ABSTRACT
The dramatic removal of alopecia was also the Achilles heel of the procedure, because the patients with large bald areas needed little encouragement to continue returning for further procedures. This impetus to remove the last vestiges of vertex alopecia led to three significant problems:
“Stretch-back”—in the first two months following each AR 1. there was a tendency for the bald area in the vicinity of the central scar to widen. As an example, although a 10 cm bald area could be reduced to 6.5 cm during the procedure, within three months the area often measured approximately 7.5 cm. Removal of another 3 cm decreased the diameter further to 4.5 cm but once again almost 40% of the gain was lost to stretch-back and the alopecic area measured 6 cm. It sometimes required an additional three procedures to join “hair-to-hair” and then there was still the problem of the “central slot” and “white-sidewalls.” The IrishAmerican surgeon Gerard Seery eventually showed that stretch-back could be prevented by the use of galeal anchoring ( 4 ) but by the time his paper appeared in 1997 AR was already virtually past redemption. “Central slot” is the residual hairless scar, which 2. remained after the left and right sides of the scalp were joined ( Fig. 18A-1 ). The hair on either side was directed in opposing directions and even when the scar was very narrow this divergence of hair was very obvious, like a landing strip in the Amazon, and the residual hair extremely difficult to style. Worse still, the posterior point of the scar was several centimeters inferior to the posterior rim of the former crown baldness. Many surgical procedures were attempted to correct this abnormality and the most effective was the triple-flap procedure developed in 1990 by the brilliant Frenchman, Patrick Frechet ( 5 ). A variety of other AR designs had been introduced and a regular “alphabet” of designs appeared. In addition to the () shape there was the C, U, J, Y, and finally the M design.
