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 Cicatricial Alopecia (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 SexAgeDiagnosisStable Yrs Test Date Date of Hair Transplantation Total Graft No. 1M41Pseudopelad720 th Oct 2011900 2F27Liken pilanopilaris1201121 st Nov 201170 3M42follikülitis dekalvans 528 th Nov 2011670 4M26Liken pilanopilaris2201322 nd Apr 2013 19 octıber 2013 300 1600 5M39folliculitis decalvans&AGA 211 th Nov 20131750 6M41pseudopelad424 th Feb 20141100 7F31frontal fibrozan alopecia 319 th Nov 20141400 8M42Lichen planopilaris2201428 th May 2015416

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