Scalp Flap Surgery for Hair Restoration

Skin Flap Surgery

Skin flap surgery is a method of moving a "flap" of skin and underlying tissue from one area of the body to another. It is surgery performed to (1) repair a non-traumatic cosmetic defect such as male pattern hair loss, (2) repair a site of traumatic injury to restore its functionality and cosmetic appearance, or (3) repair a skin defect caused by a congenital malformation.

The flaps used in both cosmetic and reconstructive surgery are either "pedicle" flaps or "free" flaps:

  • Pedicle flaps are flaps that are surgically removed from a donor site and transferred to a recipient site with an attached pedicle of tissue that contains the flap's artery-vein blood supply along with the flap tissue. Transfer of artery-vein blood supply along with the flap improves the survival and health of the transferred tissue. Pedicle flaps are the type most often used for cosmetic hair restoration.

  • The free flap is called "free" because it is transferred from donor site to recipient site without any attached pedicle. However, it must contain arteries and veins that are reattached to blood vessels at the recipient site by microvascular surgery. Free flaps are often used in reconstructive surgery when local skin is not sufficient to raise a pedicle flap to cover a defect-for example, to cover a substantial area of scarred scalp tissue. In recent years, free flaps have been used for cosmetic hair restoration by skilled and highly trained physician hair restoration specialists.

Scalp flap surgery has an important but limited role in hair restoration. The surgeon who performs the procedure must be a skilled physician hair restoration specialist with specific training and experience in use of skin flaps for hair restoration. In the hands of an appropriately trained and experienced surgeon, scalp flap surgery can be a highly successful approach to hair restoration in carefully selected patients.

Patient Selection
Patients with frontal baldness exclusively are good candidates for scalp flap hair restoration, but many physician hair restoration specialists do not regard scalp flap surgery as first-choice treatment for frontal baldness. The choice of scalp flap surgery, hair transplantation, scalp extension or scalp expansion as first-choice treatment for frontal baldness should be weighed carefully in discussions between patient and physician hair restoration specialist.

Frontal baldness may be in any degree from "frontal only" to "frontal to mid-scalp". When scalp flap surgery is the treatment selected, the rotation of one flap or multiple flaps from the hair-bearing donor area of the scalp to the bald area provides instantaneous full hair coverage; narrow gaps between transferred flaps may require some subsequent "touch-up" by hair transplantation or alopecia reduction procedures.

More extensively bald men with vertex (crown of the head) balding may benefit substantially from scalp flap hair restoration with proper preoperative planning, and when the procedure is performed by a skilled, experienced physician hair restoration specialist.

Evolution of Scalp Flap Surgery for Hair Restoration
Scalp flap surgery for hair restoration was performed as early as the 1930s but did not become an established technique at that time. In 1969, plastic surgeon Dr. José Juri, Buenos Aires, Argentina, reported development of the scalp flap techniques that are the basis for practically all scalp flap techniques for hair restoration in use today. A master of flap surgery, Dr. Juri uses both pedicle and free flaps as a method of choice for treating baldness of various types and degrees as well as baldness due to various causes.

However, since the 1980s, the majority of physician hair restoration specialists prefer hair transplantation and alopecia reduction as first-line treatments for cosmetic hair restoration because of the success of these methods. Scalp flaps now tend to be reserved to correct traumatic and congenital defects in reconstructive hair restoration.

Facts About Scalp Flaps

Pedicle Flaps
The transfer of tissue from one site to another on the scalp is usually done in a series of procedures a week or more apart. These procedures include planning and marking the flap(s) and recipient site(s), incising the flap, raising and transferring the flap with its attached pedicle of blood vessels, and closing the wound at the donor site. The same series of procedures are carried out for any subsequent flap procedures.

Planning for flap transfer to a bald area must include a consideration of hair direction in the transferred flap. Hair does not grow in a uniform direction on all areas of the scalp-it grows in several different directions on various scalp areas. Planning of flap transfer from donor to recipient area should aim to avoid the potential problem of distorted hair pattern that can be a complication of scalp flap surgery.

Although scalp flap surgery produces immediate heavy growth of hair over bald areas, there may be narrow gaps of thin or no hair between multiple flaps. Subsequent hair transplantation or alopecia reduction may be necessary to close these gaps. Adjustments in hair styling may be all that is needed to disguise small differences in hair growth direction and narrow bands of thin hair growth between flaps.

Some potentially serious complications of scalp flap surgery are:

  • Failure of blood supply to the flap due to "kinking" or pressure on the flap's blood supply, resulting in partial or total loss of the flap;
  • Transection of nerves during surgery with resulting loss of feeling over all or part of the scalp;
  • Scarring at donor or recipient sites; and,

Permanent loss of hair at donor sites that could be necessary for future hair transplantation.

Microsurgical Free Flaps
The "free" flap is surgically removed from the donor site and transferred to the recipient site without any attached blood supply. The free flap must, however, have a well defined arterio-venous system that can be reattached to the recipient site's circulation by microsurgery.

Surgeon innovators of microsurgical free flaps for cosmetic hair restoration have presented results showing that use of microsurgical flaps can eliminate the complications of distorted hair pattern and inconsistent hair density. They recommend microsurgical free flaps as a treatment of choice of various types and degrees of baldness. It is important to note that microsurgery is an advanced technique in cosmetic and reconstructive surgery that requires great skill, training and experience. Most physician hair restoration specialists have not sought such training and would not recommend use of microsurgical flaps for cosmetic hair restoration.

Scalp Expansion
Expansion of hair-bearing scalp by the technique of scalp expansion can also be characterized as a scalp flap technique. The expanded hair-bearing scalp created by scalp expansion makes more hair-bearing scalp available for a variety of flaps useful in the treatment of alopecia. Several procedures are necessary to achieve a final result: (1) placement of the expander under the scalp, (2) inflation of the expander over a period of weeks, (3) removal of the expander, (4) creation and transfer of flap(s) from donor to recipient area, and (4) closure of the wound at the donor site. Patients with an extensive area of baldness may require a second expansion series to achieve complete coverage.

Skilled and experienced physician hair restoration specialists who use this technique cite its advantages as:

  • Excellent frontal coverage,
  • Natural horizontal frontal hairline,
  • Excellent design of hair placement in temporal areas, and
  • Good hair direction and avoidance of distorted hair pattern.

Scarring at the temple regions is a potential complication of the expansion/flap technique.

As for other flap procedures, the expansion/flap procedure should be performed only by skilled and experienced physician hair restoration specialists who have training in dermatologic or plastic surgery.

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