These are radical surgeries that create massive scarring, and permanently change the orientation of the patient's scalp.

The "logic" behind these techniques is that a surgeon can simply cut the balding area away, and then stretch the remaining scalp together. But all too often, it causes a negative end result in the patient's appearance.

Note that this section contains graphic images, and is divided into two sections. (Link to Part 2 at bottom of page).

I hope this section of my website will help consumers make an educated decision about these procedures. I have tried very hard to make this website 100% medically accurate, however I am not a doctor, so I apologize if there are any errors.

The diagram below shows some typical patterns that can be used for a scalp reduction. The doctor uses a scalpel, to cut the outline of a pattern (shown by the shaded areas). Then the connective tissue underneath the shaded area (attaching the scalp to the skull) is carefully severed, using a scalpel or a scissors, "releasing" the small area of bald scalp . Once the shaded areas are cut away, that shaded area is now a GAP where there is no scalp. The remaining scalp is forcefully pulled together and sutured, and the gap is closed.

Notice how the surgery will create LONG SCARS in an area of the scalp where there is no hair available to conceal the scarring. The patient hopes that future hair grafting will conceal the scarring. But very few patients have enough donor hair to cover a very large balding area. So a high percentage of scalp reduction patients will have scars that are easily visible.

And here is another MAJOR FLAW in the logic of the ordinary Scalp Reduction. Because the scalp is anchored all over the skull with connective tissue, just removing a small section and pulling the gap closed will usually accomplish very little. The connective tissue keeps the rest of the scalp anchored in the same place, and the scalp nearest to the gap is s-t-r-e-t-c-h-e-d to close up the gap. In other words, the TOTAL amount of bald area is often NOT reduced at all, or maybe just a trivial amount... not enough to justify the huge amount of scarring that was created. Very often, the scalp will gradually return itself to the SAME ORIGINAL POSITION after Scalp Reduction surgery, a process known as "stretchback". According to Dr. Swinehart's textbook, stretchback after a Scalp Reduction is "often significant" and may require "more operations than originally planned".

In other words Scalp Reductions often ACCOMPLISH NOTHING, while at the same time causing PROBLEM SCARRING. And the more scalp that is successfully removed, the more likely the patient's remaining scalp will be distorted, causing the remaining hair to be angled incorrectly.

This photo shows the approximate pattern of MY scalp reduction. The approximate oval area was cut away, and the resulting gap was stretched together and sewn shut, leaving a straight line valley-like scar. It's hard to see the scar in a photo, because it is "white on white" and also there is so much other chaotic damage there. This photo was taken under flourescent lights, which tend to "flatten" things out. The scar is easier to see in-person, and you can feel a permanent cleft there. My scalp reduction ACCOMPLISHED NOTHING except for causing a cleft-like scar in my scalp, and also making the clinic an extra paycheck. Afterwards Dr. Puig put a few plug grafts into the scar, in a feeble attempt to conceal it. I will never forget the horrific "scraping" sounds of my scalp reduction, as the oval of scalp was surgically detached from my skull. I used to hear that sound in my nightmares. As bad as Scalp Reductions are, they are nothing compared to the Scalp Lift. Scalp Lifts are similar, but much more extreme and much more damaging, as we will see.

Scalp Reduction was invented in 1976, and became popular with hair transplant clinics, especially during the 1980s. Clinics liked it, because it was an additional procedure they could charge the patient for, and in a very superficial way it appeared that the industry was improving it's approach to "surgical hair restoration". However this was a "false progress" as it seems that more patients were permanently damaged by the procedure than the number who were helped by it. The Scalp Reduction was a "garbage technique" that usually couldn't live up to it's sales hype, and made far too many patients actually look WORSE. Such bad results and serious scarring was caused, that gradually Scalp Reductions became less popular in the late 1990s.

However Scalp Reductions and Scalp Lifts are still regularly performed on patients, even today! These techniques are still being taught when doctors hold training seminars, and some doctors are lobbying each other for a return of the popularity of the Scalp Reduction and Scalp Lift. BUYER BEWARE!

