Scalp Reduction Surgery: Procedure, Risks and Alternatives

Hair loss is among the most common shared experiences that happen to men as they age, although many of us don’t like to talk about it. But whether you’re genetically predisposed to male pattern baldness (androgenetic alopecia) or losing hair for other reasons, you might be exploring treatment options like medications or hair transplant. 

Another option is scalp reduction surgery, or alopecia reduction (AR). This plastic surgery removes the parts of your scalp affected by hair loss and replaces them with skin containing active, growing hair follicles.

Below, we detail how scalp reduction works, how long recovery might take, potential risks, and alternatives you should know about when making a decision.

Compared to modern hair restoration techniques, scalp reduction is a relatively old cosmetic surgery. It was first developed around 1977 and was practiced throughout the late 70s, 80s, and 90s as a treatment method for extensive hair loss. 

To be honest, scalp reduction isn’t the best option anymore for most men. It’s pretty invasive and, as a result, can have a lengthier recovery than more modern hair restoration options. Because of this, most men opt for other surgical hair restoration procedures.

But let’s get back to the initial question: what is this procedure?

Scalp reduction surgery helps restore areas of lost hair. It involves surgically cutting away areas of your scalp with extensive hair loss and then stretching the areas of your skin that still have dense, thick hair to replace the removed skin.

In other words, you’re removing hairless skin and stretching hair-covered skin to replace those areas. It’s sort of like when you button a jacket to cover a stain on your dress shirt.

This procedure is done under anesthesia. First, the surgeon may make the cuts for skin removal in a few patterns, such as an ellipse pattern, a three-way (“rocket ship”) pattern, an S-shaped pattern, or an M-shaped pattern.

After removing the areas of skin with hair loss, the surgical wound is closed, which covers the hair loss-affected area and creates the appearance of a fuller, thicker head of hair.

As mentioned, scalp reduction surgery usually has a longer recovery time than other hair replacement procedures. Here are some things you might want to know about recovery if you’re considering this surgery: 

• Recovery time, pain, and outcomes depend on how much hair loss you’re treating and how extensive the surgical work is.

• You won’t be able to wash your hair the first few days, but most people can gently scrub their scalp by day three.

• You’ll typically have stitches or sutures removed between one week and ten days after the surgery.

• Common complaints are pain, feelings of tightness, and throbbing sensations — all of which can be managed with pain medications.

• As with other surgeries, your stitches are susceptible to bleeding if you do strenuous activity, so it’s best to find lower-impact exercise options for the first few weeks.

• Touch-up procedures may be necessary later but are generally less invasive and intense than the initial surgery.

Furthermore, the American Society of Plastic Surgeons says your hair may fall out for approximately six weeks following surgery. After that, it can take another six weeks to see new hair growth.

Why Would You Have Scalp Reduction Surgery?

While scalp reduction surgery helps create the appearance of fuller, thicker hair by pulling hair where you want it, it doesn’t increase the number of hairs in your bald patches. So, why would someone be interested in this procedure?

There are four primary reasons you might have scalp reduction surgery:

• It can treat extensive hair loss. The biggest advantage of scalp reduction surgery is that it can create the appearance of a fuller head of hair in men with extensive hair loss. When performed correctly, scalp reduction can often have a convincing, aesthetically pleasing result, even in large areas of your scalp. 

• The source hair is more resistant to hair loss. A second advantage of scalp reduction surgery is that the hair used to cover the bald area of the scalp is sourced from the back and sides of the head. This hair is more resistant to dihydrotestosterone (DHT), the hormone that causes male pattern baldness, and is, therefore, less likely to fall out in the future.

• It’s safer than you’d expect. From a surgeon’s perspective, most scalp reduction procedures are relatively safe and easy to perform. This made scalp reduction surgery a popular option for treating hair loss before more modern techniques were developed.

• It can be combined with other techniques. These days, scalp reduction surgery is sometimes combined with other surgical procedures, such as hair transplant surgery. This combination uses donor hairs to give you extra coverage and improved thickness in certain areas of the scalp.

So, who makes an ideal candidate for scalp reduction? Honestly, the people with the worst hair loss — those who might otherwise feel too far gone. 

A good candidate for this surgical procedure has:

• Extensive hair loss

• Thick hair on the hair-bearing scalp

• Lots of hair on the sides and back of their head and neck

• Tried other (less-invasive) treatments and hasn’t seen results

Scalp reduction surgery is generally recommended for men above age 40 with Norwood Grade 4, 5, or 6 hair loss, which is, significant hair loss on the frontal scalp and crown. It’s also better if the hair loss is stable or not getting significantly worse.

The Norwood Grading System evaluates the extent of male pattern baldness, categorizing hair loss into seven stages, with seven being the most severe. In the case of Grade 7 hair, you might only have a narrow ring of hair remaining around the sides and back of your head.

