Scalp reduction techniques

This procedure had the following advantages:

The results were instantaneous. Other than the time between the first surgery to create the flap and the second one to relocate it, there was no waiting around for hair growth.
A hairline with thick hair was created when the flap was secured in its new location.

These advantages may make the procedure sound appealing, if perhaps a bit macabre (moving pieces of scalp around your head?). Unsurprisingly, there were many problems with flaps, including the following:

Unless the surgeon was very experienced, the blood supply to the flap could fail, leaving the patient with part or all of the flap dying in its new location in the recipient area.
The wounds at the recipient site were often a problem, creating a bald area where there was formerly hair. The new bald area often scarred heavily, sometimes with the appearance of an elevated keloid-type scar or just a scar along the edge of the flap.
The hair didn’t grow forward, as natural hair in the bald area would have grown. It often grew to the side, or even backward because it maintained its original hair direction in the flap.
There was a distinct change from the hairless forehead to a heavy line of thick hair and then, if the patient had any degree of baldness behind the flap the ‘island’ of flap would be easily seen.
Unlike a natural hairline, which has a slow transition from the bald forehead to the thicker hair area behind it, the flap had a detectably abrupt hairline and then an abnormal transition to baldness on the back side of the scalp.
One flap couldn’t cover the entire reconstructed frontal hairline, so two flaps were often used and joined in the middle or off to one side. This produced two open wounds in the area it was taken from (one on each side), two directions for frontal hair growth, and a small (or large) cleft between the flaps.
Multiple flaps often weren’t equally positioned, so it wasn’t unusual for the hairline to be off balance, with a shape determined by the surgeon’s need to cover the scalp rather than aesthetics. As a result, the new hairline of many of these patients just didn’t look right.
The flaps were relatively permanent after they were created. The patient had to live with the results, like it or not.

Moving to the scalp reduction technique

The first of the creative solutions to the problems with the flap technique (see the previous section) came in the late 1970s with the scalp reduction procedure for the treatment of balding in the crown area. The procedure was defined by Dr. Blanchard and Dr. Bosley commercialized this technique and published the first large series of scalp reductions. With a business focus, Dr. Bosley created his own terminology for the procedure, calling it male pattern reduction.

The essence of this surgery was removal of the bald spot in the top and back of the head. After the bald spot was removed, the surgeon lifted the entire scalp off the head to gain looseness and then attempted to pull the scalp together from the sides to close the defect. Sometimes the defect was too wide to close, so the patient would have only part of his balding spot removed and would return for more surgery some months later.

With a bald area 6 inches wide, it may have taken six or more surgeries to cut out the entire bald area, and the patient was left with an ugly scar where the scalp was put back together. Sometimes more surgeries were required to address stretched scars, and as more and more scalp was removed in successive surgical procedures, the hair on the sides of the head became stretched, reducing the density of the side hair.

The procedure didn’t even solve the problem of a bald crown, instead placing a scar in a bald of otherwise normal scalp. This led patients to need hair transplants just to cover the scar and make the crown appear normal.

The scalp reduction surgery was a radical, yet a simple procedure, and the number of surgeries performed spread like wildfire. It could be done in under 30 minutes and cost only $1,500 to $3,000. So the scalp reduction flourished among some cosmetic surgeons, who seemed to forget that patients were paying for the removal of their bald spots with pain, suffering, deformities (see Figure 12-3), and seemingly never ending surgeries.

Although thought to be an attractive solution for the bald male at the time, scalp reduction surgery has since fallen out of favor due to high complication rates, high failure rate with bald spot recurrence, poor aesthetic results, and a disgruntled patient population. This procedure brought out the worst of the doctor’s greed for the high surgical fees.

Dr. Mario Marzola tried to improve upon the scalp reduction by dissecting the scalp down to the level of the ears so that more of the lifted scalp could cover a wider defect. With his ability to stretch the sides of the scalp, he was able to remove a wider area of bald skin so the patient would, in theory, require less surgeries. In 1983, he performed the first scalp lift, but to maximize the amount of bald area he removed, he had to cut the nerves on the sides of the head leaving the entire scalp without feeling. Definitely not an acceptable side effect.

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Scalp reduction techniques

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