*4.2.2.4 Advantages of FUE technique hair transplantation*

FUE technique hair transplantation is the safe, effective and repeatable method in cicatricial alopecia including several advantages; provides a large amount of individual FUs harvesting on donor area with minimally invasive, less pain, less discomfort, lesscomplication method, high FUs graft survival rate, small implantation hole without formation of a linear scar and neurovascular damage, well accepted by patients with natural-looking hair growth and high level of satisfactory results. Additionally, transplantation of hair FUs to cicatricial alopecia carries epidermis, dermis, hair follicle, skin appendages that sebaceous and sweat glands, neurovascular bundles, piloerectile muscles, surrounded by a sheath of collagen and hair follicle stem cells increases the quality of the scar. FUE has led to improved graft survival and better cosmetics. Moreover, FUE needs less manpower, less equipment and minimal graft preparation period. All patients can be treated at an out-patient clinic with short hospitalization and a faster recovery period without general anesthesia (**Figure 5**) [16, 19, 28, 29, 34, 35, 37].

### *4.2.2.5 Disadvantages of FUE technique hair transplantation*

FUE technique hair transplantation is time-consuming procedure and needs to technique skills. Because it is difficult to keep the punch parallel to the follicles to avoid transactions that result inflammation, cyst formation and inability to harvest all the hair from the mid portion of the donor area [35]. Multistage procedures need to obtain satisfactory hair density in poor vascular scars. Wide donor area and spot scar formation on the punched-out sites are other limitations [1, 14, 28, 35].

#### **Figure 5.**

*The intra-operative images of the submandibular (a) and scalp (c) donor areas of follicular unit extraction (FUE) technique hair transplantation. After 1 week of hair transplantation, submandibular (b) and scalp (d) donor areas heal uneventfully.*

#### *4.2.2.6 Scalp restoration*

The scalp is the most common area of scarring alopecia with its large surface. Several well-established treatment modalities have been used for the reconstruction of scarring alopecia on the scalp, including primary excision, local flaps, tissue expander and hair transplantation. The defects affected 50% of the scalp can be reconstructed by aesthetically and homogeny redistributing of remaining scalp tissue with excellent cosmetic density [16, 17, 33, 36]. It is very important to determine the hairline and exit angle of FUs during scalp hair transplantation. The anterior hairline should reconstruct approximately 8 cm above the glabella in males, approximately 5.5 cm in a female by using single hair FUs. Two or more hair FUs can be used for central scarring alopecia to increase density [16].

#### *4.2.2.7 Beard and mustache restoration*

Beards and mustaches are important hair-bearing aesthetic subunits for hirsute men. Especially male patients who underwent cleft lip surgery suffer from bilateral philtrum scars and prolabial alopecia. Hair transplantation is the best treatment option for scarring alopecia on the beard and mustache. The submandibular beard is the best match donor area for beard and mustache (**Figures 6** and **7**). The singlehair FUs from the scalp can be used for beard and mustache restoration in beardless man [2].

#### *4.2.2.8 Eyebrow restoration*

Hair loss in the eyebrow causes de-humanization of the appearance (**Figure 3**). Modern makeup and micropigmentation techniques provide a 3-dimensional eyebrow appearance close to normal [14]. The exit angle and growth direction of the transplanted hair should be determined for the aesthetically pleasing result, that the medial hairs are oriented vertically, followed by the upper marginal hairs angled down and the lower marginal hair angled up. The donor hair can be taken from the opposite eyebrow, single-hair occipital and post-auricular scalp and nasal vibrissae [16].

#### *4.2.2.9 Eyelash restoration*

The eyelash restoration can be performed by retrograde or anterograde techniques with the single-hair occipital and post-auricular scalp. In the retrograde technique, hair FUs are implanted in the lid margin with classical techniques [19]. In the anterograde technique, the distal end of long hair is pulled out by a curved needle at the lid margin and provides better control of the growth direction of the hair [14, 16].

#### **4.3 Future**

It is a well-established fact that scarring alopecia has lower graft survival rates as compared to non-scarring alopecia. Tissue engineering studies need to develop scar-less wound healing and increase scar maturation similar to normal tissue.

## *Surgical Management of Scarring Alopecia DOI: http://dx.doi.org/10.5772/intechopen.107323*

Perhaps in the near future, alopecia will be treated routinely by in-vitro culturing of hair FUs [2, 14]. However, nowadays otology redistribution of existing hair FUs is the most commonly performed treatment for scarring alopecia [16].

#### **Figure 6.**

*A 22-years-old male patient had serious scarring alopecia after cleft lip surgery (a, unshaved image; b, shaved image). The patient underwent single-stage FUE hair transplantation from the submandibular area (c, d). After 3 years of hair transplantation, lip scarring alopecia has been successfully camouflaged (e, f).*

#### **Figure 7.**

*A 27-years-old male patient had multiple scarring alopecia on the face after trauma (a). The patient underwent single-stage FUE hair transplantation from the submandibular area (b). After 24 months of hair transplantation, scarring alopecia has been successfully camouflaged (c).*
