Follicular Unit Extraction in Management of Secondary Cicatricial Alopecia

INTRODUCTION

The term "cicatricial alopecia" refers to a scarring that ends up with loss of hair that outcomes from a various set of disorders that devastate the hair follicle, substitute it with scar tissue, and cause persistent hair loss. ¹

Cicatricial alopecias are sorted as primary and secondary. In primary cicatricial alopecias the stable portion of the hair follicle (stem cells of the bulge area and the infundibulum) is the target of the destructive inflammatory disease and the cause varies from autoimmune diseases Lichen Plano Pilaris (LPP), Discoid Lupus Erythematosus (DLE), pseudopelade of brocq), to infections like folliculitis decalvans.²

Secondary cicatricial alopecias, result from damage of the  hair  follicle  subsidiary  to  a Non-follicle-directed

process or external injury, such as burns, radiation, trauma or severe infections like tinea capitis.³

Surgical correction of cicatricial alopecias is highly valuable. While the affected area is most often treated with hair transplantation, alternative approaches include alopecia reductions (the excision of the hairless region) and/or flap procedures, alone or sometimes in conjunction with hair transplanting.¹

The era of hair restoration surgery commenced in Japan with techniques developed to treat burn survivors. In the 1930s, Okuda published his technique of transplanting hairs derived from punch grafts.⁴

Hair transplant consists of harvesting hair from a donor area (usually the occipital and posteroparietal scalp) using a single strip excision or small punch excisions used to harvest individual follicular units (FUE) and grafting them into the recipient site.⁵

Hair transplantation has proven efficacy in cases of androgenetic alopecia with the advantage of minimal scarring, but it requires good donor area, the application of this method has been adebate in many studies in the face of traditional methods of scar excision, tissue expanding & flap surgeries.⁶

Aim of the work was to assess results of Follicular Unit Extraction in management of secondary cicatricial alopecia.

PATIENTS AND METHODS

This interventional clinical study – prospective cohort study, on 20 patients with secondary cicatricial alopecia. These Patients were operated upon in the Plastic surgery and burn department, Al-Azhar University Hospitals and were referred to our outpatient clinic for follow up visits.

All patients were subjected routinely to Consent and routine clinical assessment and pre-operative investigations.

Inclusion criteria: Age range 15 to 35 years old, having secondary cicatricial alopecia, and scalp defect from area 5cm² to 45 cm².

Exclusion criteria: Patients with total loss of scalp area, patients under 15 years old and over 35 years old, patients with cardiac disease, patients with blood diseases, and patients with liver viral infections.

Pre-Operative Preparation:

Hair shaving on a length of 1mm over the skin: Patient should have a shower in the day of the operation and to be operated under complete aseptic condition. The patient should wash his head completely with Betadine (Bovidine Iodine) Shampoo just 10 minutes before surgery and drying with dry sterile towels.

Pre-operative photographing: Recording the vital signs of the patient (Pulse, B.P.) one hour pre-operatively was done to know his/her base line and to detect any abnormalities in vital signs during surgery.

Pre- Operative medication: Intravenous Canula. 500cc glucose as slowly drips. Analgesics and sedatives: Phenaramine 2 mm³ I.V. one hour pre-operatively as a sedative and anti-allergic together with IM. Injection of non-steroidal anti-inflammatory analgesic, Diclofenac sodium 75mg tab as moderate pain killer during the operation and to minimize the Post-operative pain. Combined prophylactic Broad spectrum antibiotics to guard against gram +ve and gram -ve organisms such as: Sulbctam and Amoxicillin 1.5gm vial IV, Gentamycin 80mg Amp.

