Hair transplant for Quiet FFA

Hair transplantation surgery and scalp reduction may be an option for women with FFA. There is always a concern for disease reactivation. Indeed, facelift surgery has even been proposed as a trigger for some women with FFA.

A recent study by Pham and colleagues showed an 8 fold increased risk of FFA following facial procedures so clearly there is a concern that surgery could potentially activate FFA

Arasu et al, 2022

Authors from Australia present a nice report of female patient with FFA who was first stabilized with medical therapy and then proceeded to undergo successful scalp reduction surgery followed by hair transplantation. Medical therapy was on board before the procedure and was continued post- operatively and there was been no evidence of FFA reactivation six years post procedure.

The specific details of the patient were that she was diagnosed with FFA at the age of 42 with typical frontotemporal hair loss, and bilateral eyebrow loss. She was started on medical therapy that consisted of Dutasteride 0.5 mg, Minoxidil 0.5 mg, and Spironolactone 50 mg once daily together with topical bimatoprost to her eyebrows. She was instructed to cease use of sunscreen to her forehead. After 2 years of documented clinical evidence to support disease stability, she underwent hairline-lowering surgery.

The procedure involved undermining of the hair-bearing scalp behind the hairline, in the subgaleal space. Approximately 2 cm of the forehead scalp was excised with forward advancement of the hair-bearing scalp. Serial photography over the ensuing years has confirmed that her condition remains in remission with no evidence of reactivation. The patient did not experience any adverse effects and the scarring is acceptable and concealed by the hairline.

Four years after her hairline lowering surgery, the patient decided to have a hair transplant. Her disease was noted to still be in remission. She underwent underwent additional hair restoration surgery, with 1000 grafts transplanted bilaterally into the temples. Six years from her initial surgery, her condition remains stable, with no progression of the hairline and no loss of transplanted hair.

Comments and Conclusion

This is a nice report with several great lessons for us all:

1) First, medical treatment of FFA is key prior to any type of surgery - and likely after too.

My professional view is that nearly all patients with FFA need to have treatment of some kind before surgery and probably need to be on treatment of some kind heading into surgery. We probably need to be reminding the immune system at all time during and after surgery “not to even think about activating”

2) Serial photographs are the best way to document stability

Photographs are key. I really liked this paper because it reminds us of how important photos are. If you are a clinician, you are truly kidding yourself if you think you can just eyeball the scalp in FFA and determine that it is quiet. FFA can look quiet and not be quiet. Photos over 2 years are the most important thing in my mind. Show me 2 sets of detailed excellent photos 2 years apart and I will tell you if FFA is likely to be quiet or not. Anything else you tell me if not going to change my mind.

No patient with FFA should really ever undergo surgery for scarring alopecia unless they have a great set of photos two years apart showing zero change. Of course there are exceptions, but few.

3) If you are going to operate on FFA (and LPP) you need patience. Patience gives the best outcomes. She had hair transplants 4 years after forehead reduction

I liked this study because it highlights the slow pace that’s needed. If you want to increase your likelihood of having a successful hair transplant or scalp reduction in FFA, you need to be patient. This patient had a scalp reduction after the disease was quiet for 2 years and had hair transplantation 4 years later.

4) Promising 100 % survival is not appropriate.

I think it’s a bit of a stretch in anything surgery to conclude there was “no loss of transplanted hair.” So I think that was a bit of a disappointment in this paper. I think the best way to phrase it is “we see no evidence of a reduction in the density achieved post operatively.

Unless you count hairs one should not conclude there is no loss of transplanted hair. In fact, we expect some loss of transplanted hair and this patient’s follow up may not truly have been long enough. By year 2 there can be some reduction in some patients but year 5 is much more telling.

5) This title may not be the best.

The title of the paper “Scalp reduction surgery does not reactivate frontal fibrosing alopecia: A case report” but not have been the best title and is misleading.

The key to this paper was that the patient was managed really well with medical therapy and remained on medical therapy. The title should really be “A Case of Successful Scalp reduction surgery and Hair Transplantation in a Patient with Treatment Induced inactive Scarring Alopecia”

All in all, a nice paper highlighting the successes that are possible with proper medical management of FFA.

REFERENCE

Arasu et al. Scalp reduction surgery does not reactivate frontal fibrosing alopecia: A case report. Dermatol Ther. 2022 Mar 16;e15451.