algorithm of hair restoration surgery in children
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Algorithm 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 because -
1. A child’s hair is very fine, thin and less dense as compared to adults.
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 is required.
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 out.

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 measure.

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 to.

Algorithm 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. PMID: 12900598
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