ISSN Online: 2177-1235 | ISSN Print: 1983-5175
The authors present a clinical case of sideburn reconstruction following the removal of a skin tumor. Resection of the tumor resulted in a large, superficial surgical wound. A full-thickness glabrous skin graft was placed over the temporal region, with a partial amputation of the sideburn. Two sessions of hair transplantation, using follicular units, were performed, transplanting hair grafts to the skin graft, thus reconstructing a temporal hairline with the same characteristics as the opposite side burn. Hair transplantation remains an interesting and relatively simple method to reconstruct atypical cases of alopecia.
Hair transplantation; alopecia; reconstruction of hairline
Os autores apresentam um caso clínico de reconstrução da região pilosa temporal e da linha pilosa temporal anterior (i.e., costeleta) após a ressecção de neoplasia cutânea. A exerese tumoral resultou num grande defeito de superfície, que foi tratado com um enxerto de pele total da região inguinal. Esta reconstrução ocasionou a amputação parcial da área pilosa temporal, com acentuado defeito estético. Duas sessões de microenxertia foram realizadas, com um transplante de aproximadamente 360 unidades foliculares sobre o enxerto de pele. Obteve-se como resultado final uma área pilosa e uma linha de implantação de boa densidade, com as mesmas características da região temporal contralateral. Os autores concluem que o transplante de cabelo é um método eficaz de reconstrução de áreas glabras em couro cabeludo.
Transplante de cabelo; alopécia; reconstrução de couro cabeludo
A 68 year-old woman (N.L.V) presented to the second author (CAJ) in May 2000 with a large skin tumor, located over the right temporal region (Fig. 1). This lesion had suffered three previous resections, and its recurrence had been noticed by the patient 6 months previously. The tumor measured approximately 28 cm2 (7.0 X 4.0 cm). The clinical aspect suggested a malignant tumor (a basocellular epitelioma), and an excisional biopsy was indicated. This was performed in a hospital setting, as an outpatient procedure, with local anesthesia and endovenous sedation. Resection included a wide margin of safety, removing tissue down to the temporal fascia. A pathologist assured complete removal of the tumor during surgery. A wound of approximately 42 cm2 was created, and a full-thickness skin graft was harvested from the lower right abdomen, taking care not to include any pubic hair. This graft was placed over the wound, secured by sutures with a tie-over dressing. One week postoperative, the dressing was removed, and the graft was observed to have taken completely.
Fig. 1 - The skin tumor before surgical resection.
On a late postoperative visit, the patient mentioned that the defect to the hair-bearing scalp on the right temporal region caused aesthetic discomfort, and reguested reconstruction of the sideburn. Hair transplantation was mentioned by the surgeon as the most efficient alternative. She was referred to the other author (HNR). On inspection, an area measuring 40 cm2 of hairless skin (part of the full-thickness graft) was noticeable in the hair-bearing scalp (Fig. 2). The patient was told that at least two sessions of hair transplantation would be necessary to complete full hair density, and she agreed to this.
Fig. 2 - A full-thickness skin graft: was used to cover the surgical wound. Demarcation of the temporal hairline is seen.
The area of transplantation was demarcated, by transferring the limits of the opposite sideburn (Fig. 3). Under local anesthesia, a first session of hair transplantation was performed on February 2001 (i.e. 9 months foliowing the tumor removal with skin grafting) , with a total of 120 follicular grafts placed on the skin graft. Donor area was the posterior aspect of the scalp (i.e. the lateral right occipital region), where hair density was greatest. Care was taken not to place the grafts toa closely, as risk to the skin graft was a prime consideration. Nevertheless, bleeding was noticed in every orifice created to place the individual grafts, and the viability of the skin graft was seen to be excellent at the end of the procedure (Fig. 4).
Fig. 3 - The contra-lateral hairline is used to demarcate the right temporal region.
Fig. 4 - Recipient sites are prepared, respecting the angle and direction of hair growth.
The patient returned six months postoperatively. Hair growth was visible, yet density was less than desired. A second procedure was performed, which included the placemem of 240 follicular grafts. These were inserted between existing transplanted hairs. The donor site was the same as in the first session.
