Forehead, Skull Reconstruction - Hair Restoration

Question 1

A 37-year-old woman who has Fitzpatrick type I skin requests intense pulsed-light therapy for reduction of blond hairs over the upper lip. Compared with a person with darker hair, which of the following best describes the outcome of this procedure?

(A) Decreased risk for permanent scar

(B) Decreased risk for prolonged erythema

(C) Increased risk for hyperpigmentation

(D) Increased risk for malignant transformation

(E) Less effective hair reduction

Answer 1

The correct response is Option E.

Melanin is the target chromophore for laser and intense pulsed-light (IPL) hair reduction. Melanin pigment is responsible for skin and hair color and absorbs energy at wavelengths of 250 to 1200 nm. Thermal injury to the melanin €‘containing cells of the bulb and matrix results in destruction of the hair follicle. Patients with greater melanin content have darker hair and are more likely to have effective laser or IPL hair reduction. In very fair-haired individuals, the limited melanin content makes hair reduction less effective. At higher energy levels, fair-skinned patients can have prolonged erythema. In patients with darker pigmentation, surrounding skin can absorb energy, resulting in blistering or pigment changes.

Question 2

Which of the following is a CONTRAINDICATION to the use of finasteride as a treatment for premenopausal women with hair loss?

A) Amenorrhea
B) Galactorrhea
C) Hirsutism
D) Masculinization of facial features
E) Pregnancy

Answer 2

The correct response is Option E.

Although FDA-approved for male-pattern hair loss, finasteride is not approved by the FDA for use in women. It is classified as Pregnancy Category X (highest risk) and should not be taken or handled by pregnant women, women who may become pregnant, or those who are breast-feeding. Finasteride has been linked to abnormalities of the external genitalia of a male fetus of a pregnant woman who receives finasteride.

The other choices are not common problems with finasteride, although breast tenderness has been reported.

European studies have selectively used the drug in women for cases of hair loss associated with hyperandrogenism.

Question 3

A 55-year-old man who has had stable hair loss for the past several years wishes to undergo hair transplantation. Conservative management with administration of finasteride has not been successful. On examination, he has Hamilton’s class 6 male pattern alopecia that extends from the anterior hairline to the vertex. He has dense, curly hair in the parieto-occipital region of the scalp and excellent scalp vascularity and elasticity.

Which of the following is the most appropriate initial management?

(A) Psychological profile and screening
(B) Trial therapy with minoxidil
(C) Establishing the anterior hairline with punch grafts
(D) Establishing the anterior hairline with scalp flaps
(E) Sagittal scalp reduction

Answer 3

The correct response is Option E.

Scalp reduction is currently the most appropriate management of male pattern alopecia. This technique is simple and associated with few complications. Surgical removal of the hairless scalp will diminish the total area that requires grafting and will assist with conservation of donor sites. Although various excision patterns can be used based on baldness pattern, sagittal excision patterns are preferred because they will remove the greatest amount of bald skin due to the excess of scalp laxity seen in the sagittal plane. The surgeon should perform scalp reduction before surgically re-establishing the anterior hairline.

Minoxidil is an antihypertensive drug that has been shown to increase hair growth when applied to the scalp of men who have thinning hair. However, this drug does not work in patients who have extensive hair loss, such as those
Psychological screening is not routinely performed in patients who request treatment of male pattern alopecia.

Question 4

Which of the following is most closely associated with male pattern alopecia?
A) Absence of a genetic predisposition
B) Decreased activity of 5alpha-reductase within genetically susceptible hair follicles
C) Increased serum level of testosterone
D) Prolonged anagen phase
E) Prolonged telogen phase

Answer 4

Correct answer is E.

Male pattern alopecia is associated with a prolonged telogen, or quiescent, phase of the hair growth cycle. During this phase, the follicle becomes inactive, and active hair growth ceases.

Inheritance is the only known cause of male pattern alopecia. Although hereditary alopecia is controlled by a single, dominant, X-linked autosomal gene, polygenetic modifying factors, such as androgen production and age, affect its expressivity.

Male pattern alopecia can only be triggered by a normal adult male serum androgen level if there is genetic predisposition.

Alopecia results from increased 5alpha-reductase activity within genetically susceptible follicles.

It has not been shown to be associated with increased plasma levels of testosterone.

The anagen phase of the hair cycle, during which hair actively grows, is typically shortened in patients with alopecia.