Example of common Scalp Reduction. The patient is typically awake and under local anasthesia only. On the left, the gap in the scalp after a piece was removed. The doctor and his staff will forcefully pull the patient's scalp together, and stitch it up. Post surgery on the right. The scar will turn pink (and someday hopefully white). Hopefully the scar will not stretch, and hopefully the patient will have enough donor hair to graft over the scar. The scar from a Scalp Reduction can be prone to stretching, due to tension in the scalp. This can cause an enlarged scar. "Stretchback" is highly possible, meaning the scalp may gradually return to it's original position. That would mean that the surgery accomplished nothing.

Below, an example of aggressive Scalp Reduction. This one removed a little more scalp than typical (and may have required some extra "undermining" or cutting loose of the scalp's connective tissue) BEYOND just the piece of scalp that was removed. We will see examples of "undermining" in the section on Scalp Lifts. Undermining may be necessary to close a large gap like this.

On the right, the patient's remaining hair in the back, appears to have been pulled up out of position and the scalp appears somewhat distorted. The hair on top of the scalp is supposed to be angled forward... but that hair now on top is permanently angled backwards. Incorrect hair angles can look bizarre, in some cases. This patient will have a major scar, right in the center of his balding area, that may be hard to hide with hair grafts later. Graft survival in scar tissue can have mediocre survival rates, and a lot of valuable grafts may go to waste, trying to hide it.

Example of a Scalp Reduction SLOT SCAR on the left. This is a real risk, when certain Scalp Reduction patterns are used. One of the goals of a typical Scalp Reduction is to reduce the amount of bald "crown" in the back. As a result, certain Scalp Reduction patterns can cause serious scarring that "extends" the patient's bald spot into his "permanent zone". This patient is worse off AFTER surgery. Slot Scars are common enough, that doctors developed special surgeries just to specifically address them. We'll see that correcting a slot scar is not always easy, in the next photos. This scar will very likely reduce the patient's ability to harvest grafts from the "permanent zone". He now has a major scar, and less ability to harvest enough hair grafts to hide it. Note that scars don't always show up well in photos, especially when a flash is used. You can see this thick scar mainly because there is a lack of hair there.

A Scalp Reduction Case Study

This patient has already had two Scalp Reductions and two Hair Transplants at a "chain clinic", when these next two photos were taken. You can see the SLOT SCAR that goes deep into his hair, in both photos. This "surgical defect" was caused by his Scalp Reductions.

Below, we see the long oval pattern that Dr. Swinehart will remove during the patient's third Scalp Reduction. This surgery will attempt to remove more bald scalp, and "correct" the SLOT SCAR (by removing most of it). The patient will then also have a Hair Transplant, after the Scalp Reduction is performed. (A typical Scalp Reduction takes less than an hour to do).

On the right is the patient immediately after surgery. (The patient is awake and fully conscious during a typical Scalp Reduction.) You can also see the areas where his grafts were transplanted.

On the left is the patient after healing up from the last Scalp Reduction and Hair Transplant. You can see that the SLOT SCAR is still about as bad as it was, before the surgery.

On the right, we see the pattern of scalp (purple outline) that Dr. Swinehart will remove during another corrective surgery attempt. This time, using the Frechet Flap technique to try to remove the SLOT SCAR.

Slot Scar still remains, after two "corrective surgeries". These photos show quite a "comb-over" attempt to portray more hair coverage than the patient actually has.

On the right, the patient after FOUR Scalp Reduction surgeries and FIVE Hair Transplants. (Two Scalp Reductions at "chain clinic" and two with Dr. Swinehart. Two Hair Transplants at "chain clinic" and three with Dr. Swinehart).

Do you think that "results" LIKE THIS are what the patient had in mind, when he was being sold on Hair Transplant surgery by a "consultant" (salesman) at the doctor's office? Not every Scalp Reduction patient will have a problem with a SLOT SCAR, but serious scarring (in general) is COMMON with this surgery.

This shows a TYPICAL OVERALL RESULT for the amount and type of surgeries he had.

Photos like this are NEVER been shown to potential customers, in a Hair Transplant Clinic... because honesty would be bad for sales.

