- Scalp reduction is a procedure in which a bald area of the scalp is surgically removed and covered by surrounding hair-bearing areas.
- Scalp reduction is associated with a high risk of complications, which may require subsequent operations to treat.
- This procedure is considered outdated by many experts, though it is still performed in some cases.
- Alternative options for hair loss treatment can produce very good results with fewer complications.
Hair thinning and balding is a common problem that affects both men and women, potentially causing significant distress. Male pattern baldness, the most common cause of hair loss, affects a full 53% of men by the time they reach their 40s.
Throughout history, people have resorted to various methods in an attempt to fix this problem with varying degrees of success. In this article, we’ll discuss a more extreme treatment option—scalp reduction surgery.
What is scalp reduction?
Scalp reduction (also known as alopecia reduction) is a procedure in which an area of the scalp with little or no hair is surgically removed. The surrounding areas of the scalp with high hair density are then pulled up to cover the defect left by the removed part and stitched together. In theory, hair should continue to grow normally in this part of the scalp, minimizing the bald area.
Scalp reduction was a very popular procedure in the 1960s-80s but is rarely performed anymore.
“Nowadays the heir of this procedure is the hairline advancement procedure. It’s technically a forehead skin reduction but we sometimes combine it with hair restoration surgery,” says Dr. Vartan Mardirossian, a Jupiter, FL board-certified facial plastic surgeon.
Many public figures are said to have undergone the procedure during its heyday. For example, some believe that US president Donald Trump underwent scalp reduction, but nobody has been able to prove it conclusively.
“It’s certainly possible he has had a scalp reduction in the past, which may be the reason why he has such an unusual hairstyle with comb-overs to cover the visible scarring,” suggests Atlanta-based board-certified plastic surgeon Dr. Benjamin Stong.
How it’s done
Scalp reduction can be performed in an outpatient setting under local anesthesia, though general anesthesia is often required for more extensive forms of the operation.
The surgeon will start by excising the bald spot (usually the crown area) at predetermined incision lines. The incision may take the form of an inverted Y shape, U shape, or it may be round or oval. An area of up to four centimeters in diameter can be removed in one operation.
After this, the surrounding hair-bearing skin is loosened and stretched before being pulled up to meet at the margins of the removed area. It is then sewn into place.
Scalp reduction may be performed alone or in conjunction with hair transplantation, a process which involves the surgical relocation of individual or small patches of hair follicles from a donor site to a bald area.
In some cases, a tissue expander may be used in the weeks prior to the procedure. This is a balloon-like device that is inserted under the skin of the scalp and gradually inflated, stretching and loosening the scalp.
What can go wrong?
As with any surgical procedure, there are potential complications.
- Infections, swelling, scarring, and bleeding — “Scalp reduction is very rarely performed nowadays, but when it is a visible scar could be a possible long-term complication,” says Dr. Mardirossian.
- Necrosis — Blood flow to the scalp may be compromised, resulting in necrosis (tissue death) and gangrene, a very serious complication.
- Pain — Older versions of the procedures — including the Fleming/Mayer flap, which Donald Trump is said to have undergone — were associated with significant post-operative pain. More recent versions of the operation are less painful.
- Unnatural appearance — Normal hair does not grow in the same direction all over the scalp. The relocated area of the scalp will continue to grow hair in its original pattern rather than adopt the pattern of its new location, which can leave it looking unnatural.
- Loss of elasticity — Stretching the scalp too much can make it lose its elasticity. This sometimes results in a specific pattern of scarring called a “dog ear scar.”
- Hair loss — Stretched scalp may lose its vitality, leading to hair loss. This can be temporary or permanent.
- Numbness — Loss of sensation in the scalp may occur following the procedure. This is usually temporary and resolves within several months, although it can also be permanent.
- Revision surgery — This may be necessary to conceal the scarring and fix any complications that can occur.
New and improved scalp reduction surgical techniques have been developed to increase the effectiveness and reduce the risk of complications.