Question 5

Alopecia results when which of the following changes in the hair growth cycle occur?

      Shortened        Prolonged

(A) Anagen phase Catagen phase

(B) Anagen phase Telogen phase

(C) Catagen phase Telogen phase

(D) Telogen phase Anagen phase

(E) Telogen phase Catagen phase

Answer 5

The correct response is Option B.

Balding occurs when the anagen phase is shortened and the telogen phase is prolonged.

Human hair undergoes a normal cycle of growth and rest characterized by three stages: anagen, catagen, and telogen. The anagen (active) phase lasts 1000 days in men and two to five years longer in women. At any one time, 85% to 90% of hairs are in the anagen phase. The catagen (degradation) phase follows anagen and lasts several weeks. During this phase, the follicular bulb atrophies and degrades. After this, the telogen (resting) phase begins and lasts two to four months. At any given time, approximately 10% of hairs are in the telogen phase. On average, 50 to 100 telogen hairs fall out every day and are replaced with new growing hairs. Balding occurs when the anagen (active) phase is shortened and the telogen (resting) phase is prolonged.

Question 6

Which one of the following statements is correct regarding the blood supply to the scalp?
A) The anterior scalp is supplied by the supraorbital and supratrochlear vessels from the external carotid artery.
B) The supratrochlear vessels are lateral to the supraorbital vessels.
C) The posterior territory is the largest area and is supplied by the occipital vessels.
D) The lesser occipital artery supplies the posterolateral scalp.
E) The lateral territory is supplied by the superficial temporal artery, which arises from the external carotid artery.

Answer 6

Convert answer is E.

The lateral territory is supplied by the superficial temporal artery, which arises from the external carotid artery.

The scalp derives its blood supply from both the internal and external carotid systems. It is divided into four zones: anterior, posterior, lateral, and posterolateral. Each zone has its own blood supply, with collateralization between zones. This is clinically relevant with respect to scalp reconstruction using local flaps.

The anterior scalp is supplied by the supraorbital and supratrochlear vessels. These derive from the internal carotid vessels (not the external carotid vessels). The supratrochlear vessels lie medial (not lateral) to the supraorbital vessels.

The posterior territory is supplied by the occipital vessels and perforators from the splenius capitis and trapezius, but it is not the largest territory.

The largest is the lateral territory, which is supplied by the superficial temporal arteries. A lesser occipital artery does not exist. The greater and lesser occipital nerves supply sensation to the occipital territory.

The posterolateral scalp is the smallest territory and is supplied by the posterior auricular artery.

Question 7

A 65-year-old woman who has undergone multiple resections for recurrent lentigo maligna melanoma with repeated central advancements of the remaining scalp via skin grafting over the past 10 years has frequent irritation of the skin at the grafting sites (image shown). No evidence of further disease has been noted over the past four years. Which of the following is the most appropriate management at this time?

A) Full-thickness skin grafting
B) Micrograft hair transplantation
C) Rerotational flap advancement
D) Staged excision and primary closure
E) Tissue expansion

Answer 7

Correct answer is E.

Because of continued skin breakdown in this area of postsurgical alopecia, tissue expansion followed by adjacent tissue transfer is the most appropriate surgical procedure at this time. This patient has had multiple excisions with repeated advancement followed by skin grafting. The remaining native vessels should be sufficient to supply the expanded scalp skin. Tissue expansion and coverage are usually tolerated well by patients of this age.
Hair transplantation is unlikely to be successful in this patient because of extensive scars in the area. Staged excision of the prior skin grafts and primary closure will not improve this patient’s alopecia and are unlikely to relieve the skin irritation caused by the thinned skin over the calvaria. Because advancement has already been done, little additional advancement can be achieved without back-grafting exposed areas. Full-thickness grafts will not allow sufficient hair growth or replacement.

Question 8

Male pattern baldness is characterized by which of the following growth phase disturbances?

Answer 8

The correct response is Option A.

Male pattern baldness follows an X-linked dominant inheritance pattern. The anagen phase of hair growth is the active growth phase and lasts approximately 1000 days in men. In the anagen phase, follicular cells are actively multiplying and becoming keratinized. In men with normal hair growth, 85 to 90% of hairs are in this phase, with hair growing 1 cm per month. The catagen phase is known as the transitional or degradation phase and typically lasts 2 to 3 weeks and is characterized by atrophy of the bulb, with keratinization of the hair base, and separation of the hair base from the dermal papilla. The telogen phase of hair growth usually lasts 3 to 4 months and is also known as the resting phase and is characterized by the inactivation of the hair follicle, cessation of hair growth and hair shedding.

