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Donor Area and Second Hair Transplantation
01/12/2023
Determining Factors for a Second Hair Transplantation Procedure
12/12/2023
This article addresses the challenging topic of hair transplantation into scarred tissues like the face and scalp of burn victims. In severely burned patients, hair can be a significant factor in the aesthetics of the surface. However, there are numerous factors that complicate successful hair transplantation in these patients. Among these are stiff and less elastic scar tissue, hypertrophic scars, keloids, reduced vascular perfusion in scar tissue leading to relative ischemia, and distortion of natural facial structures.
Jack Fisher's article titled 'Commentary on: Hair Transplantation in Burn Scar Alopecia After Combined Non-Ablative Fractional Laser and Microfat Graft Treatment' is under review. In the case of burns on the scalp, the tissue depth can be extremely thin. The article indicates that the mechanical properties of scar tissue in recipient areas make hair transplantation challenging by reducing graft survival. Burn scars lose their elasticity and do not easily retain grafts, unlike normal scalp skin. Moreover, in the case of scalp burns, the tissue depth can be extremely thin, and placing grafts might be difficult because they sit directly on the periosteum.
The authors of the article express difficulties in placing grafts closely together or at the correct angle in these challenging cases before utilizing fat transfer. When the recipient tissue is scarred, closely placed grafts tend to pop out. Also, having the correct angulation of grafts is crucial, especially in scalp and eyebrow areas. Thin recipient tissue can prevent grafts from sitting at the correct angle.
It's noted that attempting direct hair transplantation into burn scars without any prior treatment in these challenging patients resulted in unfavorable outcomes. The authors report a similar experience before implementing scar tissue management techniques for hair transplantation. Particularly in scalp transplantation where the burn scar is directly on the bone, this scar management issue is critical.
Normal scalp tissue has the necessary thickness and vascularity for hair transplantation. Thickness allows closely placed grafts, while a rich blood supply ensures graft survival and growth. However, these crucial properties are often lacking in burned scalp tissue.
Fat transfer in burn scars
The authors emphasize the importance of fat transfer in this group of patients. Fat transfer improves the mechanical structure of scar tissue and enhances blood flow. The benefits of fat transfer have been well-documented, particularly when used in irradiated breast tissue.
The changes that fat transfer can induce in scalp burn scars are often remarkable. The images of the patient in the article demonstrate the significant ability of fat transfer to dramatically alter both the vascularity and thickness of the scalp.
Four months after injecting fat between the scar tissue and periosteum, a hair transplant was performed on this 15-year-old female (same as in Figure 1). Prior to the fat injection, graft placement was not feasible. The scalp is now significantly thicker and healthier, evidenced by tissue bleeding.
This patient suffered extensive scalp burns as an infant. Despite undergoing several tissue expansion and scalp advancement procedures that significantly reduced the burn scar area, the remaining scar area was unresponsive to further interventions, resulting in very thin avascular tissue directly sitting on the periosteum. This avascular and thin scar tissue was unsuitable for hair transplantation. Small incisions were made in the scar tissue, revealing absence of bleeding and immediate contact with the bone tip of the blade. It was evident that any attempt at hair transplantation at this time would be unsuccessful.
The initial step in reconstruction involved fat transfers directly under the scar. The scar was lifted, and around 10 to 12 mL of fat was placed between the periosteum and scar tissue. The second photo shows the patient five months after the fat transfer, undergoing a hair transplant. The photo demonstrates a significant increase in the thickness of the scar tissue and a remarkable rise in vascularity as observed during the insertion of hair grafts. Attempting hair transplantation into severely scarred areas without first enhancing both the thickness and vascularity of the recipient area may have a high incidence of graft failure.
The protocol used by the authors consisted of multiple fat grafting sessions, usually at three-month intervals, until they considered the scar tissue to be soft and flexible. My own experience, primarily limited to scalp and eyebrow areas in burn patients, typically involves one or two sessions of fat transfers followed by allowing the areas to mature for at least 4 to 5 months. As expected, significant changes occur in the scar tissue during that time.
The authors performed hair transplantation using the follicular unit extraction technique, which has now become one of the major methods for performing hair transplants. In this article, they did an excellent job documenting the results using both subjective evaluations by the patient and third-party evaluators, along with objective hair growth analysis. Before transplantation, all their patients showed improvement in the scar tissue recipient areas following treatment with non-ablative fractional laser and fat transfer. The authors documented an average 85% hair growth survival rate. Considering the clinical situation with significant burn scars, this growth rate is excellent.
Benefits of microfat transplantation in other areas
The authors had previously reported using non-ablative fractional lasers and microfat grafting for managing hypertrophic scars and keloids in burn patients. They have now extended this treatment protocol to hair transplantation patients with facial burns. The authors have also reported on the use and benefits of microfat transplantation in other areas. Their reports not only include improvements in skin texture but also increased softness of scarred areas. Any plastic surgeon who has performed reconstructive surgery on facial burns knows that one of the greatest challenges is the loss of skin pliability.
Although I have experience using fat transfers in this patient group, I do not have experience combining it with non-ablative fractional lasers. The authors present a compelling argument for the benefits of combining these two modalities to maximally improve the recipient burn scar area.
The authors also discuss a procedure that has been applied in limited fashion in the United States, which involves the use of cryopreserved harvested fat. This allowed them to use stored fat for follow-up sessions of fat grafting. In my own experience, due to the ease of harvesting small amounts of fat when additional amounts are required, I usually perform another session of liposuction. While the concept of cryopreserved fat is interesting, it has not gained widespread acceptance.
In summary...
This article discusses hair transplantation in burn patients on the face and scalp. Hair loss in patients with burns can negatively impact the success rate of hair transplantation when scar tissue is present. The article explores the difficulties of hair transplantation in such patients and how methods like non-ablative fractional lasers and fat transfer can be used to improve the quality of recipient scar tissue before transplantation. This approach of first improving the quality of the recipient area and then performing hair transplantation is presented as a logical approach to these challenging cases.
