management of alopecia - university of texas medical branch · management of alopecia elizabeth j....

Management of Alopecia

Elizabeth J. Rosen, MD

Faculty Advisor: Karen H. Calhoun, MD

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

May 29, 2002

Management of Alopecia

Anatomy and Physiology

Androgenetic Alopecia

Classification Systems

Medical Therapy

Surgical Therapy

Scalp

S: Skin

C: subCutaneous

A: galea Aponeurotica

L: Loose connective

tissue

P: Pericranium

Blood and Nervous Supply Frontal

Supratrochlear

Supraorbital

Temporal

Superficial temporal

Zygomaticotemporal

Parietal

Retroauricular

Auriculotemporal/Great

Auricular/Lesser Occipital

Occipital

Occipital

Greater occipital

Hair Follicles

Embryonic development

at 9-12 weeks

Ectoderm

Hair matrix cells

Melanocytes

Mesoderm

Erector pili

Dermal papilla

Follicular Sheath

Blood Vessels

Hair Shaft

Cuticle

Medulla

Cortex

Sheath

Hair Density

5 million follicles

100,000-150,000 on

the scalp

Birth: 1135/cm2

1 year: 795/cm2

20-30: 615/cm2

30-50: 485/cm2

80-90: 435/cm2

Follicular Units

1-4 terminal hairs

1-2 vellus hairs

Sebaceous glands

Erector pili muscles

Blood vessels

Nerves

Connective tissue

Hair Growth Cycle

Types of Alopecia


Alopecia Areata

Cicatricial Alopecia

Traumatic Alopecia

Diffuse Alopecia


Male Pattern Balding

Female Pattern Balding

Pathophysiology

Miniaturization of

follicles

Decreased anagen/

increased telogen

Increased latency


Autosomal dominant –

variable penetrance

30% of white men by

age 30

50% of white men by

age 50


Site-specific action of androgens

Pubic/axillary/chest/beard: vellusterminal

Scalp: terminalvellus

Men—testosterone

Women—adrenal androgens

5-alpha reductase

Testosteronedihydrotestosterone

Why the pattern of hair loss?

Increased follicle susceptibility

Norwood Classification

Ludwig Classification

Medical Therapy

Minoxidil

Antihypertensive

Side effect: hyper-

trichosis

Topical 2%, 5%

Stop progression

and reverse changes

Delayed onset

Prolonged use

Finasteride

Specifically inhibits 5-alpha reductase, type 2

Lowers dihydro-testosterone levels

1mg/day

Side effect: decreased libido

Not used in women

Why treat?

Lower self-esteem

Mental distress

Stereotypes

Older

Weaker

Less productive

Less attractive

Less virile

Patient evaluation for surgery

Expectations?

Motivations?


Donor Hair

Type I

Type II

Type III

Type IV


Age

NOT a contra-

indication for surgery

Established pattern

Hair color

Co-existing medical

conditions

Surgical Therapy

Scalp reduction

Scalp flaps

Hair grafting

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

Scalp Reduction--Pitfalls

Tension

Excessive reduction

Tissue necrosis, widened scar

Raposio & Nordstrom

500-1,500 gr

Galeotomies

40% reduction in tension

“Stretch-back”

Tendency for the

remaining bald

scalp to expand

after a reduction

10-50% of the

reduction

2 months

Scalp extenders

Frechet, 1993

1mm thick silastic, two

rows titanium hooks

200% stretch

Memory

Effect: negative

stretch-back

Anchoring Galeal Flaps

Raposio, et al., 1998

Leave galea attached to one scalp flap

Create 3 2x3cm galeal flaps

Suture flaps to undersurface of opposite galea

80-88% reduction in stretch-back

Nordstrom Suture

Nordstrom et al., 2001

Silicone polymer

suture, 2mm diameter,

cutting needle

Running, buried,

mattress suture

Negative stretch-back

3x greater than with

extenders

Tissue Expanders

Increases total hair-

bearing surface area

Placement/Incisions

Filling

Useful in conjunction

with scalp reductions

or scalp flaps

Scalp Flaps

Lateral

Temporoparietal

Occipital (TPO), AKA

Juri

Preauricular

Free flap

Juri Flap

Uses: recreate frontal hairline

Parietal branch of superficial temporal artery

Flap

Pedicle: 2-2.5cm

Width: 4-6cm

Length: 23-25cm

Delay

Juri Flap

Design hairline

Elevate flap

Close donor site

Inset flap

Resect bald scalp

Free Juri Flap

Advantages

1. Avoid delay

2. Avoid revision

around pedicle

3. More natural

pattern of frontal hair

growth

Hair grafting

Okura, 1939

Orentreich, 1959

Punch graft

Strip graft

Follicular-unit graft

Punch grafting

Strip Grafting

Vallis, 1964

Free composite graft

Reconstruct frontal hairline

Dimensions

Length

Width

Un-operated

Previous operation

Follicular-unit Grafting

Minigrafts

3-4 hairs/graft

Micrografts

1-2 hairs/graft

Barrera’s technique

Follicular-unit Grafting

Revision Surgery

Removal

Repositioning

Reduction

Addition

Scar revision

Conclusion

Wide variety of methods for the correction

of alopecia

Don’t forget medical management

Individualize treatment plans

Counseling, Counseling, Counseling

BIBLIOGRAPHY

•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.

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20-23.

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17-21.

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259-267.

•Frechet, P. Scalp Extension. Journal of Dermatologic Surgery and Oncology. 1993, 19; 616-622.

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(7); 2454-2458.

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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.

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Reconstructive Surgery. Apr 2000, 105 (4); 1528-1536.

management of alopecia - university of texas medical branch · management of alopecia elizabeth j....

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