The deformity caused by cicatricial alopecia (CA) can significantly affect self-image and self-esteem; therefore, it is important to improve the patient's appearance.
A 19-year-old man presented with large, uneven, slightly hypertrophic scars on his forehead and the frontal region of his scalp (patient 1) (Figure 1A). At 3 years of age he had experienced extensive full-thickness burns on his scalp, trunk, and upper extremities from hot cooking oil. The sizes of the CA lesions were estimated to be about 4 × 10 cm on the right frontal scalp and 2 × 4 cm on the left temporal scalp. The affected scalp skin was inelastic and adherent to the skull. Tissue expansion and scar reduction surgery was recommended, but the patient declined to have this treatment because of the expected visible disfigurement caused by the balloon expansion and the probable visible scar.
Patient 1. A, Before follicular unit hair transplantation; B, 1 year after hair transplantation.
Because the deformity caused by CA can have a significant impact on self-image and self-esteem, improving the appearance is of great importance.1 There are 2 critical points that should be mentioned. First, CA lesions are well known to have poor graft recipient conditions owing to reduced blood perfusion.2 The percentage of grafted follicles that survive depends in great measure on the blood supply of the vascular bed.3 In addition to causing poor graft survival and graft failure, a limited blood supply can leave the recipient area more vulnerable to infection, further ischemia, and necrosis because grafting may potentially cause additional vascular injury.3 Second, hair transplantation in Asian subjects differs from that in white subjects. The generally straight black hair and lower hair density of Asian subject result in obvious see-through contrast of the scalp, which is rarely seen in less-dense scalp areas of white subjects.4 Also, the scalps of Asian subjects seem to be thicker, less mobile, and less elastic, and Asian subjects tend to experience a higher incidence of hypertrophic or stretch-back and/or stretch-atrophy scars.5 Therefore, scarring may become extensive and obviously noticeable when scalp reduction surgery is performed. The results of surgical procedures involving scalp flaps or scar reduction with tissue expansion are less satisfactory in Asian subjects than in white subjects.3
A punch biopsy specimen was obtained from the frontal cicatricial scalp of patient 1, and immunohistochemical staining, using anti-human CD31 antibody (BD Pharmingen, San Jose, Calif), showed poor vascular density in sclerotic tissue (Figure 2A). Two designated frontal alopecic regions were selected; one was pretreated with a carbon dioxide laser (hereinafter, pretreated area), and the other was left untreated as a control area. To create thermal injury in 3-dimensional patterns, round serial 1.0-mm holes were created by ablation using a collimated handpiece, about 3 to 5 mm deep into the skin, with a high-energy, ultrapulse carbon dioxide laser (model 1000U; SNJ Co, Seoul, South Korea). A continuous-wave beam with a pattern density spacing of 5-mm hole-to-hole distance and a pulse energy of 400 mJ was delivered for all applications at a frequency of 100 Hz. Clinical relevance was assessed at 1-month intervals. Two months later, the pretreated area became pinkish, with widened dimples resulting from the previously laser-drilled holes (Figure 3A). Immunohistochemical analysis of a subsequent biopsy sample showed a marked increase in vasculature (Figure 2B).
Patient 1. Immunohistochemical staining using CD31 antibody (BD Pharmingen, San Jose, Calif) at baseline (A) and after carbon dioxide laser treatment (B) (original magnification ×100).
Patient 1. A, Two months after carbon dioxide laser treatment (inset, original magnification ×4); B, 100 hairs implanted on a carbon dioxide laser–treated area and an untreated control area, respectively; C, 3 months later, hairs have grown in the carbon dioxide laser–treated (86 hairs) and in the untreated control (56 hairs) areas.
A hair micrografting test was performed to assess the feasibility of carbon dioxide laser–assisted scar remodeling as an improvement to the outcome of hair transplantation. One hundred hair follicles (34 single hairs and 33 double hairs) from the occipital scalp were transplanted using a Choi-type hair transplanter on 1 × 1.5-cm pretreated and untreated control areas, respectively (Figure 3B). A 3-month postoperative evaluation showed that many more hairs were grown on the pretreated area (82 hairs) compared with those on the control area (56 hairs). In addition, the hairs in the pretreated area appeared to grow thicker and faster (Figure 3C).
After the pretreatment was confirmed to have improved the vascularity of the recipient bed and to have enhanced the hair growth of transplanted follicles, the whole CA scar region was treated with an ultrapulse carbon dioxide laser by following the protocol already described. Two months after pretreatment, the donor area was harvested from the occipital scalp, and in a single session, a follicular unit (FU) of about 2500 hair follicles (composed mainly of bundles of 2 or 3 hairs) was transplanted. One year after a single procedure, a significant cosmetic improvement was seen (Figure 3B).
