1. Management of Alopecia Kyle Kennedy, M.D. Karen Calhoun, M.D. September 9, 1998

2. Introduction n alopecia affects both men and women n variety of causes n substantial emotional impact n medical and surgical therapy available n realistic treatment plan

3. Etiology of Alopecia n trauma n burns n neoplasms n autoimmune disorders n chemotherapy n dermatologic conditions n androgenetic alopecia

4. Androgenetic Alopecia n most common cause of alopecia n three distinct forms recognized-MPAA, FPAA, diffuse AA n caucasians most commonly affected n mode of inheritance unclear n terminal hairs to vellus hairs n presence of androgens (esp. DHT) essential n mechanism of action on follicles unclear

5. Patient Selection n general history and physical examination n patient’s motivations and expectations n discussion of Tx options and limitations n pattern of alopecia incl. frontal hairline and donor hair n conservative approach n older patients typically better candidates

6. Treatment Options n medical n non-surgical hair restoration n surgical hair restoration

7. Medical Management n antiandrogens n biologic response modifiers

8. Antiandrogens n spironolactone n cyproterone acetate n cimetidine n estrogen and progesterone n finasteride (Propecia)

9. Biologic Response Modifiers n minoxidil (Rogaine)

10. Surgical Management n punch-graft hair transplantation n minigrafts and micrografts n scalp reduction n extensive scalp reduction n tissue expansion n transposition flaps

11. Punch-Graft Hair Transplantation n autografts n standard plugs 4 mm diam. n multiple sessions n adequacy of donor sites-finite number of donor hairs n technique

12. Minigrafts and Micrografts n minigraft-3 to 8 hairs each, created from quadrisection of 4.5 mm diam. grafts n micrografts-1 to 2 hairs each, created from periphery of standard punch grafts

13. Scalp Reduction n various patterns-midline sagittal ellipse, Y, and lateral n reduce area of alopecic scalp with elevation of temporal fringes toward midline n reduce recipient:donor ratio n ideal-older pt with stable mild to moderate area of alopecia of crown/vertex

14. Extensive Scalp Reduction n differ from standard scalp reduction in degree of undermining required n usu. combination of bilateral occipitoparietal and bitemporal flaps n remaining frontal alopecic areas are hair transplanted n technique n increased incidence of complications

15. Tissue Expansion n scalp reduction or advancement limited by poor scalp flexibility n scalp stretched with redistribution of donor hair over wider surface area n variety of expanders available n repeated injection and discomfort, temporary scalp deformity

16. Transposition Flaps n relatively rapid restoration of frontal hairline n Juri flap-pedicled on superficial temporal artery n multiple stages n technique

17. Complications n cobblestoning n divot/delling n compression n cyst formation n telogen effluvium n folliculitis n arteriovenous fistula n pyogenic granuloma

18. Complications (cont.) n stretch back n slot defect n scalp necrosis n inappropriate shape of hairline n inappropriate hair direction n hair loss

19. Summary n conservative approach n realistic treatment plan n long-term commitment n expect the worst n the more you need, the less you have