JURI FLAP

The Juri flap is a pedicled transposition flap based on the STA (16). A single flap is used for frontal hairline restoration in patients with hair loss limited to the frontal region. In suitable candidates with more advanced balding over the top of the head, two flaps and a scalp reduction can be staged to provide about 12 cm of dense hair in the frontal and mid-scalp regions.

The Juri flap requires four stages for completion. The first stage begins with designing a hairline and the flap (Fig. 188.6). The STA is identified by Doppler ultrasonography about 3 cm above the root of the helix. The flap is 4 cm wide and has the STA located in the central portion of the base. The base begins posteriorly about 3 cm above the root of the helix and inclines 35 to 45 degrees in an anterior and superior direction. The flap is arched superiorly into the temporal scalp and gently turned posteriorly and inferiorly into the parietal and occipital regions, taking care not to cross the midline or to extend into any areas having the potential for future hair loss. The flap length is determined by measuring the distance from the base of the flap across to the distal end of the frontal hairline. About 4 cm is added to accommodate the dog-ear that forms when the flap is transposed.

FIGURE 188.6. The Juri flap. Left: The temporal and parietal portions of the flap are incised during the first stage (solidlines). The second stage involves mobilizing the tail of the flap in the occipital region (dashed lines). Center: The donor site is closed, and the flap is transposed during the third stage. Right: The flap is designed to recreate the frontal hairline.

The first two procedures are performed using a local anesthetic. To prevent flap necrosis, epinephrine is never used near the base or the tail of the flap. The first stage consists of incising the proximal three fourths of the flap through the galea aponeurotica, taking care to maintain a bevel that preserves hair follicles. The flap is not elevated during this stage. One week later the tail of the flap is incised and elevated to the level of the previous week's incision lines. The occipital vascular plexus is cauterized or ligated and the flap then laid down without entering the region of the prior week's procedure.

The flap is transposed 1 week after the second delay procedure, most often under general anesthesia. The flap is elevated in a subgaleal plane and carefully inspected for adequate circulation at the distal end. A beveled incision is made across the planned anterior hairline, and the scalp is widely undermined in a subgaleal plane superior and inferior to the flap donor site. Homeostasis is checked, and the donor site is closed in layers.

After the donor site is closed, the flap is transposed to lie across the frontal region. A 1-mm strip of epidermis is removed from the frontal edge of the flap with fine forceps and tenotomy scissors. This maneuver allows the surgeon to bury a small strip of dermis along the hairline aspect of the flap below the forehead skin. As hair grows along the deepithelialized strip, it will exit through the overlying forehead skin and incision line, thereby helping to camouflage the frontal scar. The frontal incision line is carefully sutured together. Any overlapping bald skin posterior to the flap is then excised, taking care to avoid tension along the incision line.

Any dog-ear that forms at the transposition site is revised 6 weeks after rotating the flap. The flap is cut directly across the dog-ear. Limited incisions are made adjacent to this cut along the anterior and posterior margins of the flap. The base of the flap is rotated posteriorly, thereby restoring natural hair direction over the entire temporal scalp. The hairline side of the cut flap is then turned posteriorly to recreate a frontotemporal triangle that is symmetric with the contralateral side. Overlapping bald skin posterior to the flap is excised to accommodate proper flap positioning.

If needed, a second flap is placed 4 cm posterior to the first flap 2 to 3 months after restoration of the frontal hairline. The bald space between the two flaps is excised 2 to 3 months later, resulting in 12 cm of dense hair coverage over the anterior scalp.

One sequela of the Juri flap is the posteriorly oriented frontal hair that results after flap transformation. The severe complications of scalp necrosis and permanent hair loss are more common with flap procedures than with other forms of hair-restoration surgery. These problems are unusual in patients with normal scalp circulation; however, patients with a history of extensive donor graft harvesting over the flap's donor site are especially prone to these complications. Poor hairline design, wide scars, infection, and hematoma are other possible complications of frontal flap hairline restoration.

HIGHLIGHTS

Androgenetic alopecia, commonly referred to as male pattern baldness, is the most common cause of hair loss in adults.

Many surgical options are available to manage all but the most severe cases of alopecia.

Currently, topically applied minoxidil (Rogaine) and oral finasteride (Propecia) are the only medications approved by the FDA for the medical management of hair loss in humans.

The term donor dominance refers to the fact that hair-bearing autografts maintain characteristics of the donor tissue when transplanted into other regions of the body.

In the past, standard punch-graft techniques were often criticized for producing unnatural, artificial-appearing hairlines, especially in patients with straight dark hair and light skin color. Technical advances with minigraft and micrograft hair transplants allow the reconstruction of natural, non-surgical-appearing frontal hairlines.

Various scalp reduction techniques are available to reduce crown baldness, offering hope for patients with advanced alopecia who want to attain natural hair restoration over the entire scalp.

Tissue expansion permits the effective removal and restoration of large alopecic regions in patients with tight, inflexible scalps. For patients desiring maximum hair density, the Juri flap is another tested option for completely restoring the frontal hairline.

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