Fan Jin-Cai, Wang Ji-Ping
Ninth Department of Aesthetic Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing 100144, China.
Zhonghua Yi Xue Za Zhi. 2009 Apr 28;89(16):1098-101.
To investigate the proper ways to manage a large cicatricial scalp alopecia.
Based on the location, size and condition of the scarring lesions, 218 patients with 20 - 75% scarring alopecia were selected and treated with either dense-packing hair grafting technique (136 cases) or tissue expansion (82 cases). There were 209 in burn, 5 in avulsed injury and 4 in tumor excision. The lesions with thick, stable scars in the frontal or/and temporal areas undergoing either hair grafting or tissue expansion process as desired by the patients. In addition, the alopecia in an unstable scar on the skull, with skull defect under the lesion and the lesion involved in the back of the head was only treated with tissue expansion. The hair-grafting technique was carried out by harvesting a scalp strip from the back of the head, then dividing it into a series of 1 - 3 hair grafts and finally implanting them into the prepared recipient holes of the lesion with a desired hair direction. Ten areas with 1 cm(2) size in 10 patients were randomly selected to examine the hair survival over 8 months post-operation. Tissue expansion was performed by firstly positioning a tissue expander in the subgaleal pocket of the scalp and serially inflating it with normal saline in 5 - 7 days intervals for about 3 months. Thereafter, an expanded scalp flap was designed, with the combination of advancement and rotation flap transplantation principles, to be transferred to the recipient site after lesion removal.
In patients with hair-grafting technique, hair density reaching 60 - 80 hairs/cm(2) per session. Over 8-months following-up, the grafted hairs grew good with 98% hair survival. Forty-five patients with 20% - 30% scalp hair loss were reaching very satisfactory results with only one session while 91 patients with 31% - 50% hair loss were needed a second session to improve their appearance. In those with tissue expansion, 56 patients with 20% - 50% scalp loss were managed in one session and 26 patients with 51% - 75% scalp loss needed secondary tissue expansion. All of the expanded hair-bearing flaps survived well with only minimal complications (9.8%) of the infective dome explosion in 3, slight skull depression in 2, seroma in 5 and early infection in 1.
Either hair grafting or tissue expansion is proven as a safe and effective technique for restoration of large cicatricial scalp alopecia. The former technique could be of benefits to simple, mini-surgical procedure, natural hair growth and good for lesion size under 30%. And the letter technique shows wider clinical indications, especially for the patients with unstable scar, skull defect under lesion and lesion over 50%. But the obvious drawbacks are multi-clinic visiting, disfigurement and long-term procedures.
探讨大面积瘢痕性头皮脱发的合适治疗方法。
根据瘢痕性病变的位置、大小和情况，选择218例瘢痕性脱发占20%-75%的患者，分别采用毛囊单位密集移植技术（136例）或组织扩张术（82例）进行治疗。其中烧伤后瘢痕性脱发209例，撕脱伤后5例，肿瘤切除术后4例。对于额部和/或颞部有厚而稳定瘢痕的病变，根据患者意愿进行毛发移植或组织扩张。此外，对于颅骨上不稳定瘢痕、病变下方有颅骨缺损且病变累及头后部的脱发，仅采用组织扩张术治疗。毛发移植技术是从头部后方取一条头皮条，然后将其分割成一系列1-3根毛囊单位，最后按照所需毛发方向将其植入病变部位预先准备好的受区。随机选取10例患者，在其病变部位取10个1平方厘米大小的区域，观察术后8个月毛发存活情况。组织扩张术是先将组织扩张器置于头皮帽状腱膜下间隙，每隔5-7天用生理盐水依次扩张约3个月。此后，根据推进皮瓣和旋转皮瓣移植原则设计扩张头皮瓣，在切除病变后转移至受区。
采用毛发移植技术的患者，每次移植后毛发密度可达60-80根/平方厘米。术后8个月随访，移植毛发生长良好，毛发存活率达98%。45例头皮脱发20%-30%的患者仅需一次移植即可达到非常满意的效果，而91例脱发31%-50%的患者需要进行第二次移植以改善外观。采用组织扩张术的患者中，56例头皮脱发20%-50%的患者一次手术即可完成治疗，26例脱发51%-75%的患者需要二期组织扩张。所有扩张后的含毛发皮瓣均存活良好，仅出现轻微并发症（9.8%），包括3例感染性皮丘破裂、2例轻度颅骨凹陷、5例血清肿和1例早期感染。
毛发移植和组织扩张术均被证明是修复大面积瘢痕性头皮脱发的安全有效技术。前者适用于简单、微创的手术，能实现自然头发生长，且对病变面积小于30%的情况效果较好。后者临床适应证更广，尤其适用于瘢痕不稳定、病变下方有颅骨缺损及病变面积大于50%的患者。但其明显缺点是需要多次门诊就诊、存在外形改变且治疗过程较长。