Scalp reduction surgery is also usually recommended for guys with dense hair on the sides of the scalp since this is where the skin used to cover baldness will come from.

If you’re considering scalp reduction surgery, your surgeon will pick the most effective incision type based on your hair loss pattern, scalp laxity (how tight or loose your skin feels), and other factors.

Scalp reduction surgery has declined in popularity over the last several decades largely due to its lengthy list of disadvantages, including:

• An unusual shape to the residual bald area. The shape of the area treated with scalp reduction surgery can become irregular over time, leading to an unnatural appearance that’s often difficult to conceal.

• “Stretch-back.” Stretch-back is when the hair-bearing skin used for scalp reduction surgery stretches over time. It can result in a large, hairless area around the incision, often in the middle of the scalp.

• Scarring. Since scalp reduction surgery involves surgically cutting away parts of the scalp, scarring is an unavoidable side effect. Luckily, scarring from scalp reduction surgery can be concealed under your hair most of the time. However, some patients develop noticeable scarring, especially if their hair is short or light in color.

• Ongoing baldness. Though scalp reduction surgery can help cover areas with hair loss, it doesn’t actually prevent more of your hair from falling out. So, yes, you may continue to lose hair after the surgery. And if your baldness worsens after surgery, it may expose the scars from the scalp reduction procedure.

• Surgical complications. Like other surgical procedures, scalp reduction surgery may lead to complications. Bleeding, infection, a tingling sensation or numbness, and issues with the wound not closing or healing correctly can and do occur.

Everyone’s situation and preferences are different, which means that while we’re not saying scalp reduction should be a last resort, it shouldn’t be at the top of your list either. 

Newer treatment options, such as hair transplant surgery and hair loss medications like finasteride and minoxidil have largely replaced this type of hair restoration surgery.

Hair Transplant

A hair transplant is a cosmetic surgical procedure that involves extracting hairs from the back and sides of your scalp (areas resistant to DHT) and then transplanting them to your hairline, crown, or other parts of the scalp with noticeable hair loss. This can be done with smaller strips of skin or even one hair at a time.

Early transplants were infamous for their “pluggy” appearance, but modern hair transplant techniques usually create hairlines with a natural look and feel. 

The problem in most cases is cost. Hair transplant surgery isn’t cheap, and depending on the size of your transplant, your location, and the surgeon you choose, your bill could be anywhere from $3,000 to $15,000 (or more).

Hair Loss Medications

Want something more affordable? Medication might be the answer.

There are two science-based medications approved by the Food and Drug Administration (FDA) to slow down or stop hair loss and stimulate the growth of new hair: 

• Finasteride. Finasteride is an oral medication that prevents the conversion of testosterone to DHT. Research shows that finasteride is highly effective at preventing hair loss. For example, a long-term study in Japan found that over 99 percent of balding men who used finasteride experienced no worsening of their hair loss over ten years. Furthermore, about 92 percent of the men experienced an improvement in hair growth while taking finasteride. 

• Minoxidil. Minoxidil is a topical, over-the-counter medication that stimulates hair growth and slows down hair loss. It’s available as a liquid or foam and is applied directly to the scalp in areas with noticeable thinning. 

We offer oral finasteride, topical minoxidil (as a foam and a solution), and a combination topical minoxidil and finasteride spray.

Although scalp reduction surgery was a popular hair loss treatment in the past, it’s just not at the top of the charts anymore. 

You may have valid reasons to get hair grafts for your scalp — especially if your trusted healthcare provider believes it’s a good fit. Still, the decision to go through with scalp reduction shouldn’t be taken lightly.

Here’s what to keep in mind when weighing your options:

• It’s one part of a whole solution. Scalp reduction surgery was one of the first mainstream surgical procedures for treating hair loss. Today, it usually works best when it’s performed in combination with hair transplant surgery. As with many health procedures, it’s not a one-and-done situation since it won’t prevent more hair loss in the future. 

• It’s not for everyone. If you have thin hair on the back and sides of your scalp or near-total hair loss (like a Norwood Grade 7 pattern), scalp reduction surgery may not be appropriate for you. Also, several factors limit the extent of the scalp that can be removed, including the flexibility of your skin and the amount of skin stretching that may occur following surgery.

• Other options are available for treating less extensive hair loss. FDA-approved medications like finasteride and minoxidil can help preserve your hair and prevent further thinning. It’s best to chat with a hair restoration specialist or plastic surgeon to determine the best steps and treatment strategy for your unique needs and goals.

We offer many hair loss treatments online to explore, including minoxidil and finasteride, both of which are included in our Hair Power Pack. 

Have questions about what option makes the most sense for you? Start by taking our free online hair quiz.