Despite the best efforts at cleft lip repair, whether done as an infant, teenager or as an adult cleft lip revision, the ability to detect the cleft lip scar usually persists. This is most manifest in men because the thickness of the upper lip beard skin on both sides of the cleft lip scar make the hairless scar that much more apparent.
While cleft lip scar revision is the best method to minimize the width of the cleft lip scar, it does not always work as well as one would like. It can be very difficult to get a cleft lip scar that is narrow as one would like, no matter how many efforts are made to revise the scar.
It is important to recognize that the cleft lip scar in a male has two fundamental deficits…lack of hair follicles and skin that is thinner and more atrophic. One simple method to address one of the deficits of the cleft lip scar is that of hair transplants. Placing small hair transplants (follicular extraction units, FUE) into he cleft lip scar not only adds hair growth to the scar but the presence of a follicular unit also has a rejuvenative effect on the lip scar. Whether the man ends up with a fuller moustache that crosses the cleft lip scar or merely ends up shaving (microdermabrasion) the cleft lip scar on a daily basis, the hair transplant helps with cleft lip scar camouflage.
When placing hair transplant into the cleft lip scar it is important to orient the hairs in a completely downward orientation that is nearly parallel to the surface of the skin. This will allow them to grow downward in the same direction as the rest of the upper lip hairs.
Background: A flat back of the head, also known as occipital brachycephaly, is a not uncommon aesthetic skull shape concern. It may occur from the way one laid in utero, how they were positioned as an infant while sleeping or from a genetic tendency based on race. To those so afflicted with this skull shape deformity, they can go to great lengths to camouflage it using hair styles, hats and other concealing maneuvers.
The flat back of the head can be very effectively treated by occipital augmentation using various bone cements and implants. The incisional approach to place these skull augmentation materials can be either high up on the occiput just behind the vertex or low in the occiput just along the nuchal line. There are very few reasons for a long coronal incision with most of today’s implant materials.
But one fundamental principle of occipital augmentation is that there has to be enough scalp to accommodate the amount of ‘bone’ expansion required. The scalp tissues are fairly tight and there is a limit as to how much they can stretch with an immediate augmentation. It has been my experience that about 10mm to 15mms of central occipital expansion can be obtained with an immediate augmentation. More than that will require a scalp tissue expander to be placed before attempting implant placement. The expander only needs to be inflated to about the size of the occipital augmentation needed. Another reason for a first stage scalp expansion are scars and prior scalp tissue loss due to injury or previous surgery.
Case Study: This 41 year-old male had a very flat back of the head that had bothered him for years. He had two prior hair transplant procedures done using a strip harvest method in the low occipital region with a scar that wrapped around ear to ear. Using computer imaging predictions, it was determined that the amount of augmentation he needed was 15mms at the central occipital region. But given his prior hair transplant harvests his scalp was very tight and it was felt that even this amount of occipital augmentation could not be safely achieved.
A first stage scalp tissue expander was placed through the central aspect of his hair transplant scar in the low occipital region. It was inflated at home slowly up to 100ccs over six weeks. In the interim, a 3D CT scan was used to create a custom occipital implant with 16mms of thickness in its central aspect.
A second stage procedure was done through the same occipital incision. The tissue expander was removed and it could be seen that it matched fairly closely to the size of the occipital implant. The custom occipital silicone implant was perforated with a 2mm dermal punch throughout to create multiple perfusion holes. It was inserted through the incision, positioned and the incision closed.
It could be seen immediately after surgery that the occipital contour was augmented to a perfectly normal shape from the profile view.
Occipital augmentation for a flat back of the head can be done using a custom implant even in a patient with prior scalp surgery such as a hair transplant. The loss of scalp tissue does require a prior scalp expansion to prevent the risk of skin necrosis over an implant or to even get the right sizes implant in place.
1) Augmentation of a flat back of the head that has had prior tissue excised and scars from hair transplants lacks adequate scalp tissue to safely cover an implant.
2) The scalp tightness caused by previous hair transplant harvests can be overcome through a first stage tissue expansion.
3) A custom occipital implant (2nd stage) can be inserted through a hair transplant harvest scar after initial scalp expansion. (1st stage)
Hair Restoration for the Thinned or Absent Eyebrow
I used to see one or two patients a year who had lost their eyebrows due to an accident such a burn injury or an avulsion from a motor vehicle accident. While these still do occur, I am now seeing more patients that have very thin eyebrows due to original underdeveloped thin eyebrows, over-tweezing, or loss of eyebrow hairs due to age. In some elderly patients due to decreased vision, I have had a few requests for eyebrow management as they could no longer see well enough to ‘paint on their eyebrows’. In the past, all of these eyebrow problems were treated with tattooing or medically speaking, micropigmentation. While placing permanent tattoo colors in the skin was effective, it was not the most natural as it was not real hair or even looked like hair. It was just a painted on eyebrow so to speak.
It is now becoming more popular to consider hair transplants as an option in these cases. Eyebrow hair transplantation has been done for decades but only more recently is it now being performed regularly. Its emergence as an alternative to tattooing is the general hair transplantation concept of follicular unit grafting. Hair transplants in the scalp have gone from the old-fashioned ‘corn row’ look to single hair follicle transplants. This has produced more natural hair restoration in the scalp and is perfectly suited for the eyebrow. Given that the eyebrow is a small area, the number of transplants needed is less than 200 per brow. Since this requires only a small donor area from the scalp, almost any patient is a candidate for the procedure. Eyebrow hair transplants are done in the office, under local anesthesia, and both brows can be completed in a few hours. Other than some potential for upper eyelid swelling and bruising, there is very minimal discomfort after the procedure.
Several important concepts for patients to know are: 1) The transplanted eyebrow hairs will grow like the scalp so they will have to be trimmed and shaped regularly (more so than your normal eyebrow hairs), 2) After transplantation, the new hairs will fall out in a few weeks (remember hair is dead, it is the follicle that is alive). The follicles must grow new hair which will take several months to be seen again, 3) Not all transplanted hairs will survive, although 90% or greater take is the norm. Touch-up grafting may be needed, and 4) Like scalp hairs, eyebrow transplanted hair can be dyed as well.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.