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
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Hair Shaft
Cuticle
Medulla
Cortex
Sheath
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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
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Types of Alopecia
Androgenetic Alopecia
Alopecia Areata
Cicatricial Alopecia
Traumatic Alopecia
Diffuse Alopecia
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Androgenetic Alopecia
Male Pattern Balding
Female Pattern Balding
PathophysiologyMiniaturization of
follicles
Decreased anagen/
increased telogen
Increased latency
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Androgenetic Alopecia
Autosomal dominantvariable penetrance
30% of white men by
age 3050% of white men by
age 50
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Androgenetic Alopecia
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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Patient evaluation for surgery
Donor Hair
Type I
Type II
Type III
Type IV
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Patient evaluation for surgery
Age
Is NOT a contra-
indication forsurgery
Established pattern
Hair color
Co-existing medicalconditions
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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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Follicular-unit Grafting
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Follicular-unit Grafting
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Follicular-unit Grafting
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Follicular-unit Grafting
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Follicular-unit Grafting
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Follicular-unit Grafting
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Follicular-unit Grafting
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Follicular-unit Grafting
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Follicular-unit Grafting
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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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