Hair Transplantation and Cicatricial Alopecia.

Unger W, Unger R & Wesley C. The surgical treatment of cicatricial alopecia. Dermatologic Therapy 2008: 21: 295–311.

Do not miss this book: Unger WP, Shapiro R. Hair Transplantation, 4th edn. New York: Marcel Dekker, 2004.


Availability of donor hair 
The long-term donor-recipient area ratio – that is, the ratio of “permanent” donor hair relative to the ultimate size of present, as well as future areas of alopecia that might develop – is perhaps the most important factor to consider. In many patients, however, the ratio is inadequate to satisfactorily treat both the current and possibly future areas of cicatricial alopecia, in addition to addressing surrounding areas that are likely to develop male pattern baldness (MPB) or female pattern hair loss (FPHL). Furthermore, if donor hair is taken from an area that is eventually destined to lose its hair secondary to MPB/FPHL or some of the diseases that cause unstable cicatricial alopecias (UCAs), it will also be lost in the recipient area.
Given the difficulty in accurately estimating this ratio, excision is generally preferable to hair transplanting. This is especially true with respect to larger alopecic regions in younger individuals, while older patients with small areas of scarring may often be appropriately treated with hair transplantation.

Scalp laxity
The less scalp laxity, the more preferable hair transplantation is to excision.

Patient’s healing characteristics 
Hypertrophic or keloid scars, less or greater than average scalp laxity (especially those with Elhers–Danlos syndrome), and individuals who have experienced inexplicable excessive postoperative bleeding in the past favor a decision to utilize hair transplantation as opposed to excision.

Vascular circulation
Grafts in the center of a large scar are most distant from a good blood supply. To test the blood supply of a large area, it is recommended that one first anesthetize a portion of the area with a 2% lidocaine solution without epinephrine. Then a 19-G needle can be used to make several incisions. There should be evidence of bleeding when this is done. If not, the area would be best treated with surgical excision.

Area of involvement
Hair transplantation is preferable in sites such as the hairline and eyebrow. If excision is employed, ideally the surgeon should use a “trichophytic” closure in which a narrow zone of the epidermis of one flap of the wound is removed and the wound is closed in such a way as to result in hair which grows through the scar itself.