In men with normal hair growth, 10% of hair follicles are in the telogen phase, causing approximately 50 to 100 hairs to be shed on average per day. In male pattern baldness there is an increased percentage of hairs in the telogen phase and a decreased percentage of hairs in the anagen phase.

Question 9

A 44-year-old woman comes to the office for consultation regarding loss of hair on the scalp. Which of the following findings in this patient is LEAST amenable to surgical follicular transplantation?
(A) Alopecia associated with chronic telogen effluvium
(B) Alopecia at the site of surgical scars
(C) Frontal temporal alopecia
(D) Generalized thinning of hair with discrete areas of alopecia
(E) Global diffuse thinning of hair

Answer 9

The correct response is Option A.

Female alopecia differs from male alopecia in that it requires a more in-depth history and workup because of the numerous hormonal and medical causes for hair loss in women.

Alopecia due to hormonal and medical causes, including chronic telogen effluvium (persistent increased telogen hair shedding), is usually not responsive to surgical hair restoration, and such procedures may exacerbate the alopecia.

Patients with global diffuse hair thinning may benefit from surgical restoration; however, in these patients, donor hair tends to be of poor quality.

Generalized hair thinning with discrete areas of alopecia is the most common pattern of hair loss in women and is responsive to surgical restoration. Traumatic or surgical scar alopecia may also respond to surgical restoration.

Women with frontal temporal alopecia may be treated in a similar manner as patients with male pattern hair loss.

Question 10

In micrografting hair transplantation, which of the following best represents the structure of the transplanted unit?
(A) Isolated hair follicles
(B) Hair follicles with dermal elements
(C) Hair follicles with subcutaneous tissue
(D) Hair follicles with galea
(E) Hair follicles with pericranium

Answer 10

The correct response is Option B.

Hair in healthy scalp grows in one, two, three, or four hairs, each with their own associated neurovascular bundles, sebaceous glands, sweat glands, and piloerectile muscles surrounded by collagen. These €œphysioanatomic € units, when used as micrografts, have been shown to provide excellent results in hair transplantation.

The anatomy of an individual hair follicle includes the dermal papillae bulb, consisting of the dermal and epidermal coat. The dividing cells within the bulb form a cement column of keratinized dead cells held together with a cystine matrix to make the hair shaft.

The macroscopic hair transplantation technique of hair plugs with multiple hair follicles, intervening skin, subcutaneous tissue, epicranial and subepicranial tissue can successfully transplant hair but with an unnatural appearance.

Question 11

Hair follicles are found in which of the following layers of the scalp?
A) Epidermis
B) Papillary dermis
C) Reticular dermis
D) Subcutaneous layer

Answer 11

Correct answer is D.

The hair follicles are located within the subcutaneous layer of the scalp. Human hair is primarily composed of the keratin protein; the hair shaft is produced by the matrix, which is in turn produced by the follicle. Hair follicles are indentations of the epidermis located within the subcutaneous layer of the scalp. It is important to know the anatomy of the hair follicle in order to successfully harvest and transplant scalp hair, which can be retained with some degree of permanence following transplantation. Because successful punch grafting depends on meticulous technique, the grafts should be harvested at the appropriate depth while avoiding trauma to the hair follicles.

Question 12

A 7-year-old girl who sustained burns to the head three years ago is scheduled to undergo reconstruction with tissue expansion. Preoperative physical examination shows a 7-14 cm area of alopecia on the scalp and scarring on the forehead. Which of the following is the most appropriate placement of tissue expanders in this patient?
A) Deep to galea and superficial to pericranium
B) Deep to the galea and superficial to the frontalis muscle
C) Deep to the pericranium and deep to the frontalis muscle
D) Deep to the pericranium and superficial to the frontalis muscle
E) Superficial to the galea and deep to the frontalis muscle

Answer 12

Correct answer is A.

To provide the maximal amount of safe expansion, tissue expanders are placed between the galea and periosteum in the scalp and between the frontalis muscle and periosteum in the forehead. Placement of the expander deep to the periosteum would result in difficult, painful, and unpredictable expansion. Placement of the expander superficial to the galea might result in premature extrusion of the device and an unreliable flap after its removal. Expansion of the galea and frontalis is critical in optimizing blood supply to the expanded forehead skin and scalp.

