Surgical Correction of Primary Cicatricial Alopecia

Dr. Ekrem Civas – DermatologistDr. Andaç Aykan - Plastic surgeonProf. Dr. Muhitdin Eski - Plastic Surgeon

www.civashairtransplant.comekremcivas@yahoo.com00 90 312 437 07 37

DISCLOSURES

No relevant financial relationships or conflicts of interest to

declare.

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Introduction

Primary Cicatricial Alopecia (PCA) is a poorly understood group of hair loss disorders in which follicles are irreversibly destroyed and transformed to scar like fibrous tissue resulting in permanent hair loss in the affected area.

Why Surgical Correction? Unfortunately, the currently available

medical treatment options for PCA are only limited to slow down/stop the progression of the disease and eliminate the symptoms.

There is no treatment method that can stimulate hair follicle neogenesis in the human scalp at present. Follicles destroyed by PCA will never re-grow hair.

Why Surgical Correction?

Once progression of the disease is burned out; there is need to cosmetically camouflage the residual scarred areas.

With sufficient donor hair, autologous hair transplantation is the only corrective surgery approach to cover the bald patches; provided the disease is stable.

Objectives

• Different considerations have been presented in literature on the question of the optimal minimum stability period before hair transplantation (1 or 2 years).

Objectives

Can the disease re-activate years later after stability? Publication shows that re-activation of the

disease was inconspicuous. There are only few studies in the

literature that show long-term results of surgical treatments.

Can we state that patients beyond the active stage of PCA are surgically stable alopecia?

Objectives

Literature on surgical correction of SCA reveal that hair transplantation can be done on the scar tissue in suitable conditions; Sufficient Donor hair No medical contraindications Sufficient blood supply in the scar

This background information together with existing literature on similar cases shed a light for us to embark on this research;

Method

Between 2011 and 2014, 8 patients (5 male 3 female, aged 26-42) with histo-pathological diagnosis of PCA and stable for at least 1 year were enrolled in the study.

MethodTable: Patients Data

PatientNo

Sex

Age Diagnosis Stable Yrs

TestDate

Date of Hair Transplantation

Total GraftNo.

1 M 41 Pseudopelad 7 20th Oct 2011 900

2 F 27 Liken pilanopilaris

1 2011 21st Nov 2011 70

3 M 42 follikülitis dekalvans

5 28th Nov 2011 670

4 M 26 Liken pilanopilaris

2 2013 22nd Apr 201319 octıber 2013

3001600

5 M 39 folliculitis decalvans&AGA

2 11th Nov 2013 1750

6 M 41 pseudopelad 4 24th Feb 2014 1100

7 F 31 frontal fibrozan alopecia

3 19th Nov 2014 1400

8 M 42 Lichen planopilaris

2 2014 28th May 2015 416

Method

Detailed medical and family history of the patients was obtained. Young patients with risk of future

Androgenetic Alopecia (AGA) hair loss. Physical, dermatological and

dermatoscopic examinations were performed.

Donor area graft density and estimated numbers of grafts needed for reconstruction were evaluated.

Method

3 patients (2 males, 1 female) underwent pre-transplant test session What is the criteria of selection▪ Two of these patients (case 2 and case 4) were

young▪ Case 2: whose clinical findings were suspicious, new

lesions appeared 3 months after test session and this patient was excluded from the study due to activation medical treatment was commenced.

▪ In Case 8 his dermatologist requested a test session

Method

Assessment of the vascular supply in scarred tissue was determined by pricking the 19G needle into the scar. Evaluation of scar circulation demonstrated a

bleeding pattern similar to that of the patients with non-cicatricial alopecia.

During canal opening in scarred areas, it was observed that PCA patients have evidently better vascularization than SCA patients.

Tumescent solution for scarred tissue was prepared using saline containing lower amount of Adrenalin than in non-cicatricial alopecia (1/250.000) cases.

Method

Hair transplantation method: FUE was selected as the most ideal method to

avoid creating an additional scar; since the patients already have existing scars from the disease.

FUE method resulted in small wounds at the donor site, patients recovered faster with feeling less pain and discomfort after procedure.

With FUE method, the donor hair is used more efficiently

For the above reasons, FUE method was preferred even with female patients.

Method

0.8 to 1.0 mm diameter punches were used to score the grafts

The recipient area was prepared using 0.9 to 1.1 mm diameter lateral slit technique with graft density of 10 to 20 FUs/cm2.

Method

Classical hair transplant post-op procedures were followed. Follow up of the patients was more

frequent than the AGA patients

Challenges

After medical treatment of PCA, autologous hair transplantation is the most reliable way to camouflage the scars created by PCA.

However hair transplantation in PCA has some important medical, surgical and technical challenges encountered as compared to the classical hair transplantation.

Challenges

Difficulties in diagnosis; Even with extensive examination, accurate

diagnosis remains elusive in some cases. It is difficult to distinguish the different

types of PCAs on the basis of histologic findings only, especially at their end stages

The highest diagnostic yield is procured when histo-pathological and clinical examinations are both considered.

Challenges

There is no certain clinical and laboratory finding to predict the stability of the disease.

Unfortunately, available medical treatment options can only prevent and slow down the progression of the disease and eliminate the active symptoms.

Challenges

Hair transplantation may be unsuccessful in the patients who are not in stable period.

Surgical treatments are recommended after 1-2 years stable time period after active phase of the disease ends. In the patient with 1 year stable period

(Case-2), activation was observed 3 months after test transplantation.

Challenges

Insufficient donor hair may lead to unsatisfactory cosmetic results.

Liken pilanopilaris Test session 416 grafts 6 months post surgery

Pseudolapad1100 grafts 1 years post surgery

Pseudolapad1100 grafts 1 years post surgery

Pseudolapad1100 grafts 1 years post surgery

Pseudolapad1100 grafts 1 years post surgery

Diagnosis: Follikülitis Dekalvans&AGA 1750 grafts 6 months post surgery

Diagnosis: Follikülitis Dekalvans&AGA 1750 grafts 6 months post surgery

Diagnosis: Follikülitis Dekalvans&AGA 1750 grafts 6 months post surgery

Diagnosis: Pseudolapad 1900 grafts 2 years post surgery

Diagnosis: Pseudolapad1900 grafts 2 years post surgery

Conclusion

Conclusion

Apart from Neutrophilic PCA which typically appears like a true scar due to diffuse dermal fibrosis and loss of elastic tissue; Histo-pathological studies show that in

other PCA variations only the hair follicle is replaced by fibrous tissue▪ Could this be the reason why hair

transplantation in PCA is more efficient than in Secondary Cicatricial Alopecia (SCA)?

Conclusions

FUE method is ideal for PCA patients Pre-operative evaluation of scarred

tissue with regard to blood supply is another important parameter in the determination of suitable candidates.

Graft density and amount of adrenaline in the tumescent anesthesia should be determined with regard to the nature of the scar and blood flow through the scar.

Conclusion

In 7 patients, infection, necrosis or any other complication was not observed following the procedure

The graft survival and hair growth progress was not different from the AGA or SCA patients.

Conclusion

In our opinion it will be safer to do surgical correction after 2-year stable period

Conclusion

Hair transplantation is the only corrective alternative method for PCA

Satisfactory cosmetic results can be obtained in stable PCA patients.

Stability of PCA is the most important parameter to consider before surgical treatment.

Thank you for your attention

Dr Ekrem Civaswww.civashairtransplant.com

ekremcivas@yahoo.com00 90 312 437 07 37