Surgical treatment of scarring alopecias


Cychial Alopecia: definition

The term Cychial Alopecia is used to indicate the definitive loss of hair follicles and hair, usually in patches, whatever the cause. The most significant element that characterizes a scarring alopecia is the irreversibility of the pathological process due to the destruction of stem cells in the region of the hair follicle protuberance.

Scarring alopecia can be defined as “form of permanent alopecia ab initio, due to destruction of hair follicles, with atrophy and sclerosis always coexisting although with different predominance”.

We distinguish two major groups of acquired scarring alopecia: the primary forms and the secondary forms. Where there is sufficient clinical, histopathological, and experimental evidence to demonstrate that the destructive inflammatory process is specifically directed against the pilo-sebaceous unit, we will speak of true cicatricial alopeciasprimitive or follicular (LYMPHOCITARY, NEUTROPHILIC, OR MIXED). If this is not the case, we will then introduce a second subcategory, that of true cicatricial alopecias secondary or non-follicular (FROM PHYSICAL-CHIMICAL CAUSES: trauma, burns, radiodermatitis, chemicals, surgical outcomes; INFECTIVE OR METABOLIC-DEGENERATIVE).

Not all scarring alopecias can be treated by surgical intervention. Particularly in primary alopecias (lupus erythematosus, lichen planus pilaris,…), the destruction of stem cells in the bulge area of the hair bulbs caused by inflammation caused by the lymphocytic and antibody response determines the definitive disappearance of the bulbs. The same fate can occur with hair grafts placed in the area affected by scarring alopecia, not guaranteeing the results of the autograft intervention.

Surgical therapy is more indicated in cases of secondary alopecia, caused by injuries of the scalp secondary to trauma (car accidents, sports injuries, work-related injuries), outcomes of surgery (neurosurgery, facelifts),  thermal burns caused by contact with hot substances such as metal or scalding with hot water, chemical burns caused by exposure to corrosive substances such as industrial acids or alkalis, cleaning solutions, radiation burns caused by excessive exposure to excessive amounts of ionizing radiation (X-rays or gamma rays).

The blood supply to a scar area is usually reduced, in some cases compromised. Hair follicles need an adequate blood supply to survive and function. The baldness surgery specialist should always assess the blood supply of the scar area:.

  • Using various techniques to establish the pathways and viability of blood vessels in that area;
  • By placing a limited number of test grafts in the affected area before undertaking a larger procedure.

An important factor to evaluate is the thickness of the scalp in the area to be autografted. Different types of scars have different properties regarding thickness and friability. If the scar is very thick, hypertrophic, the scar tissue may limit accessibility to the underlying blood vessels.

If the scar is very thin (atrophic), the scar tissue may be too thin to support the implanted follicles.

It is not recommended to perform an autograft on scar tissue from neurosurgery with an underlying metal plate. The presence of a metal device at the base may be compromised by autograft surgery or become the starting point of a bacterial infection.

Clinical case: Scarring alopecia as a result of pressure sores

Thomas, 25 years old, at the age of 18 following a car accident, was in a coma for about three months. The presence of a pressure sore in the occipital area resulted in a scar area without hair (7 cm x 4 cm) (Fig.1).

Scar area

The scar was inhomogeneous both in terms of thickness and irrigation, so a rooting test was performed, i.e. the placement of some FU (Follicular Unit) tests in different areas of the scar. The extraction of the grafts was performed by FUE technique (Follicular Unit Extraction) with motorized and implantation by technique DHI (Direct Hair Implant) (Fig.2)

Fig.2 Implantation test

After 20 days, the check was done and all FUs had taken root. (Fig.3).

Fig.3 Checking the rooting test after 20 days

At this point, the entire area was covered(Fig.4)with an adequate number of FUs. The follicular units were implanted not too close to each other, in order to allow each one the correct irrigation and nourishment. After some time, it was found that all implanted hairs grew back (Fig.5).

Fig.4 FU implantation in the scar area
Fig.5 Hair regrowth at the scar area at 7 days.


Fig.6 Hair in regrowth at the scar area at 30 days


Fig.7 Result at 6 months after surgery

Dr. Elisa Francesconi, Medical Surgeon Helvetic Sanders Institute of Perugia Health Facility.


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