A) The hair in the front of the scalp with a scalp flap is angled backwards like a cowlick.          B) The hair in the front of the scalp is angled forward with a transplant just as it is found in nature.

The final problem is the shape of the bald spot in the vertex left behind after starting scalp reductions or after balding around previous scalp reductions. If the standard single excision down the middle of the scalp is used, the bald spot will turn from a circle to an ellipse. This football-shape is not normal and people notice. As the scalp reductions progress the patient may also notice a hump of extra skin developing in the very back of the scalp. This is due to excess tissue being pushed together at the ends of the excision. The surgeon may then want to repair these problems with a Frechet Flap. This is a complicated, step-like surgical flap that entails its own separate risk of complications.

Scalp reductions distort the bald area in the back of the scalp and lead to a protrusion of excessive tissue in the donor area. The scar is present on top of the scalp making it difficult to hide.

As the hair from the sides of the scalp is pulled towards the top of the scalp with scalp reductions, the hair next to the scar angles away from the scar leading to a “parting of the Red Sea” pattern.

But that is just the beginning of the scalp reduction problems. Frequently, the scar on top of the head will develop “stretch back”. The surgeon may have sewn it together flawlessly, but because the wound is under tension, it will be prone to develop a wide scar after it heals instead of a fine line. Thus, the patient gets a wide, white line that may develop a depression along its length. Because the wound will likely be sewn together under some tension, he should anticipate significant pain for a few days. As the hair is brought up from the sides to close the excision of bald skin at the top of the scalp, the patient will notice problems with hair styling. The hair that has been brought up will be angled away from the scar. This leads to the development of what we call “parting of the Red Sea”. The scar will lay between two edges of skin in which the hair angles directly away from the scar. This makes normal styling of the hair and hiding of the scars difficult, if not impossible.

The first problem with scalp flaps is that the angle of the hair at the hairline is reversed. Instead of angling forward like normal hair, it will angle backwards like a cowlick. Only this cowlick will cover the entire hairline. Try as the patient might, even combing his hair straight back, it will look funny. In addition to the wrong angle, he will now have an abrupt wall of hair as his hairline. Instead of the hair gradually becoming more dense in his hairline the further back it goes, his hairline will go from no hair to a wall of hair in one-sixteenth of an inch. Usually micrografts are sprinkled out in front of this wall of hair to decrease the abruptness. This is largely ineffective because of the sheer number of micrografts that would have to be transplanted. Why would a surgeon not use follicular units instead of micrografts? The answer is that because if the surgeon were able to perform follicular unit transplantation, he probably would not still be doing flaps in the first place.

remains the same. At first glance, the surgical removal of the bald skin seems like an ideal answer. It is quick. There is no waiting for transplants to grow. There is also a whole other side to the story, however. No matter which design is used with these excisions, scars will be placed on the patient’s head in an area very likely to show. Unless the surgeon is able to entirely remove all of the bald skin, a scar will be visible directly on the top of the head. If the surgeon is able to completely remove all the bald skin, it will likely only be after multiple procedures. Patients must not forget that male pattern baldness is progressive. A scalp reduction patient had better hope Propecia or Rogaine is able to stabilize his baldness, because, if it does not, he can anticipate that scar becoming more and more visible. Just like with transplants, there is a limit to what can be removed from a scalp before there is no laxity remaining. Once the scalp is tight enough—no more scalp reductions and possibly no hair transplants.

Scalp reductions involve the surgical removal and then closure of slices of balding skin from the top of the scalp. There are many variations and designs, but the concept