of hair restoration surgery in children
It is very common for all of us to think that hair loss occurs
only in adults especially men. However, hair loss occurs in a
few women and also in children. Irrespective of their sex, children
can be victims of hair loss due to congenital defects, burn injuries
due to fire or chemicals, surgery related, accidents resulting
in hemorrhage, chemotherapy and x-ray irradiation treatments involved
in curing leukemia and other cancers.
Our society accepts a bald man as associated with age related
developments, but on the other hand bald children invite attention
mostly out of curiosity. The ‘look good’ feeling among
children of their age group and their sensitive minds make the
hair loss all the more obvious. This makes hair transplantation
necessary in children and hence hair transplant surgeons have
come up with a few techniques to help them look better. The most
common techniques used to restore hair loss in children are simple
excision, excision with scalp flaps, expansion of flaps using
expanders, flaps from extended scalp and finally hair transplantation.
Extra care for hair transplant procedures in children is necessary
1. A child’s hair is very fine, thin and less dense as compared
2. The skin on the scalp is thinner but is highly elastic. Hence
post -operation, scars get expanded as the child grows. This elasticity
is of use when expanders have to be used.
3. Children are very sensitive to pain and hence general anesthesia
4. Since the blood supply in the scalp region is very good, hair
transplantation procedures are easier to perform.
Dr. Kolasinski has studied children in the age group of 4 to
17 years over a period of 18 years. The most common causes of
hair loss in this group of 57 children were burns, x-ray irradiation
and mechanical trauma. In most of these patients the hair was
transplanted using the four hands stick and place technique.
Four hands-stick and place technique
In this technique, hair follicles are harvested as strips [1cm
wide and 7-12 cm long] from the back of the head. The strip is
then sectioned to obtain micrografts [1-2 hairs/graft] and minigrafts
[3-4 hairs/graft]. Using a scalpel an incision is made in the
scalp, the wall of the incision held under slight pressure to
keep it open and the graft is placed immediately with the help
of a forceps. This procedure involves two people, the surgeon
and his assistant who use their hands deftly in a highly coordinated
manner. The transplanted regions are then dressed which is removed
under the surgeons care the following day. Neomycin was applied
externally and Doxycycline given as oral medication in order to
prevent infection after the transplantation.
When the area to be treated was largely devoid of hair, expanders
were used and this in combination with hair transplantation was
found beneficial. The use of expanders was done in two steps.
250-500cc expanders were used to first increase the volume of
the skin and then in the second step that was performed 2 weeks
after applying expanders, the expanded skin was removed and the
bald areas covered with it. The patients could be discharged within
24 hours of the procedure. The result of most of these procedures
were the formation of hair patterns called dog ears due to the
alignment of the expanded skin flaps. From these areas, donor
hair was harvested and hair transplantation procedure was carried
out as necessary after 3-4 months of using expanders.
In all the patients treated, the hair transplant technique was
successful irrespective of there hair loss reasons. Since in these
cases the involvement of androgens is very less, the probability
of hair growing back is relatively high. Hence it is advisable
that the surgeon wait for 6 months to a year in order to assess
the growth pattern of the hair in the bald areas before deciding
on the type of transplantation he can apply on his patient.
In children balding patterns have been classified by McCauley
and his colleagues into 4 categories depending on the location
and degree of damage. Type I is a simple single bald area with
subtypes I A to I D depending on the percentage of bald area.
Type I A is 25% single bald area and type ID is 75% and above;
Type II - 2 damaged areas separated by undamaged scalps with subtypes
II A to II D assessed similar to type I; Type III – several
undamaged scalp areas surrounded by bald scalp and Type IV – fully
damaged scalp. Dr. Kolasinski has added another type, Type V – several
bald patches all over the scalp. This overall classification of
the bald patterns gives the surgeon a base to evaluate and suggest
transplant procedure according to the need of a patient.
Type IA patients – simple excision if the area to be treated
is in the back of the head, coverage using expanders when the
area falls on the crown along with hair transplantation are carried
Type IB, IC and Type II patients – use of expanders become
necessary ad then correcting using the expanded flaps. To avoid
showing of scars it is necessary to take care of the orientation
of the hair. If that is not possible, use of mini and micrografts
are suggested after 4 months of using expanders as a corrective
In type III, IV and V, surgery may not be necessary. But in
some cases where the patient has gone through irradiation therapy
and in all likelihood may continue to stay bald, hair transplantation
using follicular unit grafts is the most ideal solution. In one
session hair grafts ranging from 1000-3000 can be implanted. Since
children need general anesthesia before the procedure can commence,
time plays an important role in maintaining the growth characteristics
of the transplanted hair. Since about 1000 grafts can be placed
in position within 2 hours and about 3000 grafts within 3 hours,
the patient does not experience any anesthesia related complications.
Best results according to Dr. Kolasinski has been achieved by
his team using the four hands stick and place method. This method
has one major advantage in that all the incisions made are used
for placing the grafts and no incised scalp is left unattended
of hair restoration surgery in children references
- Kolasinski J, Kolenda M.
Algorithm of hair restoration surgery in children.
Plast Reconstr Surg. 2003 Aug;112(2):412-22.