The patient had an uneventful follow-up. At three months postoperative she noticed the beginning of hair growth, and returned for final evaluation seven months after the second session. She referred complete satisfaction with the aspect and design of the sideburn, and the density of the transplanted hair. She did not wish to have a further session of hair transplantation (Fig. 5).
Fig. 5 - The patient is seen after six months following the second session of follicular unit transplantation.
Hair transplamation is currently one of the most freguently performed aesthetic procedures in the male population. There are two main reasons for its popularity: results are considered extremely natural and the correct surgical technigue has been mastered by a large number of plastic and dermatological surgeons. The transfer of very well prepared grafts without any excess surrounding skin (i.e. follicular units) assures that the transplanted hair maintains all of its characteristics (texture and cycle of growth). lndividualized hair shafts are therefore almost indistinguishable from native hair.
Follicular unit transplantation has also been applied in situations other than male or female-pattern baldness, which may be called atypical alopecia, and has been addressed by many authors(1-10). Among these is the correction of the sideburn, in women that have been submitted to one, more usually two or three, ritidoplasties. Due to excessive traction on facial flaps, these patients will invariably complain of an increase in the distance between the temporal hairline and the lateral eyebrow, with a conseguem "pulled back" look (also called the lizard-face aspect).
Another common complaim in this population is the presence of a pre-trichial incision in the temporal region or a visible scar along with an interruption of the posterior, cervical hairline. Transplantation of well prepared grafts, comaining no more than 3 or 4 hair follicles, becomes a very useful method to reconstruct the sideburn, to camouflage the visible scars, and to hide the step-off in the cervical region.
Reconstruction of the temporal hairline reguires a final result with the following aspects: a delicate quality; good density and design; hair shafts that grow in a slanted direction, allowing the patient to comb back hair. Although several alternatives are available (such as tissue expansion with flap rotation or even flap rotation without previous tissue expansion), hair transplantation is considered the most favorable solution for most of these cases.
A few technical aspects regarding hair transplantation to this region deserve further considerations. Implantation to the sideburn demands that the final growth of hair be at an acute angle, imitating the natural direction of this region. This requires precise angulation of the needles that are used to create the orifices. These tiny slits are made with an 18-gauge NoKor needle (for the larger grafts) and a 40X12 18G gauge needle (for the single-unit follicular grafts). The hair follicles must be delicately handled throughout the procedure, from the harvesting to the placement, being careful not to traumatize the grafts by trimming excessively(i.e."skeletonization") during preparation, or by an exceedingly forceful insertion in the recipient area.
In this specific case, where follicular units were placed in a full-thickness skin graft, there were two concerns: that the recipient site be adequate (permitting the hair grafts to take and then grow), and that the multiple orifices did not cause interruption of the vascular supply to the skin graft. Both of these considerations proved not to be of concern, as the skin graft survived with no visible ischemia, and hair growth was noticed to be normal after six months. Having observed the absence of any untoward result, it was then considered safe to place a larger quantity of hair grafts in the second session, thus doubling the amount transplanted in the first session.
A full-thickness skin graft was used to cover a large surgical wound secondary to tumor resection in the right temporal region, creating a defect to the temporal hairline. As a secondary procedure sixmonths later, a total of 360 follicular units were placed on the skin graft in two sessions, resulting in a sideburn with the following natural characteristics: good density and design; delicate quality of hair; well-angulated hair shafts. The authors believe that no other technique is capable of creating such a natural-looking temporal hairline.
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I - Assistam professor of the Post-Graduate Course in Plastic Surgery of the Pontifícia Universidade Católica do Rio de Janeiro and the Instituto de Pós-Graduação Médica Carlos Chagas. Member of the Brazilian Society of Plastic Surgery.
II - Assistant professor of the Post-Graduate Course in Plastic Surgery of the Pontifícia Universidade Católica do Rio de Janeiro and the Instituto de Pós-Graduação Médica Carlos Chagas. Member of the Brazilian Society of Plastic Surgery Member of the Brazilian Military Academy of Medicine.
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