Question 13

A 41-year-old woman comes to the office for consultation regarding breast reconstruction after mastectomy. She is also embarrassed by her sudden loss of hair as a result of chemotherapy with paclitaxel. All of her hair has fallen out, and she wears a wig. Which of the following is the most likely diagnosis for this patient’s hair loss?

A) Alopecia areata
B) Anagen effluvium
C) Androgenetic alopecia
D) Telogen effluvium
E) Traction alopecia

Answer 13

The correct response is Option B.

Anagen effluvium occurs after an insult to the hair follicle that impairs its mitotic or metabolic activity. This hair loss is commonly associated with chemotherapy. The characteristic finding in anagen effluvium is the tapered fracture of the hair shafts. The hair shaft narrows as a result of damage to the matrix. Eventually, the shaft fractures at the site of narrowing and causes the loss of hair. Hair regrowth occurs after the cessation of chemotherapy.

Androgenetic or androgenic alopecia is caused by the action of androgens. Dihydrotestosterone (DHT) is partially to blame, as it is in men. Androgenic alopecia can be caused by a variety of factors tied to the actions of hormones, including some ovarian cysts, taking high-androgen-index birth control pills, pregnancy, and menopause.

Telogen effluvium is attributable to stress on the body, such as childbirth, malnutrition, severe infection, major surgery, or extreme mental stress. Many of the 90% or so of hairs in the growing (anagen) or transitional (catagen) phases can shift all at once into the resting (telogen) phase. A few weeks to several months after the stressful event, a shedding phenomenon called telogen effluvium begins. It is possible to lose handfuls of hair at a time. This phenomenon is usually self-limited, and hair growth returns.

Alopecia areata is an inflammatory condition thought to result from the immune system attacking the hair follicles at the root. Treatment may include steroids or minoxidil. Hair loss can be temporary or permanent.

Traction alopecia is caused by localized trauma from tight hairstyles, braids, cornrows, etc. If recognized early enough, the hair will grow back.

Question 14

A 27-year-old man has traumatic absence of the lateral third of the right eyebrow one year after sustaining avulsion and laceration injuries to the forehead and cheek. On current physical examination, there is an avulsion scar in the supraorbital region and a laceration extending from the lateral canthus directly posterior to the temporal scalp, both of which are well healed. The patient would like to undergo reconstruction of the avulsed eyebrow.

Which of the following is the most appropriate reconstructive option?

(A) Composite scalp graft containing hair follicles
(B) Median forehead flap containing hair-bearing tissue from the anterior scalp
(C) Temporal scalp flap based on the ipsilateral superficial temporal artery
(D) Washio flap
(E) Microplug hair transplantation

Answer 14

The correct response is Option A.

In this patient who has absence of the lateral third of the eyebrow resulting from trauma, composite grafting from the scalp is the most appropriate reconstructive option. This technique would be associated with the greatest chance for hair growth in this patient; in addition, the donor scar would be inconspicuous.

Reconstruction with a median forehead flap is a procedure that requires multiple stages and would result in an unsightly donor site scar. Both the temporal scalp flap and Washio flap would be based on the posterior temporal branch of the superficial temporal artery; however, this artery was most likely transected when the patient sustained the facial laceration, eliminating the possibility of using these flaps. Microplug hair transplantation is unreliable over scar tissue, especially traumatized soft tissue and radiated scars.

Question 15

An otherwise healthy 26-year-old man with a receding hairline presents for hair restoration of the frontal scalp. Which of the following phenomena most accurately describes features associated with this patient’s condition?

A) Absence of vellus hairs
B) Decreased duration of telogen
C) Eosinophilic perifolliculitis
D) Increased duration of anagen
E) Miniaturization of hair follicles

Answer 15

The correct response is Option E.

Male androgenic alopecia is determined by a genetic predisposition. The normal anagen-catagen-telogen cycle is disturbed, and the anagen:telogen ratio is altered. This is due to the lengthening of the telogen denominator in this ratio. Additional aspects include gradual replacement of the normal hair shafts with vellus hair, miniaturization of the hair follicle, and an activated T-cell lymphohistiocytic perifollicular inflammation.

Question 16

According to the donor dominance concept of hair transplantation, which of the following is the most appropriate donor site?

(A) Frontal scalp
(B) Occipital scalp
(C) Parietal scalp
(D) Sideburn
(E) Vertex

Answer 16

The correct response is Option B.