However, it has generally fallen out of favor over the past couple of decades with the advent of safer, more effective treatment options. Nowadays, its use is mostly limited to treating burn and trauma patients, although a few surgeons still perform it for cosmetic reasons.
Who is a good candidate for scalp reduction?
Scalp reduction is still performed on patients who have a large area of scalp damage due to trauma or burns. Extreme cases of alopecia (hair loss) that are not responsive to other forms of treatment may also benefit from scalp reduction.
Surgeons who still perform the procedure for cosmetic reasons will consider the following factors to determine whether you would be a good candidate for the procedure:
- You should be generally healthy and have no medical conditions that can complicate the surgery.
- Presence of healthy scalp areas with high hair density adjacent to the bald area.
- Men who have male pattern baldness classified as stage 4, 5, or 6 on the Norwood-Hamilton scale are generally better suited for the operation. Men with these patterns have healthy hair-bearing areas on the sides and back of the head to serve as donor sites.
- Good laxity of the scalp to allow for stretching without damage.
Scalp reduction is not considered major surgery and as such you may be allowed to go home as soon as a few hours after the operation. However, patients are still advised to rest for a few days and avoid strenuous physical activity for a few weeks.
Hair may begin to fall for up to 6 weeks after the operation, but it should start growing again soon, assuming the scalp retains its vitality.
Temporary numbness may persist for weeks to months following the operation. There may also be pain at the incision site.
Swelling, bleeding, or skin discoloration are signs of complications and should be looked at by a physician.
How much does it cost?
Scalp reduction surgery can cost anywhere between $3,500 and $15,000 in the United States. Various factors can significantly influence the final cost, including the size of the area to be removed, how experienced the surgeon is, whether you need local or general anesthesia, and even your geographic location.
Over the past few decades, medical sciences have made huge strides in the field of hair restoration. A number of noninvasive and minimally invasive treatment options that exist today have the potential to achieve great results—even completely treating some cases of hair loss.
Only two drugs are currently FDA-approved for the treatment of hair loss — Rogaine (Minoxidil) and Finasteride.
Minoxidil is a topical solution that can be applied to the scalp to stimulate hair growth.
Finasteride is an oral drug that was originally developed for the treatment of enlarged prostate (benign prostatic hyperplasia) and was discovered to have hair growth stimulating effects.
Both Minoxidil and Finasteride take months to work, and the results are rarely dramatic. Discontinuation of either medication usually results in the loss of the hair that had grown under their influence.
» To learn more about these and other commonly prescribed treatments, read Zwivel’s Guide to Hair Loss Pills.
Minimally invasive options
Hair transplantation (or hair grafting) is a minor surgical procedure that involves the removal of hair follicles from a donor area with high hair density (usually on the sides or back of the head), and implanting them in the bald area.
The follicles can be removed and implanted one at a time (Follicular Unit Extraction or FUE), or in small groups (Follicular Unit Transplantation or FUT).
“With the sophisticated FUE hair transplant techniques today, we can completely restore hair to the entire scalp on the top of the head and it looks completely natural. It also avoids visible scars from scalp reduction surgery,” says Dr. Stong.
Platelet-Rich Plasma (PRP) injections have been shown in research to promote hair growth. In PRP treatments for hair loss, a blood sample is taken from the patient and subjected to a process called centrifugation. The plasma, one of the products of centrifugation, is then injected into the scalp.
Scalp Reduction is an invasive surgical procedure that aims to remove a bald area of the scalp, simulating the appearance of a full head of hair.
While somewhat effective, this procedure is rarely performed nowadays. More recent hair loss treatment options generally produce effective and more natural-looking outcomes. More importantly, they’re also associated with lower risks of complications.
- Autologous Platelet-Rich Plasma: A Potential Therapeutic Tool for Promoting Hair Growth (2012) atlantahairsurgeon.aestheticbrandma.netdna-cdn.com/wp-content/uploads/2014/09/Autologous-PRP-Derm-Study.pdf
- Prevalence of Male Pattern Hair Loss in 18–49 Year Old Men (2014) doi.org/10.1111/j.1524-4725.1998.tb00009.x