnosis and Treatment, E.A.Olsen, ed. McGraw-Hill, Inc, New York; 1994. •Sinclair, R. Male Pattern Androgenetic Alopecia. British Medical Journal. 1998, 317; 865-869. •Ramos-e-Silva, M. Male Pattern Hair Loss: Prevention Rather Than Regrowth. International Journal of Dermatology. Oct 2000, 39 (10); 728-731. •Nordstrom, RE. The Initial Interview. Facial Plastic Surgery. 1985, 2 (3); 179-187. •Devine, JW, Howard, PS. Classification of Donor Hair in Male Pattern Baldness and Operations for Each Type. Facial Plastic Surgery. 1985, 2 (3); 189-191. •Price, VH. Drug Therapy: Treatment of Hair Loss. The New England Journal of Medicine. Sept 23 1999, 341 (13); 964-973. •Unger, MG. Scalp Reductions. Facial Plastic Surgery. 1985, 2 (3); 253-258. •Raposio, E, Nordstrom, RE. Tension and Flap Advancement in the Human Scalp. Annals of Plastic Surgery. July 1997, 39 (1); 20-23. •Raposio, E, PierLuigi, S, Nordstrom, RE. Effects of Galeotomies on Scalp Flaps. Annals of Plastic Surgery. July 1998, 41 (1); 17-21. •Norwood, OT, Shiell, RC, Morrison, ID. Complications and Problems of Scalp Reductions. Facial Plastic Surgery. 1985, 2 (3); 259-267. •Frechet, P. Scalp Extension. Journal of Dermatologic Surgery and Oncology. 1993, 19; 616-622. •Raposio, E, et al. Anchoring Galeal Flaps for Scalp Reduction Procedures. Plastic and Reconstructive Surgery. Dec 1998, 102 (7); 2454-2458. •Nordstrom, RE, Greco, M, Raposio, E. The “Nordstrom Suture” to Enhance Scalp Reductions. Plastic and Reconstructive Surgery. Feb 2001, 107 (2); 577-582. •Argenta, LC, Marks, MW, Anderson, RA. Treatment of Male Pattern Baldness by Tissue Expanders. In, Male Aesthetic Surgery, 2nd Ed, EH Courtiss, ed. Mosby, St.Louis; 1991. •Juri, J, Juri, C. The Juri Flap. Facial Plastic Surgery. 1985, 2 (3); 269-282. •Unger, WP. Construction of the Hairline in Punch Transplanting. Facial Plastic Surgery. 1985, 2 (3); 221-230. •Vallis, CP. Treatment of Male Pattern Baldness by Punches, Strips, and Flaps. In, Male Aesthetic Surgery, 2nd Ed, EH Courtiss, ed. Mosby, St.Louis; 1991. •Vallis, CP. The Strip Graft. Facial Plastic Surgery. 1985, 2 (3); 245-252. •Epstein, JS. Revision Surgical Hair Restoration: Repair of Undesirable Results. Plastic and Reconstructive Surgery. July 1999, 104 (1); 222-232. •Vogel, JE. Correction of the Cornrow Hair Transplant and Other Common Problems in Surgical Hair Restoration. Plastic and Reconstructive Surgery. Apr 2000, 105 (4); 1528-1536.

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