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If you gradually
expand skin over a
period of time, the
pressure exerted on
the skin actually
stimultaes new
tissue to grow. The
most common example
of this is
pregnancy, when the
abdominal skin grows
to accomodate the
enlarging baby. This
same concept can be
applied to treat
bald areas of the
scalp.
There are currently
2 methods of Scalp
Expansion :
1) Scalp
expansion surgery
using a balloon-type
device implanted
under the scalp
which is called
volumetric scalp
expansion.
Volumetric scalp
expansion surgery
employs the concept
of tension induced
tissue growth to
increase the area of
hair bearing skin,
and then use that
new hair-bearing
scalp to cover the
balding area. Skin
has an enormous
capacity to expand
in response to
under-the-skin
pressure. The degree
to which scalp
tissue can expand in
response to
under-the-scalp
pressure is seen
naturally in people
who have untreated
hydrocephalus or
large epithelial
tumors of the scalp.
A more common
example of skin
expansion in
response to
under-the-skin
pressure is the
remarkable ability
of skin to "stretch"
during pregnancy.
2) Scalp
expansion using
implanted physical
instrumentation
which is called
nonvolumetric scalp
expansion or scalp
extension. This
procedure is
pioneered by Dr.
Patrick Frechet of
Paris, France.
The expansion and
excision of bald
scalp creates the
conditions for
subsequent
approximation of
hair-bearing scalp
to cover the area of
bald scalp excision.
The man most likely
to benefit from
bald scalp excision
and hair-bearing
scalp advancement is
one who :
A) Has enough
hair at the sides
and back of the head
to provide adequate
coverage after bald
scalp excision, and
B) Does not
have rapidly
progressive
male-pattern hair
loss.
Although hair
transplantation is
by far the most
commonly performed
type of surgical
hair restoration
procedure, some
patients may be
candidates for scalp
reduction or scalp
flaps. Some surgeons
advocate the use of
these procedures in
some patients, and
the procedures may
be choices
recommended by a
surgeon in selected
patients. The scalp
reduction of scalp
flap procedures can
be performed with or
without scalp
expansion.
The basic principles
of volumetric scalp
expansion are :
1) expansion
of the bald scalp
over a period of
time with a
balloon-type device
implanted under the
scalp. The actual
expansion procedure
involves simply
inserting a needle
into a valve in the
expander and adding
fluid. It is not
painful, although
you may feel some
uncomfortable
tightness or aching
for a few hours or a
day after your
expansion. Common
over the counter
pain relievers such
as Tylenol should be
all you need to
control any
discomfort.
Expanders fully
inflated before
remova and
definitive surgical
procedure.
2) collapse
and withdrawal of
the device when
scalp expansion
reaches a
predetermined
extent,
3) excision
of the excess scalp
skin
Incisions are made,
the expanders are
removed ,the bald
scalp is cut out.
4) advancement of
hair-bearing scalp
to cover the area of
bald scalp excision.
Baldness reduced
after scalp
expansion.
A tissue expander is
a balloon that is
placed beneath the
scalp. Over a period
of weeks or months,
saline (salt water)
is gradually added
to the balloon to
slowly inflate it.
As the balloon is
inflated, it puts
tension on the skin.
Within a few days,
the scalp seems to
relax as new skin
grows in response to
the tension. Once
the scalp is lax
again, more fluid is
added and the
process is repeated
until enough
hair-bearing scalp
is present to cover
the desired area.
An implantable
balloon-type scalp
skin expander was
first used for
medical purposes
about 25 years ago
to facilitate
surgical removal of
a tattoo. By the
early 1980s the
technique of tissue
expansion and bald
scalp excision was
being pioneered at
Hershey
(Pennsylvania)
Medical Center for
treatment of massive
scalp defects in
children. By the
mid-1980s the
technique was being
used by physician
hair restoration
specialists to treat
selected patients
with male-pattern
hair loss.
Volumetric scalp
expansion begins
with the insertion
of a Silastic (non
tissue reactive)
envelope beneath the
scalp. The envelope
is inserted into the
subgaleal plane, a
space of loose
tissue between the
overlying scalp and
the blood
vessel-rich tissue
underneath. The
subgaleal space is
nearly devoid of
blood vessels, so
insertion of the
envelope causes
little bleeding and
does not compromise
blood or nerve
supply to the scalp.
As a rule, envelopes
are inserted on
right and left sides
of the head to fit
the distribution of
bald scalp.
About two weeks
after insertion of
the device(s), a
small amount of
saline fluid is
injected into the
envelope(s) through
self-sealing ports
to begin inflation
of the devices and
to begin the process
of scalp expansion.
Injections of saline
are repeated at
intervals over
succeeding weeks and
the scalp responds
by expanding. If
there are scalp
expanders on
opposite sides of
the head they may be
injected in
alternate weeks.
Volumetric scalp
expansion causes a
visible change in
head shape as the
device(s) inflate.
After the expander
(or expanders) are
placed in the first
operation, you will
begin the expansion
phase. During this
stage, your head
will begin to look
more and more
distorted as the
expanders are
inflated. Friends
and relatives can be
prepared for this
temporary change.
Strangers may be
less prepared. It
will likely be
necessary to wear a
hat to conceal your
oddly-shaped head. A
good relationship
between patient and
physician hair
restoration
specialist can
prepare the patient
for managing any
psychological,
emotional or social
problems that may
arise during the
temporary period of
scalp expansion.