In order to successfully transplant hair using minigrafting or micrografting techniques, the surgeon must understand the concept of donor dominance, which states that each hair follicle possesses its own individual, genetically-defined lifespan. Because of this, hair follicles located in those areas that tend to have a longer lifespan will continue to possess the same lifespan even after they have been transplanted. The hairs of the occipital scalp have the longest genetically-defined lifespan in most patients; in addition, this donor site is acceptable aesthetically.

Depending on the classification of male-pattern alopecia, early hair loss can occur in the frontal, parietal, or vertex regions. The sideburns often have a lifespan that is genetically similar to the occipital area, but the donor site is quite small and usually unacceptable.

Question 17

A 55-year-old woman presents with androgenic alopecia. Her husband had a hair transplant 5 years ago. Which of the following characteristics of androgenic alopecia is more common in women than men?

A) More rapidly progressive
B) Not induced by dihydrotestosterone
C) Thinning tends to be frontoparietal
D) Topical minoxidil is ineffective

Answer 17

The correct response is Option C.

Unlike in men, androgenic alopecia in women tends to spare the frontal hairline and tends to affect the frontoparietal scalp. Like in men, it is a chronically progressive disease and causes miniaturization of scalp follicles through exposure of endogenous dihydrotestosterone in patients with increased scalp androgen receptors and 5-reductase concentrations. Topical minoxidil has been shown to increase scalp blood supply and slow hair loss in both males and females.

Question 18

Which of the following terms represents the primary active phase of hair growth?

(A) Anagen
(B) Anaphase
(C) Metaphase
(D) Telogen
(E) Telophase

Answer 18

The correct response is Option A.

Normal hair growth involves two primary phases. The active phase, anagen, is the phase of hair growth. In this phase, which can last three to five years, approximately 85% of hair follicles produce hair. The resting phase, telogen, heralds the loss of the hair shaft and affects approximately 15% of hair follicles at any given time. Balding occurs when the anagen phase is shortened and the telogen phase is prolonged.

Anaphase, metaphase, and telophase are all phases in cell division and the replication of deoxyribonucleic acid. They are not specifically related to hair growth.

Question 19

A 13-year-old girl is brought to the office by her mother who is concerned about the child’s patchy hair loss. The mother began to notice the hair loss shortly after she separated from the patient’s father. The patient states she often plays with her hair throughout the day. Which of the following is the best course of treatment for this patient’s hair loss?

A) Administration of topical minoxidil 5% daily for six months
B) Injections of platelet-rich plasma to areas of baldness
C) Injections of triamcinolone to areas of baldness
D) Referral to a psychiatrist
E) Transplantation of follicular units

Answer 19

The correct response is Option D.

This patient most likely has trichotillomania, an impulse-control disorder. This is likely associated with a change in the patient’s social situation, namely the loss of involvement of her father in her life.

The other treatment options do have proven benefits in restoring hair loss, but the best course of treatment is first addressing the underlying cause, and referral to a psychiatrist would be the most appropriate step.

This patient has signs of telogen effluvium, alopecia caused by emotional stress. With appropriate psychiatric or psychological therapy, she should be expected to stop traumatizing her hair, and its growth would return.

The other options can improve thinning hair for various other causes, but they would not be the first course of treatment for this patient.

Question 20

A 27-year-old man comes to the office for hair restoration to correct alopecia of the scalp. He sustained a burn injury to the scalp when he was a child and underwent split-thickness skin grafting to treat the burn. Micrograft hair transplantion to restore the hairline is planned. Which of the following is the most likely percentage of micrograft survival and ultimate hair growth in this patient?

A) 10%
B) 25%
C) 50%
D) 85%
E) 95%

Answer 20

The correct response is Option D.

Because of their small size, micrografts and minigrafts appear to have a lower metabolic requirement to thrive. They tend to grow in areas of fibrosis and burn scars and over skin grafts and flaps, including split-thickness skin grafts. The rate of survival and ultimate hair growth under these circumstances appears to be approximately 85%, compared with approximately 95% on unscarred, healthy tissue. More recently, follicular unit grafts have been used in hair transplantation.

Question 21

A 20-year-old woman underwent subgaleal placement of two rectangular tissue expanders for an 8-cm area of burn alopecia at the vertex of the scalp. During the expansion, the skin over both expanders became red and mottled. The patient is afebrile and leukocyte count is within normal limits. Which of the following is the most appropriate next step?
A) Collect aspirate from expanders for culture
B) Continue the expansion procedure
C) Deflate both expanders
D) Initiate intravenous antibiotic therapy
E) Remove both expanders

Answer 21

Correct answer is B.

