**7. Algorithm of treatment**

flaps. [28, 29] The expanded flap can be covered by the scalp hair is not very noticeable until

**Figure 19.** The expander is in place; the patients usually grow hair on the opposite side of the expansion area to com‐

The frontal visor flap first described by Leon Dufourmental in 1919 has stood the test of time; and with tissue expansion to overcome the donor site morbidity it is the only solution in bilateral facial defects in the male patient. [30] The scalp visor flap has an excellent blood

In small defects it is possible to expand the adjacent skin and reconstruct the defect by the

Another option for reconstruction of facial hair is Hair Transplantation; there are differ‐ ent techniques of hair transplantation, each with their inherent advantages and disadvantag‐ es. The most common and known hair transplantation method is the so-called 'strip'

A strip of skin containing hair follicles is removed, cut into grafts and implanted in the recipient area. In the past years, new methods have developed of which the most promising is the follicle unit extraction (FUE). [32] With this method, whole follicle units are extracted one by one and

supply, guaranteed by its double pedicle with the two superficial temporal arteries.

**6.4. Adjacent skin reconstruction, expanded and non-expanded**

late in expansion (Figure 19).

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pensate.

**6.3. Visor flap**

"same skin".

method. [31]

**6.5. Hair transplantation**

In the female patient the final reconstruction can be done at any time but the male patient's reconstruction should be postponed until the facial hair has grown because a bearded face in a child is not socially acceptable and a non-hair bearing reconstruction of the face in these patients, although reported in the literature, might lead to dissatisfaction in later years.

Although at some point during the treatment of the patients we have combined all the treatment modalities such as covering a flap scar with hair transplantation or combining expansion with adjacent tissue VY or Z plasty I propose an algorithm of treatment based on the face units. There are generally four types of hair bearing area defects:

**Type 1** is a partial unit defect

**Type 2** is total unit defect

**Type 3** is bilateral or multiple unit defects with two subtypes type 3a: multiple unit and 3b: bilateral

**Type 4** is isolated unit 9 defect

### **7.1. Type 1 defect**

For partial unit defects (Figures 20 to 22), the treatment modalities available are:


**Figure 20.** A partial unit defect can be anywhere on the face, used by permission of author Davide Brunelli M.D, www.med-ars.it

**Figure 21.** A type one defect of unit 4

**Figure 22.** After resection and repair and one stage hair transplantation. Some areas need more transplantation

#### **7.2. Type 2 defect**

Total unit defects which can be either unit 4 or 5 (Figures 23 to 34).

The reconstruction options are :

**1.** Expanded scalp

**Figure 20.** A partial unit defect can be anywhere on the face, used by permission of author Davide Brunelli M.D,

**Figure 22.** After resection and repair and one stage hair transplantation. Some areas need more transplantation

Total unit defects which can be either unit 4 or 5 (Figures 23 to 34).

www.med-ars.it

**Figure 21.** A type one defect of unit 4

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**7.2. Type 2 defect**

**2.** Expanded submental flap

**Figure 23.** Unit 5 defects, used by permission of author Davide Brunelli M.D, www.med-ars.it

**Figure 24.** A unit five defect 20 years after reconstruction by an expanded scalp visor flap

**Figure 25.** A unit five defect 20 years after reconstruction by an expanded scalp visor flap

**Figure 26.** Unit 4 defect, used by permission of author Davide Brunelli M.D, www.med-ars.it

**Figure 27.** Unit 7 full thickness defect

**Figure 25.** A unit five defect 20 years after reconstruction by an expanded scalp visor flap

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**Figure 26.** Unit 4 defect, used by permission of author Davide Brunelli M.D, www.med-ars.it

**Figure 28.** The expanded scalp flap

**Figure 29.** Expansion is complete.

**Figure 30.** The defect after resection of scar tissues

**Figure 31.** Outline of the flap design is over the highest expanded area to bring a less dense follicle area to the recipient site.

**Figure 32.** The flap is elevated on the superficial temporal vessels as a pedicle flap

**Figure 29.** Expansion is complete.

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**Figure 30.** The defect after resection of scar tissues

**Figure 33.** The flap covers the defect completely. Note the pedicle lying over the face.

**Figure 34.** The flap pedicle ready to be severed and returned to its original place.

**Figure 35.** The flap after severance

**Figure 33.** The flap covers the defect completely. Note the pedicle lying over the face.

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**Figure 34.** The flap pedicle ready to be severed and returned to its original place.

**Figure 36.** The patient 5 years after the last operation.

### **7.3. Type 3 defect**

Bilateral unit defects or multiple unit defects may be best treated via an expanded Visor flap (Figures 35 to 45).

**Type 3a**

**Figure 37.** Type 3a defect, bilateral involvement of units or combined units, used by permission of author Davide Bru‐ nelli M.D, www.med-ars.it

**Figure 38.** A bilateral unit 4 and 7 defect

**Figure 39.** The expanded occipital flap

**7.3. Type 3 defect**

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(Figures 35 to 45).

nelli M.D, www.med-ars.it

**Figure 38.** A bilateral unit 4 and 7 defect

**Type 3a**

Bilateral unit defects or multiple unit defects may be best treated via an expanded Visor flap

**Figure 37.** Type 3a defect, bilateral involvement of units or combined units, used by permission of author Davide Bru‐

**Figure 40.** The flap is transferred on the temporal pedicle

**Figure 41.** Ten years after the operation

**Figure 42.** Another view with small Z- plasties to cover the scar

**Figure 43.** Type 3a : multiple unit with sideburn involvement; units 4 and 5 partial defects with expansion in place

**Figure 41.** Ten years after the operation

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**Figure 42.** Another view with small Z- plasties to cover the scar

**Figure 44.** Expanded supraclavicular skin for forehead coverage and expanded scalp for reconstruction of multiple units.

**Figure 45.** The result after two years

**Figure 46.** Ten years after operation

**Figure 47.** Another view of the patient with Z- plasties to cover the scar

#### **Type 3b**

**Figure 45.** The result after two years

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**Figure 46.** Ten years after operation

Bilateral near total defects (Figures 46 to 49)

**Figure 48.** Bilateral unit 4 and 9 involvement with expansion in place.

**Figure 49.** The flap in place

**Figure 50.** The result after two years.

**Figure 51.** Ten years after the operation.

#### **7.4. Type 4 defect**

**Figure 49.** The flap in place

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**Figure 50.** The result after two years.

#### *7.4.1. Isolated unit 9 defects*

These defects are unique in that although they bear hair they can be reconstructed with nonhair bearing flaps especially when unit 4 is intact. The beard will cover the scar of this area (Figures 52 - 55)

**Figure 52.** Isolated unit 9 defects can be reconstructed with non-hair bearing flaps

**Figure 53.** An isolated unit 9 defect reconstructed by an expanded trapezius flap, the anterior trunk was involved in the scar.

**Figure 54.** The flap after defatting, note the hair which was present before defatting has become very thin after defat‐ ting or transfer.

**Figure 55.** The end result after 7 years, the flap is hidden behind the beard.
