Is Hair Transplantation Always Successful in Secondary Cicatricial Alopecia?

Sir,

Secondary cicatricial alopecia refers to the destruction of hair follicles secondary to inflammatory processes such as kerion, trauma, burn, radiation therapy, carcinoma or metastatic deposition. It results in permanent hair loss when hair follicles are obliterated by fibrosis or hyalinized collagen. Surgical treatment is the mainstay of treatment in secondary cicatricial alopecia. Here, we report a case of hot oil burn-induced cicatricial alopecia treated by follicular unit transplantation.

A 20-year-old boy presented to us with a patch of alopecia on left parietal area for 18 years. There was a history of severe burn with hot oil on the affected area at 2 years of age. On examination, there was a patch of alopecia 3.5 cm × 7 cm on left parietal area [Figure 1a]. The skin was shiny, atrophic with loss of follicular ostia. A diagnosis of secondary cicatricial alopecia due to hot oil burn was made. The treatment was planned with hair transplantation with follicular unit transplantation. The strip of around 5 cm × 1 cm for donor hair was taken from the occipital scalp under tumescent anesthesia. The follicular units were transplanted on the recipient area with Kyungpook National University (KNU) implanter [Figure 1b]. There was regrowth of hair after 3 months [Figure 2a] and more growth was expected in due course of time. However, at 1-year follow-up, we noticed that there was no new growth of hair and the existing hairs also became thin [Figure 2b]. The surgical treatments for stable cicatricial alopecia are hair transplantation, scar excision, flap surgery or scar reduction with tissue expansion. The choice of treatment depends on the type of cicatricial alopecia, availability of donor's hair, scalp laxity; patient's healing characteristics and vascular supply.[1,2,3] Unstable cicatricial alopecia is secondary to disorders that have a tendency to progress and recur intermittently over the course of time. Therefore, it is essential to identify the type of alopecia and to confirm quiescence for at least 1-year.[1] The low blood flow in scarred area can cause infection, tissue ischemia and necrosis after surgery.[1,2] The vascularity can be assessed by giving multiple incisions with needle to see evidence of bleeding under local anaesthesia without epinephrine. In secondary cicatricial alopecia, the recipient site is completely bald, and there is a tendency for grafting high-density follicular unit/cm². This may lead to poor graft survival as the blood supply to scarred area is limited. Therefore in general it is not advisable to place high-density follicular unit/cm². However, higher hair concentration can be created by utilizing three and four haired follicular unit, follicular family or pairing of two smaller grafts into one incision.[4] In our patient, we did low-density follicular unit/cm² as there was evidence of poor vascular supply. The hair follicle transplantation on the scar tissue is more difficult than grafting on normal tissue because the scar is accompanied by poor blood circulation and stiffness of tissue.[5] The hair regrowth in our patient was not satisfactory at 1-year, which is due to poor blood supply on the recipient area. Excision would be a better option of treatment in this type of the linear scar.

Figure 1.

(a) Patch of secondary cicatricial alopecia; (b) Immediate posthair transplantation

Figure 2.

(a) Hair regrowth at 3 months; (b) Hair regrowth at 1-year

In our patient, the graft placement was done by KNU implanter as it helps in gentle handling of the grafts. Though hair transplantation gives a satisfactory result in scarring alopecia, patient may need subsequent hair transplantation for the aesthetically better result. The patient should be informed about the possibility of the poor result of hair transplantation in scarring alopecias.