Why aren't Dr's doing scalp reductions + HT's?

[shouldIdoit]

It seems that the scar in the donor area is being treated well enough that between good healing + native hair in the given area, make the scar completely unseen by the naked eye. As such, why aren't Dr's performing more scalp reductions in the crown area and then doing adding more grafts to the small area (to cover that scar)? It seems that since the crown area has greater laxity then the back of the head, a greater amount of "open space" can be reduced (at least on patients who are very bald in the crown area). Just curious after looking at one of the recent "post surgery" threads.

[Jotronic]

Shouldidoit,

 

Scalp reductions at first glance sound like a decent option which is why they were done for years but the problem is that the direction of hair in the areas immediately around the area "reduced" is greatly distorted and unnatural.

 

In addition the results were not as consistent as some have been lead to believe and it greatly reduces the overall laxity that one may need should they need a decent amount of hair moved later on for a transplant.

 

In general, they're just a bad idea for the long term.

[Dr. William Lindsey]

I have heard that most, if not all, of the malpractice claims related to hair transplants have been related to scalp reductions or flap surgeries. I spoke casually with a rep of a major hair transplant company a year ago and they confirmed that out of something like 100,000 cases, they had only 3 open claims, and they were from strip surgeries and scar issues. So it would appear that scar risk is the major medico-legal problem with scalp surgeries.

 

So my guess is that there are 3 reasons why scalp reductions aren't occurring today.

 

First, scars can be a real problem and can potentially disfigure (a nice legal term) someone, even in the best of hands. And alot of scalp reductions weren't done by the best of hands. Actually way back in the 90's, my fellowship director did scalp reductions and I did probably 20 or so with him. With proper technique and not being "too aggressive", the scars are usually very acceptable. One just has to limit skin tension with 2 layer closure and realistic goals. And tissue expansion really let us remove alot of bald scalp, but very few men want to walk around with a balloon expander in for a month, when they can have a modern transplant.

 

Second, the surrounding hair can get pulled into an unnatural position. But not as unnatural as in rotation flaps (Juri/Brandy etc).

 

Third, modern follicular unit grafting has greatly improved overall results with minimal potential complications.

 

Finally, using my landscape analogies that I use with patients: Imagine you have a farm that has a hill with no trees. It is easier to plant trees on the hill, than it is to grade the hill down to level so that surrounding tree'd land camouflages it.

 

Dr. Lindsey McLean VA

[Tsakalos]

And tissue expansion really let us remove alot of bald scalp, but very few men want to walk around with a balloon expander in for a month, when they can have a modern transplant.

 

 

Dr. Lindsey McLean VA

Dr Lindsey that tissue expansion balloon has to be placed for 1 month ? or for more ??

plz provide detailed info . if the patient scalp is very streched will the tissue expantion and scar revision will work or it will stretch back again ?

[Dr. William Lindsey]

Entire chapters are written on tissue expansion, so this is a brief answer at best.

 

My experience has been with expanding the forehead skin to rebuild entire noses that were removed during cancer operations. It is a debilitating deformity and the reconstruction is the most gratifying and most fun operation that I do. It is life changing for the patient.

 

Essentially you make a small incision, insert a ballon with a port used to inflate the balloon with water. Every few days the patient comes to the office and some water is injected which expands the balloon and stretches the overlying skin some. After a month or 2, there is sufficient skin to do what you need...rebuild a nose, excise a bald spot, put in an implant.... and you remove the expander and complete the surgery. If you plan it correctly, there is a bit of extra skin left over, which contracts back to its normal laxity VERY quickly. If you didn't plan correctly, you don't have enough tissue to complete the goal.

 

Dr. Lindsey McLean VA

[Tsakalos]

thx dr lindsey but is it effective if u want ti remove scar tissue from strip procedures ? can the scalp stretch back again?

[Dr. William Lindsey]

It depends on your scar. But I have never had to expand to remove a scar. It may take a couple of surgeries for really wide scars, but not expansion.

 

Dr. Lindsey McLean VA

[Dr. James Vogel]

I happened to be reading this thread and thought I would add my 2 cents. Tissue expansion is the only way to add available scalp to excise a tight or wide donor scar. The downtime, discomfort, strange appearance and potential risk that a patient takes to undergo this staged procedure is considerable however. Interestingly I am on a panel in Boston at the next ISHRS meeting to discuss this very topic. Another easier option for a wide donor scar is to place some HT's into the scar to provide as much cover as possible.

[Dr. James Vogel]

After reading my message I do want to be clear that for some selected patients, tissue expansion can be a tremendously rewarding procedure and the only solution to address their individual concerns.

JEV

[Maxxy]

Tissue expansion is the only way to add available scalp to excise a tight or wide donor scar.

