Introduction: Primary Cicatricial Alopecia (PCA), characterized by permanent loss of hair is a chronic inflammatory disease. In PCA cases there is destructive damage of the hair follicles and there may or may not be epidermal atrophy. The current medical treatment techniques aim at reducing or completely eliminating the symptoms then slow the progression of the disease and eventually stoping it. Unfortunately, a treatment method that would ensure follicle neogenesis is not available yet. That is why apart from surgical treatment, there is no other alternative method of treatment that would ensure recovery of the lost hair. Studies that have been done in this area are quite limited, that is why we would like to share our few cases and their results.

1. Dr. Ekrem Civas – Dermatologist
Dr. Andaç Aykan - Plastic surgeon
Prof. Dr. Muhitdin Eski - Plastic Surgeon
www.civashairtransplant.com
ekremcivas@yahoo.com
00 90 312 437 07 37

2. No relevant financial relationships or
conflicts of interest to declare.

3. Video recording and/or photography are strictly
prohibited in all educational sessions.

4.  Primary CicatricialAlopecia (PCA) is a poorly
understood group of hair loss disorders in
which follicles are irreversibly destroyed and
transformed to scar like fibrous tissue
resulting in permanent hair loss in the
affected area.

5.  Unfortunately, the currently available
medical treatment options for PCA are only
limited to slow down/stop the progression of
the disease and eliminate the symptoms.
 There is no treatment method that can
stimulate hair follicle neogenesis in the
human scalp at present. Follicles destroyed
by PCA will never re-grow hair.

6.  Once progression of the disease is burned
out; there is need to cosmetically camouflage
the residual scarred areas.
 With sufficient donor hair, autologous hair
transplantation is the only corrective surgery
approach to cover the bald patches; provided
the disease is stable.

7. • Different considerations have been presented in
literature on the question of the optimal minimum
stability period before hair transplantation (1 or 2
years).

8.  Can the disease re-activate years later after
stability?
 Publication shows that re-activation of the
disease was inconspicuous.
 There are only few studies in the literature that
show long-term results of surgical treatments.
 Can we state that patients beyond the active
stage of PCA are surgically stable alopecia?

9.  Literature on surgical correction of SCA
reveal that hair transplantation can be done
on the scar tissue in suitable conditions;
 Sufficient Donor hair
 No medical contraindications
 Sufficient blood supply in the scar

10.  This background information together with
existing literature on similar cases shed a
light for us to embark on this research;

11.  Between 2011 and 2014, 8 patients (5 male 3
female, aged 26-42) with histo-pathological
diagnosis of PCA and stable for at least 1 year
were enrolled in the study.

12. Patient
No
Sex Age Diagnosis Stable
Yrs
Test
Date
Date of Hair
Transplantation
Total Graft
No.
1 M 41 Pseudopelad 7 20th Oct 2011 900
2 F 27 Liken pilanopilaris 1 2011 21st Nov 2011 70
3 M 42 follikülitis
dekalvans
5 28th Nov 2011 670
4 M 26 Liken pilanopilaris 2 2013 22nd Apr 2013
19 octıber 2013
300
1600
5 M 39 folliculitis
decalvans&AGA
2 11th Nov 2013 1750
6 M 41 pseudopelad 4 24th Feb 2014 1100
7 F 31 frontal fibrozan
alopecia
3 19th Nov 2014 1400
8 M 42 Lichen planopilaris 2 2014 28th May 2015 416

13.  Detailed medical and family history of the
patients was obtained.
 Young patients with risk of future Androgenetic
Alopecia (AGA) hair loss.
 Physical, dermatological and dermatoscopic
examinations were performed.
 Donor area graft density and estimated
numbers of grafts needed for reconstruction
were evaluated.

14.  3 patients (2 males, 1 female) underwent pre-
transplant test session
 What is the criteria of selection
▪ Two of these patients (case 2 and case 4) were young
▪ Case 2: whose clinical findings were suspicious, new lesions
appeared 3 months after test session and this patient was
excluded from the study due to activation medical treatment was
commenced.
▪ In Case 8 his dermatologist requested a test session

15.  Assessment of the vascular supply in scarred
tissue was determined by pricking the 19G
needle into the scar.
 Evaluation of scar circulation demonstrated a
bleeding pattern similar to that of the patients with
non-cicatricial alopecia.
 During canal opening in scarred areas, it was observed
that PCA patients have evidently better
vascularization than SCA patients.
 Tumescent solution for scarred tissue was prepared
using saline containing lower amount of Adrenalin
than in non-cicatricial alopecia (1/250.000) cases.

16.  Hair transplantation method:
 FUE was selected as the most ideal method to avoid
creating an additional scar; since the patients already
have existing scars from the disease.
 FUE method resulted in small wounds at the donor
site, patients recovered faster with feeling less pain
and discomfort after procedure.
 With FUE method, the donor hair is used more
efficiently
 For the above reasons, FUE method was preferred
even with female patients.

17.  0.8 to 1.0 mm diameter punches were used to score
the grafts
 The recipient area was prepared using 0.9 to 1.1 mm
diameter lateral slit technique with graft density of
10 to 20 FUs/cm2.

18.  Classical hair transplant post-op procedures
were followed.
 Follow up of the patients was more frequent than
the AGA patients

19.  After medical treatment of PCA, autologous
hair transplantation is the most reliable way
to camouflage the scars created by PCA.
 However hair transplantation in PCA has
some important medical, surgical and
technical challenges encountered as
compared to the classical hair
transplantation.

20.  Difficulties in diagnosis;
 Even with extensive examination, accurate
diagnosis remains elusive in some cases.
 It is difficult to distinguish the different types of
PCAs on the basis of histologic findings only,
especially at their end stages
 The highest diagnostic yield is procured when
histo-pathological and clinical examinations are
both considered.

21.  There is no certain clinical and laboratory
finding to predict the stability of the disease.
 Unfortunately, available medical treatment
options can only prevent and slow down the
progression of the disease and eliminate the
active symptoms.

22.  Hair transplantation may be unsuccessful in
the patients who are not in stable period.
 Surgical treatments are recommended after
1-2 years stable time period after active
phase of the disease ends.
 In the patient with 1 year stable period (Case-2),
activation was observed 3 months after test
transplantation.

23.  Insufficient donor hair may lead to
unsatisfactory cosmetic results.

35.  Apart from Neutrophilic PCA which typically
appears like a true scar due to diffuse dermal
fibrosis and loss of elastic tissue;
 Histo-pathological studies show that in other PCA
variations only the hair follicle is replaced by
fibrous tissue
▪ Could this be the reason why hair transplantation in PCA
is more efficient than in Secondary Cicatricial Alopecia
(SCA)?

36.  FUE method is ideal for PCA patients
 Pre-operative evaluation of scarred tissue
with regard to blood supply is another
important parameter in the determination of
suitable candidates.
 Graft density and amount of adrenaline in
the tumescent anesthesia should be
determined with regard to the nature of the
scar and blood flow through the scar.

37.  In 7 patients, infection, necrosis or any other
complication was not observed following the
procedure
 The graft survival and hair growth progress
was not different from the AGA or SCA
patients.

38.  In our opinion it will be safer to do surgical
correction after 2-year stable period

39.  Hair transplantation is the only corrective
alternative method for PCA
 Satisfactory cosmetic results can be obtained
in stable PCA patients.
 Stability of PCA is the most important
parameter to consider before surgical
treatment.

40. Thank you for your attention
Dr Ekrem Civas
www.civashairtransplant.com
ekremcivas@yahoo.com
00 90 312 437 07 37