Surgical Hair Restoration


The search for an ideal treatment for baldness has been on for a very long time. The constant desire to produce natural-looking results and meet ever-increasing patient expectations has driven this evolution of techniques in the last few decades. Amongst the various techniques available today, follicular unit transplant (FUT) still remains, by an overwhelming majority, the most common procedure used to correct pattern baldness. Today, with hair transplantation techniques assuming a preeminent rank in modern hair restoration, where do the older methods stand?


Surgical hair restoration can be classified into following headings:

  • Hair transplantation
  • Scalp flaps
    • Rotation flaps
    • Transposition flaps
    • Temporo-Parieto – Occipital – (pedicled)/Juri flaps (TPO flaps)
    • Temporo- Parieto – Occipital (free/microvascular) flaps
    • Lateral scalp flaps
    • Temporal vertical flaps
    • Other flaps
  • Alopecia Reduction (AR)
    • Simple AR
    • Major AR/scalp lift
    • AR with prior scalp extension (non-volumetric)
    • AR with prior tissue expansion (volumetric)
    • AR with intraoperative stretching (volumetric and non-volumetric)

As this article deals with methods other than hair transplantation, hair transplantation is not discussed here.


Scalp laxity is the basis of all scalp surgeries and has two very distinct components. First is the ability of the scalp to slide or glide on the underlying pericranium. The second component of scalp laxity is its elasticity or ability to elongate (loosely termed “stretch”). This is distinct from the sliding phenomenon. Some scalps are highly elasticized, and even in the presence of the relatively inelastic galea, are capable of reasonably significant elongation.

Application of tension to the skin for a period (temporarily) causes the skin to stretch; this response is known as mechanical creep. The stretch is minimal as no tissue growth occurs. This beneficial effect of creep is utilized by use of retention sutures or towel clips to facilitate closure of skin edges. On the other hand when the skin is stretched for a longer period (weeks to months) the stretching response is more and it is known as biological creep. The mechanism underlying biological creep is not exactly known, but possibly is related to a combination of epithelial proliferation, new extracellular matrix formation, and recruitment of surrounding tissue. When prolonged stress is applied, like an extender (Frechet) or an expander, tissue growth occurs which is responsible for increased amount of skin available for excision.


Scalp flaps were initially used in patients with soft-tissue defects of scalp and later were adapted for use in hair loss. Scalp flaps require careful planning and adequate knowledge of the vascular anatomy of the scalp. Doppler apparatus is invaluable for marking out the arteries. The type of flap used for restoration will depend on the area and location of alopecia. This holds true whether one is dealing with cicatricial alopecia or pattern hair loss.


Rotation flaps are local random pattern flaps that use adjacent tissue, in which the tissue is rotated around a pivot point (arcuate slide) to cover a primary defect. Rotation flaps fill one defect by creating a secondary defect which can be closed primarily. Small areas of cicatricial alopecia can often be excised and covered with a hair-bearing rotation flap.


When the local flap is carried over an intervening area of normal skin to be placed in its recipient site, it is known as a transposition flap. These could be random pattern (based on subdermal plexus) or axial pattern flaps (a flap which has an existing, anatomically recognized arteriovenous system running along the length of the flap). Transposition flaps are generally smaller and freer in their movement than rotation flaps. Simple transposition flaps are usually wide-based and used to cover scalp defects (traumatic) or areas of cicatricial alopecia and generally need a skin graft to cover the secondary defect.


Till the mid-’70s frontal hair loss was usually treated with punch grafting and this led to a very typical corn row appearance. The curious tufted appearance of a punch graft hairline was eliminated when Juri devised a long axial pattern flap which was narrow-based to correct frontal baldness in male pattern hair loss. His design provided a longer flap (up to 25 cm in length) that spanned the entire arc of the frontal hairline. A slightly modified version of the temporo-parieto-occipital (TPO) flap was used by Stough, Cates and Dean and Mayer and Fleming. This flap was shorter and did not require extensive dissection like the Juri flap for closure of the donor site.