One of the most unusual scalp conditions is that of cutis verticis gyrata. (CVG) In this scalp condition, which is associated with an overall thickening of the scalp, linear indentations develop in a sagittal direction across the top of the scalp. Depending on the extent of the involvement a few scalp creases develop to as many as a dozen or more. In large numbers the appearance of the scalp can look like the surface of the brain. (gyrata)While often described as soft and spongy my experience has been that these folds are more often firm and non-compressible. Hair loss is not associated with these indentations despite the scalp fibrosis.
While the scalp condition has been known and described for almost 200 years, its cause remains unknown. It is known to occur much more commonly in men and often begins to develop after puberty. Its progression is slow and the presence of hair often obscures it until much later in life. Because its cause is unknown there is also no known effective treatment. Scalp excision/reduction has been suggested but the fibrotic scalp limits what can be accomplished and the scars are certainly not a good tradeoff. Releasing the indentations (subcision) sounds reasonable but is ineffective if done alone. Injectable fillers also seem a logical treatment but can not be done without subcision as the tissues are too fibrotic. The use of any synthetic injectable filler is not an economically viable one due to the volume of filler needed.
While there have yet to be any proven effective treatments for CVG, the combination of vertical indentation release with fat injections (filler) seems the most biologic approach. Due to the extent of the scalp fibrosis, this is a procedure that needs to be done under general anesthesia. The scalp indentations can be released using a small liposuction cannula, particularly that of the basket style. While the release is initially done along the indentations it is best to continue it in a criss-cross pattern as well.
Fat injections are needed to follow the scalp releases or it will just scar back down. Like all fat grafting the key is whether the patient has enough donor tissue for the volume of fat needed. Most CVG scalps can take 150cc to 200cc of the whole scalp is injected. Given the ratio of concentrated fat extraction in men is in the 20% range on average, the patient will need to be able to provide 750cc to 1,000ccs of liposuction aspirate.
The success of subcision and fat injections for sCVG remains unproven. But it is the most logical approach to date for a scalp condition whose cellular basis is unknown. Like all fat injections the combination of viable adipocytes and stem cells may improve the soft tissue quality and in so doing with some volume retention theoretically lessen the depth of the scalp indentations.
Dr. Barry Eppley
Indianapolis, Indiana