When scalp expansion
is judged to be
satisfactory the
devices are drained
and removed. The
patient is taken to
an operating room
for:
1) gathering
expanded bald scalp
into a "pleat" for
excision,
2) excising
the pleated bald
scalp,
3) advancing
hair-bearing scalp
to cover the areas
of excised bald
scalp,
4) suturing
the hair-bearing
scalp to create a
total or near-total
correction of hair
loss.
Individual patients
may require
follow-up treatment
such as "fill-in"
hair transplantation
and use of hair
restoration
pharmaceuticals (minoxidil
or finasteride) to
achieve the maximum
cosmetic
improvement.
"Fill-in" hair
transplantation may
be made more
difficult and costly
by scalp expansion
and excision,
however; bald scalp
excision and
hair-bearing scalp
approximation may
reduce the number of
donor follicles that
can be harvested in
a single
transplantation
session, thus
increasing the time
and dollar
investment of
"fill-in" hair
transplantation.
Patients can usually
shower and shampoo
the day after
surgery, not waiting
until sutures are
removed. Healing
takes place over the
following two to six
weeks. Postoperative
bleeding and
infection are
potential
complications of
volumetric scalp
expansion and bald
scalp excision.
Sometimes a
postoperative scar
forms at the site of
hairline suturing. A
scar can be revised
later to make it
inapparent, but
revision is more
technically
difficult when the
scar is a so-called
"slot defect" that
forms where two
previously
non-adjacent areas
of scalp are sutured
together
recovery
- After scalp
expanison surgery,
you will have
prescriptions for
antibiotics to
prevent infection
and pain pills to
control discomfort.
Many patients do
fine with
acetaminophen
(Tylenol) after
surgery and do not
require stronger
medication.
risks
- Scalp expansion
surgery can result
in infection,
scarring, or rarely,
insufficient blood
supply during the
expansion phase that
leads to loss of
part of the flap.
results
- Once the new
hair-bearing scalps
is in place, it will
continue to remain
just as if it were
in its original
site. Scalp
expansion surgery
does not stop hair
loss, and you will
continue to lose
hair just as you
would have if you
had not had the
scalp expansion
surgery, but usually
the effects will
last 10 to 20 years
or more.
The most obvious
drawback of scalp
expansion surgery is
the period of weeks
or months in which
the balloons are
inflated and your
head takes on an
oddly-shaped
appearance. For this
reason, scalp
expansion surgery is
nowadays very
uncommon.
Nonvolumetric scalp
expansion is
accomplished with a
physical device.
Expansion may be
over a period to
time (one to three
months) using a
stretchable band
implanted in the
subgaleal space
under constant
tension. Scalp
expansion may also
be accomplished
during a scalp
reduction procedure
using a
skin-stretching
device.
Scalp extension
allows scalp
reduction to be
performed with much
greater effect and
allows previously
determined
non-candidates to
have successful
scalp reductions.
Basically, it
involves the use of
a surgical device,
made of two rows of
hooks connected by
broad-based elastic
bands, that is
placed on the
undersurface of the
scalp during the
first scalp
reduction. Over a
one-month period,
elastic recoil
causes a constant,
gentle upward pull
of the hair-bearing
tissues, thereby
loosening and
stretching the
scalp. This allows
for another, and
usually greater,
scalp reduction to
be done. The scalp
extension process
can be repeated.
With scalp
extension, the
complete series of
scalp reductions can
be done within a 30-
to 90-day period.
In the past, some
scalps could not be
reduced at all and
those that could be
reduced often took
as long as 1 1/2
years for the
procedures to be
completed.
Scalp extension has
some of the benefits
of scalp expansion,
although the amount
of tissue stretch is
less. Its great
advantages are that
it causes little or
no discomfort and
deformity. It is a
relatively simple
procedure, thereby
adding little time
and difficulty to
the scalp reduction
operation.
Scalp
reduction–extender
is to be inserted.
Scalp reduction
completed–extender
in place.
After 4 weeks(sides
of scalp stretched).
Extender removed.
results after second
reduction.
Advantages
cited for the
implanted
nonvolumetric scalp
expander include:
1) 50%
increase in the
amount of bald scalp
removed in scalp
reduction
2) fewer
procedures are
needed to accomplish
a final result
3) reduced "stretchback"
of scalp skin and
subsequent scarring
4) reduced
postoperative hair
loss
5) early
development of
postoperative scalp
laxity
Potential
complications and
side effects
of nonvolumetric
scalp expansion
include:
1) mild to
severe pain during
the first 24 hours
after the
scalp-expanding
device is implanted
2)
occasional bruising
or edema in scalp
over the implanted
device
3) reduction
in the number of
donor grafts that
can be harvested per
session later for
"fill-in"
4) hair
transplantation
should this be
needed to achieve
the desired hair
restoration goal
5)
postoperative
scarring at the site
where hair-bearing
scalp is sutured
together - most
difficult to revise
when the scar is a
so-called "slot
defect" the forms at
the site where two
previously
non-adjacent scalp
areas are now joined
by suturing
6)
postoperative
drainage and delayed
wound healing for up
to several weeks
7) rarely,
infection in the
tissue around the
implanted device
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