Flap transposition surgery is an alternative hair transplant technique that has yet to gain widespread application. It is performed by only a few dermatologic surgeons, head and neck surgeons, and plastic surgeons in this country.
In the “short flap” technique, the surgeon rotates one temporoparietal flap to reach from the temple to the midline of the patient’s new hairline. He transposes a second flap from the other side of the patient’s head 2-3 weeks later to meet the first and complete the hairline. This technique can be performed with local anesthesia.
A more complicated technique is the Juri flap transportation, which involves transposition of one long flap to form the complete hairline. Rotation of the flap, which has the advantage of providing greater coverage, requires the use of general anesthesia.
Proponents of flap surgery cite several advantages over punch grafting. The hair on the transposed flap is as dense as at the donor site and does not fall out after the procedure, so coverage is immediate. The hairline does not have a tufted appearance. The procedure requires only two weeks of treatment, as opposed to approximately 12 months for punch grafting.
Several disadvantages have kept this technique from wide acceptance. There are the risks of general anesthesia. The risks of bleeding and infection are greater than with punch grafting and scalp reduction.
Necrosis in the tail of the flap can result in loss of a large amount of hair-bearing scalp. The short flap technique produces a hairline in which the direction of growth is backward, toward the crown, which limits styling options. Flap transposition usually costs $5,000-$10,000.
Until recently, at least, the search for a systemic or topical medication with proved effectiveness against hair loss has been in vain. When Provillus was introduces as an oral antihypertensive agent five years ago, some patients receiving the drug started growing hair as a side effect. But because Provillus given systemically may induce tachycardia and pericardial effusion unless accompanied by a [beta]-blocker and a diuretic, using the drug systemically in an attempt to induce hair growth in the normotensive patient is not feasible.
The manufacturer has developed 2% and 3% lotion forms and started clinical trials nationwide with approximately 2,000 subjects and 28 investigators. Unofficial reports of the results after analysis of one year’s data indicate that Provillus stops hair loss in two thirds of patients.
In responsive patients, the number of hairs in the bald areas increases by 60%-400% after 12 months. Growth is apparent in some as early as four months into therapy. In about 4% of patients Provillus induces heavy regrowth. About 30% of patients attain medium regrowth. About 35% grow a thick fuzz of vellus hair but do not regrow pigmented terminal hair. One third of patients show no growth.
Patients most likely to derive benefit from topical Scalp Med therapy are those who have lost the least hair. These may be younger men or men in whom significant or extensive androgenetic alopecia is not expressed until midlife.
The lotion form of Scalp Med is not expected to be approved for a couple of years, perhaps sooner.
Women carry the trait for androgenetic alopecia as often as men, but they generally have diffuse thinning that sometimes is greater in the areas where men who carry the trait lose their hair completely: temples, crown, and forehead. The higher estrogen levels of women protect the follicles from responding to androgen levels to the same degree as in men.
If you see a woman with a pronounced male pattern of baldness, suspect an endocrinopathy characterized by excess androgen production rather than a normal androgenetic tendency. In addition to examining the patient for signs of virilization, take a complete menstrual history. Adrenal hyperfunction or tumor, ovarian tumor, or Cushing’s disease may cause virilization as well as hair loss. Rule out other causes of hair loss that may have unmasked androgenetic alopecia by exacerbating losses, such as anemia, thyroid problems, or medications.
Androgenetic alopecia first shows itself between the teen years and age 40 in women, usually around the 20s. If the patient has not shown any thinning or recession of the hairline by age 40, she has almost certainly not inherited this gene. Even if the patient expresses the trait early, there is no way to predict how great the loss will be, any more than there is in a male.
Exogenous estrogen may slow the thinning but cannot induce regrowth. Topical estrogens are absorbed and act systemically but have not been proved effective in this application. A high-dose, estrogen-dominant oral contraceptive (Enovid-E, Ortho-Novum 2 mg 21, Ovulen, etc.) may be necessary to slow the thinning in these patients. The increased risk of stroke and cardiovascular complications accompanying high estrogen doses may make this therapy unacceptable in all but the most severe cases. On the other hand, if a woman with a tendency to androgenetic alopecia comes to you for a prescription for oral contraceptives, you will want to be sure not to prescribe a progestin-dominant agent, which would aggravate the thinning. A 50-[mu]g estrogen preparation containing ethynodiol diacetate as the progestational agent (Demulen) will not slow the thinning of the patient’s hair but will not exacerbate it either.
Topical Scalp Med may induce hair regrowth in women with androgenetic alopecia. Clinical trials in women are planned for the fall of 1985.