In addition to case 1, an additional 8 Asian patients with CA (5 women and 4 men) were treated and followed up at our outpatient clinic from 2001 to 2005 (Table). All scar tissue was treated with a high-energy ultrapulse carbon dioxide laser with a 400-mJ pulse set at 100 Hz. Patients returned for evaluation at 1-month intervals and were retreated if the sclerotic tissue still remained firm and inelastic and if additional treatment was indicated by clinical examination. The recipient condition was considered to be adequate when a 20-gauge hair transplanter for 2 FUs could be inserted into the cicatricial area without substantial resistance. Circular holes were ablated again serially in the middle of the hole-to-hole areas. All of the patients demonstrated fibrotic scar tissue improvement and the production of a pinkish appearance after 1 or 2 sessions of carbon dioxide laser treatment. Eschar developed in 1 patient (patient 3) in whom the hole-to-hole distance was relatively narrow, but the wound healed well with appropriate care. None of the carbon dioxide laser–treated sites had visible new scarring or showed hypopigmentation or hyperpigmentation, persistent edema, or infection. In all of the patients, we achieved acceptable cosmetic results after only 1 or 2 FU transplant sessions at a density of 50 to 70 hair follicles/cm2.
Various surgical procedures have been used to correct CA, including excision of the affected area, flap surgery, scar reduction with tissue expansion, and the use of autologous hair transplantation.2- 3,6 In cases with reduced scalp elasticity and sclerotic underlying dermal tissue, FU transplantation seems to be the sole practical solution.7 However, the survival rate of implanted FUs needs to be improved because it is unsatisfactorily impeded by limited blood supply in the recipient area, and repeated sessions are required for acceptable cosmetic results.1,7- 9
By using carbon dioxide laser–assisted scar tissue remodeling we were able to achieve acceptable cosmetic results after only 1 to 2 sessions of FU transplantation. Moreover, the grafted hair follicles satisfactorily covered the formerly alopecic areas and grew hair faster than those follicles transplanted in normal recipient areas.4 In terms of the promotion of healing by both the induction of growth factors, and the activation and mobilization of fibroblasts and endothelial cells, thermal lasers have been demonstrated to effectively promote faster wound healing and to produce better cosmetic results.10 The accelerated growth of transplanted hairs may be the result of the promotion of neoangiogenesis and the inductions of various growth factors and cytokines during the wound healing process after laser-induced thermal damage.
In our patients, an ultrapulse carbon dioxide laser was used to ablate deep into 3 to 5 mm of skin at 5-mm-distance intervals to deliver thermal damage into the whole depth of sclerotic tissue in 3 dimensions. For cases in which the CA surface area exceeded 50 cm2, FU transplantation was performed after scar reduction surgery. It is possible that laser-induced thermal injury could cause ischemic injury in precarious vascular areas in CA. However, eschar developed in only 1 patient (patient 3), whose wound healed well without contributing to new scarring. A hole-to-hole interval of 5 mm is assumed to be suitable for laser pretreatment in CA. Although we believe the safety and efficacy of carbon dioxide laser–assisted scar remodeling were demonstrated in these patients, further clinical studies are necessary to refine the optimal parameters in CA.
In conclusion, staged hair transplantation after carbon dioxide laser–assisted scar tissue remodeling could be a useful means of achieving cosmetic improvement in cases of CA and was found to be suitable for Asian subjects, who are more vulnerable to stretch-back scar formation after reduction surgery.
Clinicians, residents, and fellows are invited to submit cases of challenges in management and therapeutics to this section. Cases should follow the established pattern. Manuscripts should be prepared double-spaced with right margins nonjustified. Pages should be numbered consecutively with the title page separated from the text (see Instructions for Authors [http://archderm.ama-assn.org/misc/ifora.dtl] for information about preparation of the title page). Clinical photographs, photomicrographs, and illustrations must be sharply focused and submitted as separate JPG files with each file numbered with the figure number. Material must be accompanied by the required copyright transfer statement (see authorship form [http://archderm.ama-assn.org/misc/auinst_crit.pdf]). Preliminary inquiries regarding submissions for this feature may be submitted to George J. Hruza, MD (email@example.com). Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archdermatol.com).
Correspondence: Jun Kyu Oh, MD, Rich Hair Clinic, Yaein Bldg, Chungdam-Dong 85, Kangnam-Gu 135-100, Seoul, Korea (firstname.lastname@example.org).
Financial Disclosure: None reported.
Accepted for Publication: July 26, 2006.
Author Contributions:Study concept and design: Kwon and Oh. Acquisition of data: Kim and Park. Analysis and interpretation of data: Kwon, Chung, Eun, and Oh. Drafting of the manuscript: Kwon and Oh. Critical revision of the manuscript for intellectual content: Kwon, Eun, and Oh. Administrative, technical, and material support: Park, Eun, and Oh. Study supervision: Oh and Eun.
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