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C h a p t e r 29

Scalp Alopecia
Reconstruction
jincai fan, liqiang liu and jia tian

Background
Scalp alopecia reconstruction usually requires fullthickness soft tissue coverage for functional purpose and
hair restoration for aesthetical purpose. Since the hairbearing scalp is fixed in number after birth, the ideal
solution for scalp alopecia is redistribution of the
remaining hair-bearing scalp. Although a small alopecia
defect can be repaired by wound closure or numerous
types of local scalp flaps [1], a defect of up to 35cm in
width is commonly difficult to correct with traditional
techniques due to the great tension on the wound closure and stretch-back that occurs later on [24]. When
the scalp flap is not sufficient to repair the scalp lesion,
numerous distant flaps are traditionally applied to
improve the functional demands. Moreover, hair grafting may be another option to treat scalp alopecia only
for cosmetic purposes [5]. However, if a lesion has the
problem of unstable scar or thin skin grafting on the
skull bone that often breaks down, bleeds, or infects, the
hair grafting does not usually work well due to the high
risk of lack of hair growth.
The advent of tissue expansion started a new era to
aesthetically reconstruct scalp alopecia, as it provides a
natural hair-bearing scalp with acceptable hair density
[2, 510]. Currently, it is believed that an alopecia area of
up to 50% or more of the total scalp surface can be
repaired by using tissue expansion (multistaged tissue
expansion or serial tissue expansion) [11]. However,
when the scalp defect is such that the hair direction of

the adjacent donor is not parallel to the recipient site,

like sideburns or hemi-scalp defect, the traditional
advancement flap does not usually match the aesthetical
demand of the recipient site. On basis of the achievement of the advancement flap and rotation flap, an
expanded flying-wings scalp flap was developed in our
unit to properly manage large sideburn and hemi-scalp
defects (Fig.29.1) [8, 12].
Tissue expansion is usually not indicated to repair
acutely injured wounds due to the disadvantages of a
high risk of infection and the long time required for any
result. In such a case, the tissue expansion should be

J. Fan, MD, PhD (*)

Ninth Department of Plastic Surgery, Plastic Surgery Hospital,
Chinese Academy of Medical Sciences, No. 33 Ba-Da-Chu
Road, Beijing 100144, China
e-mail: fanjincaimd@hotmail.com
L. Liu, MD, PhD and J. Tian, MD
Ninth Department of Plastic Surgery, Plastic Surgery Hospital,
Chinese Academy of Medical Sciences, No. 33 Ba-Da-Chu
Road, Beijing 100144, China

Fig.29.1 A flying-wings flap is designed by following the

principles of an advancement flap and a rotation flap

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery,

DOI: 10.1007/978-3-642-05070-1_29, Springer-Verlag Berlin Heidelberg 2010

Scalp Alopecia Reconstruction

carried out secondarily after the wound is completely

healed by using traditional techniques (case 4).

Scalp Anatomical Characteristics

The layers of the scalp, from the superficial to the deep,
are the skin, subcutaneous tissue, galea aponeurosis,
loose areolar tissue, and pericranium. The special characteristics are as follows:

1.Between the skin and galea, there are rich connective

tissue fibers that make the structures connect firmly.
It also allows the scalp flap become less elastic.
2.The scalp is nourished with five pairs of arteries: the
supratrochlear artery, supraorbital artery, superficial
temporal artery, posterior auricular artery, and occipital artery. The scalp flap can survive in a large size
with a narrow and long pedicle.
3.The scalp is mainly innervated from the surrounding to the top with pairs of supratrochlear nerves,
supraorbital nerves, auriculotemporal nerves, great
auriculars, lesser occipital nerves, greater occipital
nerves, and third occipital nerves. Nerve blockade
can be easily achieved with good anesthetic results.
4.The subgaleal layer consists of loose areolar tissue
and is easily elevated with less bleeding.
5.The direction of the scalp hair growth is angulated to
the scalp surface.

Chapter 29

Specific Skill of the Methods

1.The donor site exposed to a tissue expander was usually selected depending on the position of the defect
to be corrected, the hair direction required in the recipient site, the convenience to the patient, and the
area of hair that will last long.
2.One or two tissue expanders are placed under the
subgaleal pocket on one or two sides of the lesion,
usually through a small incision in the lesion scalp.
3.The expander is then serially inflated with normal
saline at an interval of 57 days until the desired volume is attained.
4.An expanded hair-bearing scalp flap should usually
be designed with the combination of an advancement
flap and a rotation flap, based at least on one nominated vascular system as the pedicle. A flying-wings flap
is often used to correct hemi-scalp alopecia, where
the wings often work to correct the distant side-part
of the lesion with a great change in hair direction.
5.The expanded hair-bearing flap is elevated in the subgaleal layer when the expander is removed. The incision
should always be carried out alongside the direction of
the hair growth.
6.The scalp flap is then advanced and rotated to the
recipient site when the lesion is excised.

