First, let's talk about secondary cicatricial alopecias, meaning any scar you have on your scalp or any part of your body as a result of an external factor. It could be due to burning from a lighter, being burned with alum, a wound after surgery, a large scar from a stone hit, a gash from a fall, or even from radiotherapy causing fibrosis, and so on. Or you might have traction alopecia, which by the way, if you are watching this video, I send you my greetings, we'll see each other in the operating room. Traction alopecia results in a secondary scar, commonly found in women who have worn tightly pulled hairstyles around the temples and temporal areas, leaving a more or less permanent scar. This often necessitates subsequent hair transplantation.
In general, secondary cicatricial alopecias are highly responsive to transplantation. They tend to yield good results and look quite satisfactory. A small comment, obviously transplanting scars is akin to transplanting into an area with less blood supply to the scalp and less skin irrigation due to increased collagen and fibrosis.
We strive to achieve a very high hair density so that the hair follicles do not compete excessively for oxygen. Obviously, if we group the hair follicles too closely together in a scar, there might be a risk of some follicles not surviving and encountering some survival issues. Hence, while surgery is usually sufficient for good results in scars, there are instances where touch-ups are necessary. In other words, sometimes it might be more reasonable to consider a transplant for a scar, possibly in two stages, with the main surgery followed by a potential touch-up in the future after ensuring the hair has established well to enhance density if the initial surgery wasn’t entirely satisfactory for everyone.
Apart from scalp scar hair transplantation, there are two other options available. One is something I did many times over twelve years, but I don't do it anymore as I don’t see the desired outcome, especially for larger scars. It involves excising scars and re-suturing to minimize the scar issue, especially scars that tend to reopen or reappear. So, it’s not optimal. The result, perhaps in some cases, might not be as natural as hair transplantation.
Another option that I think can yield good results is, once again, a surgical approach using expanders. Surgeons typically use expanders, placing something under the patient's skin for many days, even weeks, to try to stretch it like an inflated balloon filled with air or liquid. This results in excess skin so that the scar can be excised and then joined. I've seen good results with this method, sometimes not as successful. Not everyone does this; if it's a very large scar, hair transplantation could also be considered.
In summary, on an operational level, if you have a secondary scar from surgery, an injury, a blow, a fall, radiotherapy, or whatever the cause may be, hair transplantation is generally a very suitable action, knowing that a follow-up might be required to achieve optimal density, although often patients are so satisfied that it isn't necessary. This might happen because there could be a slightly lower survival rate in the transplanted area due to scarring. Then, if you have a primary cicatricial alopecia, transplantation can again be considered. We transplant and it often succeeds and looks good, but there are two issues: firstly, again, it's a less favorable environment that might suffer some loss, and there's a possibility of reactivation in the future leading to a loss of follicles. Some patients understand this and say, 'Doctor, if it lasts for 10-15 years and then fades, I'm okay with that or it matters a bit less to me, but I want to be okay for some years.' Or there are patients who say, 'No, Oscar, if it doesn’t last forever, I won't have a transplant.' In that case, it seems reasonable; of course, that patient will never have a transplant in their life because that risk will always be there, but it's equally legitimate and correct.
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