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Your head is one of the parts of your body most vulnerable to injury. Head injury often includes injury to the scalp and eyebrows, with resulting destruction of hair follicles in those areas. The injured areas are often bald after healing (see Scarred Alopecia).

A common cause of scalp injury is automobile accidents; jagged metal and glass can cause injuries that heal with extensive scarring. Some people suffer scalp injuries in childhood accidents and carry scars for the rest of their lives. Other causes of physical trauma to the scalp include sports injuries, industrial accidents and personal physical violence.

Burn injuries can cause extensive and deep scarring. Thermal burn injuries may be caused by direct exposure to fire, contact with hot substances such as metal, or scalding with hot water or other liquids. Chemical burns are caused by exposure of scalp skin to corrosive substances such as industrial acids or alkalies, or cleaning solutions. Radiation burns are caused by exposure to excessive amounts of ionizing radiation-x-rays or gamma rays.

A number of inflammatory diseases can damage scalp skin and leave scars of greater or lesser extent. These inflammatory diseases include discoid lupus erythematosus, lichen planopilaris, and severe forms of psoriasis. Acne occurs on the face, chest and back. Infectious and inflammatory conditions that look similar to nodular acne may leave scarred, bald tissue after healing.

Scarring can be caused by surgery-for example, neurosurgery that required an entry would in the skull. Face lifting may result in receding of hair in the temporal region as a consequence of tissue “back lifting”.

Sometimes scarring can be self-inflicted-for example, scarring alopecia caused by tight braiding, corn rowing, or by trichotillomania, the compulsive plucking of hair. For more information, see other causes of hair loss.

Hair Restoration in the Scarred Scalp

Scalp injury and scarring destroy hair follicles. Hair does not naturally grow in scarred skin where follicles have been destroyed.

If scalp scars are small they may not cause any significant cosmetic problems. In some cases the person with scalp scarring can use hair styling to make the scars cosmetically invisible. However, the size and placement of some scars may make then impossible to disguise with hair styling.

Is hair restoration an option to consider for the scarred scalp?

The answer is “Yes” in the majority of cases. The method of hair restoration is usually hair transplantation. Skilled, experienced physician hair restoration specialists have been very successful in transplanting hair to scarred areas of the scalp (See Scarred Alopecia).

Sometimes the scarred area can be reduced in size by surgical excision and repair, leaving a smaller area that requires hair transplantation. This is an option that the patient and physician should discuss in detail before it is undertaken.

Scalp expansion, scalp flaps and scalp reduction are alternative surgical approaches to consider. They may be a treatment of choice when a scarred area is large and cannot be reduced in size for hair transplantation. A combination of surgical hair restoration procedures may be used in a large scarred area-for example, a scalp flap or scalp expansion plus hair transplantation to “fill in” as needed.

Hair restoration in the scarred scalp is not undertaken lightly. It requires careful examination of the scalp and consideration of numerous factors that can influence the feasibility and outcome of surgical hair restoration. These factors can include:

  • Underlying chronic inflammatory diseases that affect the scalp, such as lupus erythematosus, lichen planus or localized scleroderma, may be responsible for scarring alopecia. Most physician hair restoration specialists do not recommend hair transplantation if the disease is active; a minimum of two years of disease inactivity is advised before hair transplantation is undertaken.
  • Scalp blood supply in a scarred area. A very limited and compromised blood supply, due to injured and missing blood vessels, might make surgical hair restoration difficult or even impossible to carry out. Hair follicles need a blood supply in order to survive and function; if the blood supply is inadequate, the transplanted hair follicles will die or be unable to function adequately. The physician hair restoration specialist may assess the blood supply by (1) using various techniques to establish the paths and vitality of blood vessels through the scalp area that is to undergo surgical hair restoration, or (2) placing small “test grafts” into the area before undertaking a larger procedure.
  • Scalp thickness in the area that is to undergo surgical hair restoration. Different types of scars have different properties in regard to thickness and friability (the ease with which the tissue tears or crumbles). Very thick (hypertrophic) scar tissue may limit accessibility to underlying blood vessels. Very thin (atrophic) scar tissue may be too thin to hold transplanted follicles. Technical measures are available to deal with either hypertrophic or atrophic scar tissue, but the physician hair restoration specialist must be confident that these measures will produce a good result.
  • Underlying surgical repair. A person who has had surgical repair of a head injury, or repair after neurosurgery, may have a metal plate underlying the scar tissue. An underlying device such as a plate could be compromised by hair restoration surgery, or become a focus for postoperative infection. The physician hair restoration specialist may want to see the written records describing the previous surgical repair, or may wish to speak with the surgeon who did the repair. An underlying device such as a plate does not necessarily rule out surgical hair restoration; it is a potential complication that must be considered in planning surgical hair restoration.

After all necessary tests and physical examination, it is likely that hair restoration of the scarred scalp can be undertaken and have a successful outcome.

In the unlikely event that hair restoration cannot or should not be undertaken, the patient and physician hair restoration specialist can discuss hair prostheses for coverage of the scarred scalp. For more information, see hair pieces, hair extensions & weaves.

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