Corrective surgery on 60 y/o male after 2 past scalp lift procedures

[Dr. Michael Beehner]

This 60 y/o male presented to us several years ago, having previously had two scalp lifts/reductions, which raised the hair on the side of his head way above his ears (see two last photos). He also had two transplant procedures with several hundred pluggy grafts each time. Because of the scalp lift, these grafts grew very poorly. He had very little donor hair. Over two procedures three years apart he had 805 FU's the first procedure and 1020 the second procedure. At this latter surgery I obtained half of the grafts using FUE (Safe II system with 0.9mm punch. I spaced the grafts so they would obtain enough blood supply to survive. 

Mike Beehner, MD.

[Melvin- Admin]

Wow great improvement Dr. Beehner, in your opinion why did scalp lifts, flaps and reductions cause so many repair patients? 

 

[Dr. Michael Beehner]

In answer to your question about how the previous use of flaps, scalp reductions, and scalp lifts were harmful to the patient's scalp, there are several key issues.

Regarding scalp lifts, in order to lift it up as high as this patient's procedure was done, it was usually necessary to cut the occipital arteries and nerves in the back of the head in order to free the scalp up. Obviously, after the scalp is all undermined by the surgeon doing a scalp lift, the bald scalp on top is largely excised away, which is the whole purpose of the procedure, namely to reduce the bald area and move hair up there in its place. All of these scalp procedures, which I listed above, thin out the layers of the scalp, which puts a great strain on the arterial blood supply to the scalp. Probably the most important negative regarding these procedures is that there is a thing called "stretch back" that occurs. What this means is that I may reduce the side-to-side distance of bald scalp on top from 12 cm wide down to 7cm wide, and the photos right after the procedure look wonderful and almost miraculous. However, when the patient comes back in 6 months, the distance across will probably be around 9.5cm, which makes the accomplishment on top a lot less. 

Scalp flaps are procedures which take a long strip of scalp and it is left attached up near the front upper temple area, swung around and then sewed into place in an area cleared out near the hairline. It uses up too much precious donor hair and puts it in a relatively small area, where instead that amount of donor hair could be cut up into several thousand small grafts and help cover a much larger area. Also, where the flap came from at the side and back of the scalp leaves a fairly wide scar, since the flap is much wider than the typical donor strip, which can be brought together with minimal detection. 

The other negative on scalp lifts is the large bare area of scalp that now is created above the ears and just behind them. This is obvious in the photos above of my patient. Another big, big negative of all these procedures, is that after you complete them and then want to transplant the bald area that remains, the survival of the grafts is not nearly as good as when they are planted into full thickness scalp that has not been stretched out.

I hope the above is helpful.

Mike Beehner, M.D.

 

[Melvin- Admin]

Thank you so much for your answer Dr. Beehner very educational and insightful. 

[Sean]

No doubt this is impressive a d challenging repair.  Great job!

Dr. Beehner, have you worked on any patient that had ridging and cobblestoning where a removal of the tissue was necessary?  This is primarily due to tissue damage from excess trauma during dense packing.   Primarily in the hairline area?  Just wondering and trying to get an idea how successful such a surgery would be and will the scar heal well.  If you have any cases like that,  it would be great to see.  

Thanks for repairing this patient.  It was a challenging case and very few docs take on challenges as they try to show “showcase” results with virgin scalps more and more.  

I really applaud you taking on such a case and helping this person.  

[Dr. Michael Beehner]

Sean,

With follicular unit transplanting cobblestoning and elevation of the scalp in the transplanted area is much more uncommon. The closest case to that description that I recall is this man who many years previous to seeing me had large minigrafts placed across his entire front hairline. Over a few months he said that the whole area raised up and made the very obvious grafts even more unnatural. 

Because he had a little space in front of this hairline to do something, I was able to place FU's in a relatively dense pattern both in front of and behind the area that featured this cobblestoning and elevation. I will try and attach some photos of his before and after appearance.

Mike Beehner, M.D.

[Sean]

23 hours ago, Dr. Michael Beehner said:

Sean,

With follicular unit transplanting cobblestoning and elevation of the scalp in the transplanted area is much more uncommon. The closest case to that description that I recall is this man who many years previous to seeing me had large minigrafts placed across his entire front hairline. Over a few months he said that the whole area raised up and made the very obvious grafts even more unnatural. 

Because he had a little space in front of this hairline to do something, I was able to place FU's in a relatively dense pattern both in front of and behind the area that featured this cobblestoning and elevation. I will try and attach some photos of his before and after appearance.

Mike Beehner, M.D.

Dr.  Beehner,  I admire your confidence and will to take on challenging cases.  Clearly, it is not the norm of some doctors showcasing work online who tend to take mostly virgin scalps and show to the world  the so called their own realistic dense marketed expectations.  Based on some folks I know, some docs will send patients to other docs to do repairs because they can’t fix damage or want to get rid of a patient they may have did something causing a patient great harm thus possibly ruining a life.  This is where a patient may not know the magnitude of the damage caused.

Cobblestoning and ridging are uncommon no doubt, but some folks who go with some “top” docs apparently still face this.  This can happen when surgery is possibly not ethically performed and with a poor surgical protocol and etc.  

I see how you were able to blend the damaged portion with placement of grafts to cameoflage the damage.  Now the one thing some professionals mentioned to me was that resection/removal of such tissue is an option given to such patients.  Some folks said grafting in and around heavily impacted scar tissue may hinder graft growth.  From this result, it looks like you were able to attain graft growth and survival in and around the scar tissue.  

Thank you for sharing this.  You definitely saved this patient from embarrassment.  Embarrassment, ridicule, and comments by folks in person is not easy to swallow, it is quite painful.  So painful, that you can question the damage daily and question life.  I hope when a person becomes a doctor, they understand ethics actually are there for their patient, tell the truth, and are always honest.  Being a doctor is a profession not a game.  By your willingness to help fix and do repairs as well, clearly you understand your profession well.  

I do not think I deserve at all what I am facing one bit.  As a war Veteran and Marine, I always wanted to be stress free and actually have my life back.  It is doctors like you, that are treating and helping repair patients that give some hope to folks that there may be different ways out of a difficult situation a person is in.  

Thanks for sharing and showing that may be there are different ways to tackle repairs and see what different options could be.  I really appreciate it.  Thank You.