The most common method of surgical hair restoration involves removing bald resistant donor hairs from the back and sides of the head and transplanting them to the bald areas. Such hair restoration procedures are relatively minor surgeries that are done on an out patient basis and require only local anesthesia.
Scalp or Alopecia reductions are efficient ways of moving hair into the balding areas but they are more invasive surgical procedures. They can produce dramatic improvements for a carefully selected minority of hair loss sufferers. However, the risks involved with these major scalp surgeries in inexperienced hands are higher than the standard hair transplant procedure.
Given the excellent results that can now be achieved using much less invasive hair transplantation, many physicians who did perform scalp surgeries no longer do so.
Overview of Scalp - Flaps, Reductions, Lifts, Rotations, and Extensions
Some of these major surgeries include scalp - reductions, lifts, rotations, flaps, and extensions/expansions. These procedures generally work by removing sections of balding scalp and or moving sections of bald resistant hairs into the balding areas.
When done properly and on carefully selected patients, these procedures can produce dramatic and positive enhancements. But in the past they were often over used and some times poorly performed by inexperienced surgeons.
This resulted in some patients getting minimal long term benefits or worse becoming disfigured or in chronic pain. These complications, due largely to poor patient selection and inexperienced surgeons, have led to a decline in the popularity of these major scalp surgeries.
Yet in the hands of a highly experienced surgeon, the right candidate can achieve dramatic improvement. Generally the best candidates for major scalp surgeries are patients with very elastic scalp and good donor density.
Scalp Reduction Surgery
The most popular surgical procedure for reducing the balding area is Scalp Reduction Surgery. This procedure basically cuts out some or all of a patient’s bald spot. For the right patient and in the right hands, this procedure can produce a dramatic improvement in a short period of time.
For the right candidate - a potential dramatic reduction in baldness.
The below patient was told that as a “Class 7” he was too bald to successfully complete hair restoration surgery. However, he had very thick hair density in his bald resistant donor area and very elastic scalp skin. These characteristics made him an excellent candidate for scalp reduction.
Before Scalp Reduction SurgeriesAfter Two Scalp Reduction Surgeries 
Patient photos courtesy of Dr. Daniel Didocha
This patient underwent two very successful scalp (alopecia) reduction surgeries. He was able to eliminate his bald spot in the crown (back of the head) with out any grafting being required. His remaining available donor hair was then used to reestablish his hairline and mid scalp regions.
The potential “down side” of Scalp Reductions
While a scalp reduction can produce an immediate decrease in the size of a bald spot it is not without drawbacks.
Stretch Back
For some patients their skin stretches back over time and the bald spot again grows larger.
Reduced Donor Density and Elasticity
Also since the scalp on the sides and back has been pulled up tighter the elasticity (looseness) of the skin in the donor area is typically reduced, as is the hair density. So while the hair on the sides (the lateral hump) has been elevated and less grafts are required to fill in the remaining bald area, there is a reduction in the amount of donor tissue and hair that a surgeon can safely remove from the sides of the donor area.
However, if the patient chooses to do a hair transplant, the posterior donor area remains very available as the elasticity is not effected in this area. This is especially true of the mid-line reduction which also has the least impact on circulation and sensation.
Scarring and Slot Deformities
When undue tension is used in the suturing of the incision, scalp reductions can produce large visible scars in the top of a patients head. The scalp can also be painful even weeks or months after the procedure. If the occipital nerve is damaged a permanent numbness can develop.
In addition, patients may develop a “slot deformity”, which is an unnatural appearing indentation along the scar or they may develop a slot defect which is an abnormal hair direction. With a slot defect the hair tends to be perpendicular to the incision and appears as a permanent part. This defect has been also described as a “parting of the seas”.
By using galeal or anchoring sutures the indentation can be avoided. A physician who does a reduction should know how to correct the hair direction by using a technique developed by Dr. Patrick Frechet of Paris, France.
Who may be a candidate for Scalp Reduction Surgery?
Only patients with very loose skin in their balding area should be considered for this procedure. A measuring technique can be utilized to demonstrate how much tissue can be removed even before such a procedure is contemplated. By doing so the benefits can more accurately be weighed against the risks.
Cutting out the bald spot
The most common scalp surgery is a “Scalp Reduction”. This was performed either in a midline football shape excision or a mercedes incision as shown to the below.
Note – the red pattern represents the skin that is removed.
With a scalp reduction, skin in the balding area is surgically removed from the top of the scalp. The surgeon then pulls the scalp on both sides of the incision upward and together and sutures the incision closed.
The immediate affect of this scalp reduction procedure is to reduce the visible size of the balding scalp on the top of the head.