SCALP LIFTS: The Scalp Reduction Gets Taken to Extremes

As I mentioned, your scalp is "anchored" all over your skull with connective tissue. The main diference between a Scalp Reduction (which we just saw) and a Scalp Lift, is that the area of scalp that is removed during a Scalp Lift is much larger. In order to close the bigger Scalp Lift gap, the scalp needs to be detached all over the skull, so that the scalp is loose enough to be pulled together closing a BIG gap. Detaching the scalp (cutting the connective tissue) is called "UNDERMINING". When a patient gets a large scalp lift procedure, the ENTIRE SCALP might be undermined. This radical surgery requires the patient to be "put to sleep", and the surgery must be done in a hospital setting.

Note that there are two basic types of Scalp Lifts: The Bitemporal Lift and the Bilateral Lift. The doctors who use these techniques often do these surgeries in combination with each other (first the Bilateral Lift, then several weeks or months later the Bitemporal Lift). We will look at both versions.

MAJOR PROBLEMS WITH SCALP LIFTS Massive permanent scarring, right in the middle of the patients' balding area, an area that is likely to show (also true of Scalp Reductions) as well as LONG scars that travel across the entire head. Trauma of surgery can "accelerate" patient's hair loss, by causing surrounding "weak" hairs to be permanently lost (also true of Scalp Reductions). Permanent numbness of the scalp, due to cutting of nerves (also true of Scalp Reductions). Remaining scalp is pulled way out of position, distorting the scalp and the remaining hair. The normal hairless gaps around the ears are enlarged, sometimes to a bizarre degree. The nape (neck) hair is often pulled up too high (the "mushroom cap" effect). The patient's remaining hair can often be permanently re-set at an unnatural angle. (These problems can happen to a degree with Scalp Reductions, but can become a MAJOR PROBLEM with Scalp Lifts). This permanent "repositioning" or distortion of the patient's scalp can have devastating consequences!

It's FOOLISH to think that a bald guy's "permanent fringe" of hair can be stretched to cover his entire head!!! But that is the "logic" behind the Scalp Lift!

BILATERAL SCALP LIFT

There are two basic approaches to Scalp Lifts: Bilateral and Bitemporal. The following surgical images are taken from Dr. James Swinehart's medical textbook "Color Atlas of Hair Restoration Surgery". Dr. Swinehart suggests that a good approach is to start with a Bilateral Scalp Lift, and then follow up with a Bitemporal Scalp Lift a few months later. That's what we will look at, here. Scalp Lifts need to be done in a hospital setting, with the patient knocked out. These surgeries are more dangerous to the patient than a regular hair transplant or scalp reduction. On the left we see the area that the doctor will remove with the Bilateral Scalp Lift (inside the solid "U" shape). The patient has been put to sleep with general anaesthesia. The goal of this surgery is to remove the "U" shape inside the solid lines, then pull the rest of the scalp up to close the gap. The patient has had a drainage tube surgically inserted into his scalp, behind his ear, that travels all the way around (under the scalp) to the other temple. This will drain the fluids that build up, post surgery, in response to all the trauma. The drain will remain in the patient's head for 24 hours post-surgery.

When a patient is scheduled to undergo extensive Scalp Lifting, it is recommended that several weeks before surgery, the two major arteries near the bottom of the rear skull are tied off during a "pre-surgery". This forces the body to develop "alternate routes" of circulation into the scalp. Understand that a major Scalp Lift typically severs these arteries. But when the patient has developed the alternate routes of circulation, it helps prevent post-operative scalp necrosis (tissue death). If this re-routing of circulation is not done prior to a large Scalp Lift, the patient's scalp could die... a MAJOR complication. Some patients undergo a Scalp Lift on "one side at a time" in order to reduce the risk of tissue death. We will see "Bilateral" and "Bitemporal" Lifts (both sides). I hope this web page will help consumers understand what is involved in a Scalp Lift. I can't include every single step of the surgery, because there isn't enough space to go into every detail. Consider this an overview. On the left, we can see that the doctor will make incisions that go all the way down into the patient's sideburns. I personally know of several Scalp Lift patients who now complain that the scars in the sideburn area are too visible. (I don't know any patients who are happy with their Scalp Lift results, but I do know guys who deeply regret having it done). The yellow arrow points to the line in the nape (neck) area showing how far down the "undermining" will go. The patient's scalp will be detached from his skull, down to that line. The more area that is undermined (detached), the larger the area that can be stretched; The larger the area that can be stretched, the more scalp up top that can be removed, and then the scalp sewn together. A lot of the stretching will come from the nape area. The hair on a patient's neck can sometimes be permanently stretched out of the correct position by a few inches.