In a patient undergoing tissue expansion, redness and mottling of the skin over the implant is common. The next step in management is to do nothing and continue expansion.
Tissue expansion of the scalp is well tolerated and provides hair-bearing tissue to cover defects. Approximately 50% of the scalp can be reconstructed with expanded scalp tissue. A frequent complication from an expander is a superficial infection. Redness and mottling of the skin over an implant is cause for concern when the patient has a fever, spreading erythema, or frank pus. Any combinations of these factors may warrant aspiration of the expander fluid, initiation of intravenous antibiotics, or operative removal of the expander.
If infection is not suspected, expansion can proceed normally. There is no need to deflate the expander prematurely.

Question 22

An otherwise healthy 45-year-old man presents for evaluation of progressive frontal hair loss. He reports his grandfather went bald early in life. He is interested in surgical hair restoration methods but would prefer to avoid long, unsightly scars and prolonged recovery. Which of the following is the most appropriate method for hair restoration in this patient?

A) Follicular unit transplantation
B) Hair-bearing scalp flaps
C) Micrograft unit transplantation
D) Minigraft unit transplantation
E) Tissue expansion

Answer 22

The correct response is Option A.

This patient has androgenetic alopecia. Androgenetic alopecia, or patterned alopecia, is the most common form of hair loss in both men and women and is characterized by a progressive loss of hair diameter, length, and pigmentation. The genetic inheritance of androgenetic alopecia is well known, although the causative genes have yet to be elucidated. In genetically predisposed males and females, androgenetic alopecia is caused by progressive shortening of the anagen stage and an increase in the number of hair follicles in telogen. Follicular unit hair transplantation is the gold standard, because it preserves the natural architecture of the hair units and gives natural results. The follicular unit (FU) was first described by Headington in 1984 and was shown to include 1 to 4 terminal follicles, 1 or 2 vellus follicles, and perifollicular vascular and neural plexi, all surrounded by concentric layers of collagen fibers. Seager later showed that when single-hair micrografts were generated by breaking up larger FUs, their growth was less than when the FUs were kept intact, supporting the concept of the FU as a physiologic entity, rather than just an anatomic one. This gave rise to the FU transplant era, in which grafts are single FU or multi FU (2–3 FU). It was found that peripheral areas such as the hairline naturally have 1- and 2-hair FUs, whereas the more central regions have more 3- and 4-hair FUs.

“Micrografts” (1–2 hairs) and “minigrafts” (3–6 hairs) have been used in the past for hair transplantation but are not quite as effective as follicular unit transplantion and produce less natural appearing results.

Tissue expansion and scalp flaps are generally reserved for scalp burn wounds or wounds of traumatic nature with significant hair loss. They generally leave long scars and may require multiple stages and prolonged recovery which would likely not be acceptable for this patient.

Question 23

The mechanism of action of finasteride (Propecia) involves inhibition of which of the following enzymes?

(A) 2beta-hydroxylase
(B) 5alpha-reductase
(C) 6beta-hydroxylase
(D) 7alpha-hydroxylase

Answer 23

The correct response is Option B.
Finasteride is a competitive and specific inhibitor of type II 5alpha-reductase that converts testosterone into dihydroxytestosterone (DHT). Type I 5alpha-reductase is predominant in the sebaceous glands of the skin, scalp, and liver; type II 5alpha-reductase is also found within the liver, as well as in the prostate, seminal vesicles, epididymides, and hair follicles. The conversion of approximately one-third of circulating DHT is mediated by type I, and type II is responsible for the conversion of the remaining circulating DHT.

In men with androgenetic alopecia, hair follicles within the balding areas of scalp are miniaturized, and DHT levels are increased. The mechanism of action of finasteride involves preferential inhibition of the type II isozyme. Administration of finasteride rapidly decreases the concentrations of DHT within the scalp and serum, reaching a suppression percentage within the serum of 65% during the first 24 hours after oral administration of 1 mg.

The relative contributions of these decreases to the overall treatment effect of finasteride have not been defined. Finasteride appears to interrupt a key factor in the development of androgenetic alopecia in patients who are genetically predisposed to this condition.