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Clinical Cases
++ Case 1

29

A 6-year-old boy suffered from scalp alopecia after a scald in his infant period.
About half of the scalp was coronally covered with about a 1418-cm weak
scar (Fig.29.2a). A 600-mL rectangular tissue expander was placed into a subgaleal pocket of the posterior scalp of the head (Fig.29.2b) and serially inflated
to reach about 680 mL in volume with normal saline for about 4 months
(Fig.29.2c). Thereafter, a flying-wings hair-bearing flap was coronally designed
and raised from the expanded scalp, based on the posterior pedicle including
the vascular supply of the occipital arteries (Fig.29.2d). The wing-parts of the
flap were rotated to repair the sideburn defects, while the central part for coverage of the frontal defect was done with an advancement movement technique (Fig.29.2e). Excellent results were achieved (Fig.29.2f ).

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Chapter 29

253

Fig. 29.2 An anterior hemi-scalp defect was repaired

with a coronary design of a flying-wings hair-bearing flap.
(a) Preoperative view. (b) View of selecting a desired tissue

expander. (c) View of the full-expanded hair-bearing scalp.

(d, e) Intraoperative views. (f) Postoperative view after
2 weeks

Chapter 29

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Scalp Alopecia Reconstruction

++ Case 2

29

A 5-year-old boy had scalp alopecia with right hemi-scalp loss after burns
when he was young (Fig. 29.3a). Two 400 mL rectangular tissue expanders
were inserted in a subgaleal pocket of the left head and serially inflated to
reach about 900 mL in volume with normal saline for about 4.5 months
(Fig.29.3b). Thereafter, a flying-wings hair-bearing flap was sagittally designed
and raised from the expanded scalp, based on the lateral pedicle including
the vascular supply of the superficial temporal artery and postauricular artery.
The wing-parts of the flap were rotated to repair the defects of the right pre
and postauricular lesions, while the central part for coverage of the top defect
of the head was done with an advancement technique (Fig.29.3c). Excellent
results were achieved (Fig.29.3d).

Scalp Alopecia Reconstruction

Chapter 29

Fig. 29.3 A right hemi-scalp defect was repaired with

a sagittal design of a flying-wings hair-bearing flap. (a)
Preoperative view. (b) View of full-expanded hair-bearing scalp.

(c) Illustration of transferring the flying-wings expanded scalp

flap. (d) Postoperative view

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Scalp Alopecia Reconstruction

++ Case 3

29

An 18-year-old young man suffered from posterior large scalp alopecia after a
neurofibromatosis was excised. A 600-mL rectangular tissue expander was
placed into a subgaleal pocket of the anterior scalp of the head and serially
inflated to reach about 650 mL in volume with normal saline for about
4 months (Fig.29.4a). Thereafter, a flying-wings hair-bearing flap was designed
and raised from the expanded scalp, based on the anterior pedicle mainly
including the vascular supply of the left superficial temporal artery (Fig.29.4b).
The flap was transferred into the posterior defect by the principles of the
advancement flap and rotation flap, after the lesion was prepared (Fig.29.4c).
Good results were achieved with less change in the direction of the growing
hair (Fig.29.4d).

Scalp Alopecia Reconstruction

Chapter 29

c
d

Fig.29.4 A large posterior scalp defect was repaired with a single flying-wing scalp flap. (a) View of the full-expanded
hair-bearing scalp. (b, c) Intraoperative views. (d) Postoperative view

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++ Case 4

29

A 12-year-old boy had an acute large open wound on the right temporal head
in 2 weeks after a car accident, with deep important structural exposure and
slight infection (Fig. 29.5a). After surgical debridement, an acute scalp flap
was designed with a pedicle including the right occipital vessels for coverage
of the defect, while the large scalp donor site was being repaired with a splitthickness skin graft for temporary coverage (Fig.29.5b, c). After the wound
had healed well in 2 weeks, a 200-mL round tissue expander was placed into
a subgaleal pocket beside the lesion and serially inflated to reach about
250 mL in volume with normal saline for about 3 months (Fig. 29.5d). An
expanded hair-bearing flap was then designed as a rotation flap for the secondary repair of the scalp alopecia (Fig. 29.5e, f ). Very good results were
obtained (Fig.29.5g).

Scalp Alopecia Reconstruction

Chapter 29

b
f

c
g

Fig.29.5 An acute scalp wound defect was repaired with

an acute scalp flap and a delayed expanded scalp flap.
(a) Preoperative view. (b, c) Primary intraoperative views of the

scalp flap transferring and the skin grafting. (d) View of fullexpanded hair-bearing scalp. (e, f) Secondary intraoperative
views of expanded hair-bearing flap. (g) Postoperative view

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