Notice that the area about to be surgically removed still bears many useful hairs, that will soon end up in a garbage can. A logical and sensible approach to hair restoration surgery should try to conserve as much of the patient's 'natural' hair' as possible. But Scalp Lifts are not logical or sensible.

Undermining is done first, before the center U shape of balding scalp is removed. Note that they surgeon undermines well into the sideburn area. I do not enjoy presenting these images. But this is the reality of Scalp Lift surgery, which has been done on an (estimated) hundreds of thousands of patients, over the last 2 decades. Remember that the major difference between Scalp Lifts and Scalp Reductions is a matter of "degree". Scalp Lifts remove more scalp tissue, and require more extensive "undermining", but the goal is the same: removing a bald (or balding) area of scalp, then pulling the scalp together and sewing the gap closed. These surgeries are rarer now than they used to be, but they are still being done, even today.

Undermining continues. Side view of the patient, laying on his side. His shoulder is on the left, with his face pointing towards the bottom of the photo. Notice that I have condensed many of the steps, to keep this short. I could have included more grisly photos, if I was just trying to shock people. Many of the photos are redundant, or discuss the finer points, like pointing out major arteries, nerves and muscles. The lower hands (arrow A) pull the patient's ear forward for visibility, while the surgeon (arrow B) uses the blunt end of a tool to undermine down to the earlobe level. The surgeon is physically breaking apart the connective tissue that anchors the scalp to the skull. This is done using both blunt and sharp tools. Blunt tools are used to create deep tunnels into the connective tissue. Then the surgeon uses a surgical scissors to cut the connective tissue separating the deep tunnels.

Undermining complete. This is a "top view" of the patient, whose face is pointing down, towards the bottom of the photo. Next, the U shape inside the solid lines will be surgically removed.

Undermining complete. Patient is still facing down. This photo appears to be out of order, because it shows part of the U has already been removed. This is the sequence it appears in the book, though. We will see the U shape removed next. This photo is used to show the extent of undermining

Patient is still facing down. The surgeon begins cutting away the rear part of the U shape of balding scalp. The front part of the U shapes remains, but will be removed in another step. A scalpel is being used to sever the connective tissue, which anchors the patient's scalp to his skull. The scalp that is removed is thrown into the garbage can.

The rear part of the U has been removed, and the loose (undermined) scalp in the rear has been stretched forward, to join with the remaining "island". This is an intermediate step. Remember the patient is lying face down. The frontal part of the U shape still remains. Next, the surgeon grabs the loose scalp on both sides, and pulls up as far as possible. He will use the loose scalp to make a "blood print" on the frontal scalp, to show him how much of the remaining U he can remove. There is not enough space to show every single step.

Removing the front part of the U shape, on one side, based on the "blood print" shape. Patient is still lying face down, with his head slightly turned. The deep undermining makes it possible to pull the large gap closed on both sides.

The U shape has been completely removed. The surgery team uses physical effort to pull the loose (undermined) scalp on the sides up to join the remaining "island" of bald scalp. The surgeon uses a "Pulley Stitch" that will close both sides evenly. Most people do not realize how thick the scalp tissue is. The same depth that we see here is also removed, whenever a patient undergoes an ordinary donor strip hair transplant. Most people think of their hair as being "external" and don't realize how invasive the typical "Hair Restoration Surgery" is.

The Pulley Stitch in action. The undermined sides are drawn up towards the top of the skull. However deep the undermining goes, is how much scalp can be stretched, to close the gap. This will very likely pull the neck hair out of position.

Patient is finished with Bilateral Scalp Lift. Now the weeks of healing can begin. Notice how the hair on top of his head, was formerly on the sides. It is still angled the way it always was. However the hair on top of a person's head is generally angled forward. This patient's hair will not be angled correctly. Look at the nape of his neck, it already looks like the hair there is pulled out of position, too high to look natural. I will show examples of this effect later during PART 2

To see the "phase 2" of this process, the Bitemporal Scalp Lift, and also see some final results that show typical problems with Scalp Lifts, please click here for SCALP LIFTS PART 2.

We're about halfway done with SCALP LIFTS.

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