Post-operative treatment and follows up:

All patients are given Broad spectrum antibiotics Sulbctam and Amoxicillin 1.5gm vial IV for one week. Oral analgesic is prescribed in the form of NSAIDs Ibuprofen 600mg tab t.d.s. for one week. H2 blocker (Ranitidine 150 mg Tablet) twice daily is prescribed to prevent any gastro-intestinal upset with medication.  Some patients are advised to put ice bags over the eyes and forehead for the 1st 48 hours to prevent oedema. The first Post-operative dressing was done 3 days later, the patient came to the outpatient clinic and the dressing is removed very slowly under running saline. The patients start washing the scalp by anti-dandruff shampoo 3 days after dressing removal. Patients are given vitamin B₇ (Biotin 10000 IU) once daily for 6 months. Two cases received monthly platelet rich plasma injection to the recipient area for 6 months. Photographing of both donor and recipient areas at every visit.

Patient Satisfaction:

All patients are subjected to a five point questionnaire –after six months follow up- measuring their opinion in:

The surgery they underwent,

Hair density at the treated area,

Proper hiding of the scars post operatively,

Hair direction related to its new position

How much they advise other patients with same degree of cicatricial alopecia to go for the same surgery. 

Statistical analysis:

Statistical analysis Data were analyzed by Statistical Package of Social Science (SPSS), software version 22.0 (SPSS Inc., 2013). Continuous data were expressed as Mean ± SD, while the nominal data were presented by the frequency and percentage. The unpaired-samples t-test (independent t-test): compares the means between the two groups of patients regarding age, Surface area of alopecia (Cm²), Time since injury (years) and Operative duration (hours). The chi-square test of association is used to discover if there is a relationship between the duration of operation and incidence of complication. In addition, it was used to distinguish the association between the size of alopecia and incidence of complication. - The Fisher's exact test: is used instead of a chi-square test if one or more of the cells has an expected frequency of five or less. In all testes used P value < 0.05 considered significant.

RESULTS

Among the studied cases there was sixteen (80%) males and four (20%) females, the mean age of the studied cases was 18.85 (±2.94 SD) with range (15-25) years.

According to cause of injury among the studied cases there were nine (45%) due to trauma scar, one (5%) due to surgical scar, two (10%) due to post expander and eight (40%) due to burn and according to cause of injury among the studied cases there were five (25%) temporal, four (20%) parietal, two (10%) occipital, three (15%) frontal, three (15%) temp + parietal, two (10%) at occipital + sagittal and one (5%) frontal + temporal.

Among the studied cases there were eighteen (90%) who had one operation and two (10%) who had two operations, with mean operation time 3.05 (±1.40 SD) with range (1-5.5) (Table 1).

The mean number of grafts of studied cases was 420.0 (±276.92 SD) with range (150-1200). The mean area of the alopecia of studied cases was 17.15 (±9.92 SD) with range (5-45) cm². The mean survived/inserted% of studied cases was 74.91 (±8.08 SD) with range (60-85.58). The mean time since injury of studied cases was 11.45 (±6 SD) with range (2-20) (Table 2).

According to general outcome there were two (10%) bad, six (30%) good and twelve (60%) very good, according to hair density there were one (5%) poor, thirteen (65%) good and six (30%) very good, according to postoperative scars there were eighteen (90%) low and two (10%) high and according to hair direction there were four (20%) bad, eleven (55%) good and five (25%) very good. Among the studied cases there were nine (45%) who needed another surgery (Table 3).

The mean inserted of studied cases was 22.51 (±3.20 SD) with range (18.2-30) and the mean survived was 16.75 (±2.07 SD) with range (13-21). There was high statistically significant difference between mean inserted and mean survived                 (p <0.001) (Table 4).

Table 1: Distribution of the studied cases according to demographic data, studied cases according to cause of injury, site of injury, number of operations and operative duration (n=20).

Table 2: Descriptive analysis of the studied cases according to number of grafts, area of the alopecia, survived/inserted % and time since injury (n = 20).

Table 3: Distribution of the studied cases according to outcomes (n=20).

Table 4: Comparison between mean inserted and mean survived. (t: Paired t-test, p: p value for comparing between mean inserted and mean survived, *: Statistically significant at p ≤ 0.05).

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