The potential problems caused by scalp reductions were recognized early in the history of their use, but it took several decades for these problems to be fully appreciated by the majority of hair restoration surgeons. Fortunately, scalp reductions have been performed with much less frequency in recent years. Scalp reductions have the undesirable effect of simultaneously causing cosmetic problems and depleting the donor supply needed to correct them. Simply stated, they are a hair loss solution that alters the balance between supply and demand. They increase the demand for hair by producing scars in the top and crown that must be camouflaged, alter natural balding patterns and change hair direction, all without significantly adding coverage to the front of the scalp. They diminish supply by decreasing donor density and scalp laxity, thereby reducing the amount of hair available for the correction.
These problems can be partially addressed by the "hair conserving" technique of microscopic dissection, but after multiple scalp reductions, with even the best techniques, full correction is often not possible. Specific patterns of repair, such as the "hockey stick," used for treating patients who have low donor supply, are particularly useful in patients with low donor supply because of scalp reductions or scalp lifts.
Scalp reductions and scalp lifts, particularly when performed by inexperienced hands, can leave an unacceptable scar in the crown. This scar can be camouflaged, but it requires a considerable amount of hair. In addition, scar tissue limits the amount of hair that can be transplanted into a given area in one session, so that multiple sessions are often required. When hair is transplanted directly into the scar, the patient can run the future risk of having an abnormal growth pattern as the hair loss progresses. The creation of an off-center swirl, previously discussed, can be used to cover scalp reduction scars without having to place a large amount of hair directly into the scars, and can partially address future balding with its fanned hair pattern.
In general, correcting scalp reductions and their associated defects can be approached similarly to correcting plugs and depleted donor supplies. Therefore, correct the front and one side as much as possible and allow that hair to camouflage problems in the back with either light coverage or tacking hair.
Problems specific to poorly executed scalp reductions that cannot be camouflaged, such as "dog-ear" deformities (the puckering of excess tissue at the ends of the incision), should be addressed prior to the camouflage procedure. A dog-ear deformity, caused by the failure of the hair restoration surgeon to make the length of the incision sufficiently greater than the width or the failure to account for the curvature of the skull, can be corrected by excision. The hair in the excised tissue should be dissected into follicular units and re-implanted.
Ridging, another undesirable result of scalp reductions, is caused by the increased volume of tissue associated with grafts larger than follicular units and the body's reaction to that tissue. The reaction, hyperfibrotic healing, occurs with greater frequency and severity when larger grafts are transplanted. Ridging from grafts in the frontal hairline gives the head an elongated rather than rounded frontal appearance that accentuates the defects caused by the large grafts.
The growth of grafts in areas of ridging tends to be poor. The area can be improved cosmetically by punching out selected plugs where the ridging is most severe. This will decrease both the look of "plugginess" and the total tissue volume. It is important to perform a few trial punches to be certain that the wounds heal with less elevation. In some cases, even the trauma of removing the grafts seems to contribute to the hyperfibrotic change.
When hyperfibrotic change occurs around slit grafts, especially large ones, deep depressions around the grafts may be seen in conjunction with an exaggerated, tufted appearance of the hair. In this situation, every attempt should be made to completely remove the grafts. The punch should be large enough to extend slightly beyond the edges of indented skin, so that the two wound edges will lie flush when approximated and not invert. If the slits are greater than 3mm, the punch should be used to remove one-half of the defects, with the remainder being excised in a subsequent session. As an alternative, if the large slit is removed from the frontal hairline, it can be excised with a free-hand ellipse.
Once the area of ridging has been improved, it seems to accept grafts better in subsequent sessions, but the growth of newly transplanted hair may still be inconsistent. For this reason, follicular units should be placed in the normal skin in front of the hyperfibrotic change (if the position of the hairline permits) so that adequate camouflage can be ensured.
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