 

Dr. Vogel,

 

I'm sure the expansion won't be as dramatic and it may require more time but in some cases don't you feel scalp exercises can add enough laxity to remove wide scars and aid with tight scalps or do the scalp exercises work in a different way?

[Dr. James Vogel]

You are entirely correct that scalp exercises help loosen tight scalps and I recommend this maneuver to many patients. However in the case of an individual who has already undergone one, and in this case probably 2 , or more harvests from the same site there is considerable tissue physically , already missing and scalp exercises in this situation are unlikely to produce enough added laxiety to make a real difference.

Tissue expansion literally induces biochemical and physiologic tissue duplication known as tissue "creep" and adds tissue to the area and this is why expansion is such a powerful tool for selected situations

Hope this answers your question

[Megatron]

great discussion guys. I don't want to discount what anyone has said so far however, just using common sense I think is also important. "scalp reduction" sounds a lot more involved then re-planting hairs. quite frankly, scalp reduction would scare the shit out of me.

[Maxxy]

Dr. Vogel,

 

Thank you for the reply, though I'm not sure I agree. I have read of many patients who have had multiple procedures and been left with bad scarring, some of which have spoke of their worries over the scalp being too tight yet they have later received scar reductions with excellent out-comes. In all my years reading posts from such patients none have used a tissue expander to my knowledge. Of course every case will be different but your statements such as

However in the case of an individual who has already undergone one, and in this case probably 2 , or more harvests from the same site there is considerable tissue physically , already missing and scalp exercises in this situation are unlikely to produce enough added laxiety to make a real difference.

make it sound as if even after 1 or 2 procedures, if you are left with a wide scar then your only option is a tissue expander, which I hope isn't the case for the vast majority of patients. I have also read of patients that have went from having tight-normal laxity to having *too much* after scalp exercises.

 

You say "and in this case probably 2"... I'm not 100% which case you are referring to (Tsakalos?) so maybe I have missed something and you are referring to cases such as his (which I know nothing about)?

 

Tissue expansion literally induces biochemical and physiologic tissue duplication known as tissue "creep" and adds tissue to the area

To be honest I assumed this was the way scalp exercises worked. So unlike the tissue expander that duplicates tissue the scalp exercises are simply loosening and stretching the skin? Not unlike rolling out pastry, it's still the same amount of pastry only thinner and longer due to the rolling process?

 

P.S. I don't mean anything by dissecting your post and quoting you, it's simply easier to ask my questions that way.

[Dr. James Vogel]

Maxxy

No problem with the dissection of my reply

 

Tissue expansion is the end of the road, last ditch effort to repair a wide donor scar. And believe me I do it VERY infrequently. This is why you have not read about it in many or any posts over the years. My comments probably did not reflect this situation adaquately. Sorry for not making that clear.

 

In addition Scalp stretching is mechanical and not biological (like tissue expansion) Also, to be anatomically correct scalp stretching really stretches the underlying galea, which is the tight leather like covering for the skull and is adherent to the scalp. The galea is the limiting factor and perhaps you have heard of the technique in which galeotomies (scoring or incising) are sometimes performed to gain more mobility of the galea.

 

Finally, a scar revision might be a possibility for the patient who started the thread. The final determination would need to be made in person and yes, scalp exercises are always recommended !

thanks

JEV

[the B spot]

For those that do not know, Dr. Vogel does excellent repair work, and has done so for many, many years. It is great to hear he is offering those who have a last ditch effort some form of tissue expansion in order to reduce scarring.

 

It takes proper qualification and assessment of a patients donor, then it takes time and effort to properly remove, undermine and close the donor region...all to leave a proper scar.

 

What there needs to be is a set of uniform principles, guidelines and certified training (specific to HT's) that doctors learn and undergo BEFORE they begin doing hair transplantation.

 

The key to combating the malaise of poor closures is to go to doctors like Dr. Vogel FIRST.

 

Take Care,

Jason

[Maxxy]

Dr Vogel,

 

Thank you for the clarification and for explaining the mechanics behind scalp exercises.

 

I agree with B_Spot, it's great we have someone with your experience and skills willing to take on these difficult cases and offering hope to guys with bad and difficult to treat scarring.

 

When a tissue expander is necessary, does your clinic charge set cost? If so, what is this cost or is the cost dependent on the actual patients scarring, etc?

[Dr. James Vogel]

I am humbled by the kind words above from Maxxy and B-spot, thank you both

 

Regarding cost, I do keep the fees quite reduced in these cases as a way to

help these unfortunate folks bring closure to an unhappy path . The only variability is when several expanders are needed for the procedure.

[Bill - Seemiller]

Dr. Vogel,

 

I can only echo the sentiments presented by Jason and Maxxy above. Your reputation for producing ultra refined hair transplant results and performing state of the art repairs precedes you. Thanks also for taking the time to discuss this important topic with our members.

 

All the Best,

 

Bill Seemiller