2beta-hydroxylase converts testosterone to 2beta-hydroxytestosterone, 6beta-hydroxylase converts testosterone to 6beta-hydroxytestosterone, and 7alpha-hydroxylase converts testosterone to 7alpha-hydroxytestosterone.

Question 24

Hair follicles are found in which of the following layers of the scalp?

(A) Epidermis
(B) Papillary dermis
(C) Reticular dermis
(D) Subcutaneous layer

Answer 24

The correct response is Option D.

The hair follicles are located within the subcutaneous layer of the scalp. Human hair is primarily composed of the keratin protein; the hair shaft is produced by the matrix, which is in turn produced by the follicle. Hair follicles are indentations of the epidermis located within the subcutaneous layer of the scalp. It is important to know the anatomy of the hair follicle in order to successfully harvest and transplant scalp hair, which can be retained with some degree of permanence following transplantation. Because successful punch grafting depends on meticulous technique, the grafts should be harvested at the appropriate depth while avoiding trauma to the hair follicles.

Question 25

A 45-year-old man comes to the office for consultation regarding hair loss concerns. He reports that he has a friend who underwent a hair transplantation procedure that looks unnatural, especially at the front hairline. Using the minigraft and micrograft strategy, how many follicles should be in a minigraft? ## Footnote A) 1 to 2 B) 3 to 4 C) 5 to 6 D) 7 to 8 E) 9 to 10

Answer 25

The correct response is Option B. Minigrafts consist of 3 to 4 follicular units and are commonly used in concert with micrografts which contain 1 to 2 follicular units. Larger numbers of follicular units have been associated with artificial appearing outcomes (plug look).

Question 26

Which of the following is most closely associated with male pattern alopecia? (A) Absence of a genetic predisposition (B) Decreased activity of 5alpha-reductase within genetically susceptible hair follicles (C) Increased serum level of testosterone (D) Prolonged anagen phase (E) Prolonged telogen phase

Answer 26

The correct response is Option E. Male pattern alopecia is associated with a prolonged telogen, or quiescent, phase of the hair growth cycle. During this phase, the follicle becomes inactive, and active hair growth ceases. Inheritance is the only known cause of male pattern alopecia. Although hereditary alopecia is controlled by a single, dominant, X-linked autosomal gene, polygenetic modifying factors, such as androgen production and age, affect its expressivity. Male pattern alopecia can only be triggered by a normal adult male serum androgen level if there is genetic predisposition. Alopecia results from increased 5alpha-reductase activity within genetically susceptible follicles. It has not been shown to be associated with increased plasma levels of testosterone. The anagen phase of the hair cycle, during which hair actively grows, is typically shortened in patients with alopecia.

Question 27

Which one of the following statements is correct regarding scalp innervation A) The supraorbital nerve has both superficial and deep divisions. B) The zygomaticofacial nerve is a branch of the ophthalmic division of trigeminal nerve. C) The auriculotemporal nerve supplies the posterior and lateral scalp. D) The lesser occipital nerve emerges from the semispinalis muscle, 3 cm below the occipital protuberance.

Answer 27

Correct answer is A. The supraorbital nerve has superficial and deep divisions. The superficial component supplies sensation to the forehead anterior to the hairline. The deep component supplies sensation posterior to the hairline. This has clinical relevance in brow-lift procedures, bicoronal cranial flaps, and trauma in which the nerves may be damaged, leaving an area of paresthesia. The zygomaticofacial nerve derives from the maxillary division (not the ophthalmic division) of the trigeminal nerve. It supplies a region of skin lateral to the brow. The auriculotemporal nerve derives from the mandibular division of the trigeminal nerve and supplies the lateral scalp. The greater and lesser occipital nerves supply the occipital territory, but it is the greater occipital nerve that emerges from the semispinalis 3 cm below the occipital protuberance. The facial nerve supplies the scalp muscles. The trigeminal nerve supplies the muscles of mastication and the tensor tympani.

