Scalp reduction surgery does not reactivate frontal fibrosing alopecia: A case report

Dear Editor, Frontal fibrosing alopecia (FFA) is a primary cicatricial alopecia characterized by progressive recession of the frontotemporal hairline and loss of eyebrows; total loss of body terminal hairs and facial papules may also occur. The predilection for post-menopausal women suggests a hormonal basis contributing to its etiology. Facial sunscreen use has been identified as a possible external contributing factor. Lichenoid inflammation may be seen histologically. The goal of medical therapy targets inflammation to arrest disease progression. Medical therapy does not regrow hair in areas of cicatricial hair loss hair restoration requires surgery. Surgical options include hair transplantation,however, these have historically been met with hesitancy given limited and variable results reported in the literature. Scalp reduction or hairline lowering therapy has not previously been described in the context of FFA. We present a female patient with FFA, stabilized with medical therapy, who underwent successful scalp reduction surgery followed by hair transplantation. Medical therapy was continued postoperatively and there has been no evidence of FFA reactivation six years post procedure. The patient was diagnosed with FFA at the age of 42 with typical frontotemporal hair loss, and bilateral eyebrow loss. She has a history of hypothyroidism and reactive arthritis. She had no associated female pattern hair loss. She was commenced on medical therapy comprising Dutasteride 0.5 mg, Minoxidil 0.5 mg, and Spironolactone 50 mg once daily together with topical bimatoprost to her eyebrows. She was instructed to cease use of sunscreen to her forehead. In 2015 after 2 years of documented clinical evidence to support disease stability, she underwent hairline-lowering surgery (Figure 1). The procedure involved undermining of the hair-bearing scalp behind the hairline, in the sub-galeal space. Approximately 2 cm of the forehead scalp was excised with forward advancement of the hairbearing scalp. Serial photography over the ensuing years has confirmed that her condition remains in remission with no evidence of reactivation (Figure 1). The patient did not experience any adverse effects and the scarring is acceptable and concealed by the hairline. In 2019, with her disease still in remission, she underwent additional hair restoration surgery, with 1000 grafts transplanted bilaterally into the temples. Six years from her initial surgery, her condition remains stable, with no progression of the hairline and no loss of transplanted hair. The natural history of FFA is unpredictable. Follicular unit transplantation has been reported to be successful in fewer than 30% of cases due to poor graft survival or disease progression post-operatively. Peak results occur at 10–15 months; however, the long-term outcomes and longevity of transplanted units are generally poor. Progressive destruction of transplanted follicles commonly occurs within four years post-transplantation. Scalp reduction surgery has not previously been described for FFA. Our case demonstrates scalp reduction surgery can be used either stand alone or with adjuvant hair transplantation surgery. Disease stability is a prerequisite for surgery. Ideally, surgery should be postponed until disease has been quiescent for at least one to two years. Long-term follow up of our case demonstrates that surgical hair restoration is a viable treatment option for FFA in carefully selected patients with medically stable disease.