Question 28

A 34-year-old man comes to the office for a routine follow-up examination 1 month after undergoing extensive micrograft hair transplantation. He is extremely upset, complaining that "all the grafts have fallen out and are gone." Which of the following is the most appropriate response to this patient's concerns? ## Footnote A) Loss of hair shaft is expected and part of the normal healing process B) Loss of the grafts is a potential complication that was explained preoperatively C) More grafts will be performed without additional surgical fees D) The patient should wait and see what happens and return to the office in several months E) The patient will be started on finasteride immediately

Answer 28

The correct response is Option A. Hair shaft loss is to be expected after the first month following implantation as the hair follicles enter into the telogen phase. Initially, hair grafts enter the catagen phase of hair growth, which is a transitional phase. Implanted hair can grow 3 to 4 mm at this time. Following this stage, implanted hair grafts enter the telogen phase or the “resting” phase, which lasts for 3 to 4 months. During this phase, the attachment of the hair at the base of the follicle becomes weaker until the hair finally sheds, and the hair follicle is inactive and hair growth ceases. Almost every implanted hair falls out during this time, and patients must be prepared for this preoperatively. This phase can last up to 6 to 9 weeks, and this is when patients worry most about whether the surgery was indeed a success. Following this time, the anagen phase begins, generating new hair growth, which is initially quite thin. This hair then grows thicker with time. Final results of hair transplantation are not evident until 6 to 8 months in men and 10 to 12 months in women.

Question 29

A 30-year-old man with alopecia undergoes micrografting for reconstruction of the anterior hairline. The patient should be counseled to expect which of the following hair growth timelines in grafted areas postoperatively? A ) No growth for one month, followed by normal growth B ) Immediate hair loss followed by new, normal growth after one month C ) Immediate hair loss followed by new, normal growth after three months D ) Growth for one month, followed by hair loss and then new, normal growth after three months E ) Immediate normal growth

Answer 29

The correct response is Option D. Following micrografting, the patient has hair growth for one month followed by hair loss and then normal growth after three months. Once the grafting is completed, there is an initial period of false growth lasting three to four weeks. The hair follicles then pass into the telogen phase, and this new hair growth is lost. The telogen phase lasts two to three months; following this, normal permanent growth begins at a rate of 1 cm monthly. Therefore, a total of approximately six months is required for the onset of permanent hair growth in the grafted area.

Question 30

A 35-year-old woman with diffuse hair thinning comes to the office for evaluation of hair transplantation. Physical examination shows facial hirsutism, acne, and diffusely decreased hair density over the crown and frontal scalp, except for the frontal hairline, which is quite well preserved. The scalp skin appears normal. Which of the following is the most likely underlying cause? A ) Alopecia totalis B ) Polycystic ovary syndrome C ) Psoriasis D ) Tinea capitis E ) Trichotillomania

Answer 30

The correct response is Option B. Although all options listed can cause hair loss, psoriasis and tinea capitis would be associated with visible scalp changes, such as scaling or crusting. Trichotillomania, which is traction alopecia from compulsive hair pulling, would be unlikely to show a diffuse hair loss with sparing of the frontal hairline. Alopecia totalis, by definition, is total hair loss over the entire scalp, and does not fit the patient’s description. This woman has female pattern hair loss (FPHL), which is the preferred term for androgenetic alopecia in females. Typically there is a reduction in hair density over the crown and frontal scalp, with relative sparing and preservation of the frontal hairline, as described for this patient. Between 10 and 40% of women with FPHL have been found to be hyperandrogenic. The presence of menstrual irregularities, marked acne, or hirsutism in this patient should prompt an investigation for polycystic ovary syndrome or other underlying causes.

Question 31

Male-pattern alopecia is typically caused by which type of genetic pattern? (A) Autosomal dominant (B) Autosomal recessive (C) Multifactorial (D) X-linked dominant (E) X-linked recessive

Answer 31

The correct response is Option D. Male-pattern alopecia is a genetically triggered condition in susceptible men. It is caused by a single X-linked dominant gene. This condition occurs in 60% to 80% of Caucasian men; hair loss can begin as early as age 20 years. In men with male-pattern alopecia, a genetically determined increase in the activity of 5-alpha-reductase in the susceptible follicles has been observed. Plasma testosterone levels are normal in these patients. Hamilton €™s system has been used to classify male-pattern alopecia based on the appearance of the anterior hairline and the hair loss at the vertex. There are seven major classifications; each is used to draw conclusions regarding the potential for further hair loss and is helpful for planning surgical management.

Question 32

In healthy human subjects, individual hairs develop from cells at which of the following locations? (A) Base of the follicle (B) Cuticle (C) Infundibulum (D) Outer root sheath (E) Sebaceous gland

Answer 32

The correct response is Option A. Each hair is produced through the proliferation of matrix cells at the base of the hair follicles. The progeny of these cells become displaced from below, become mature, and produce keratin. The outermost layer of the hair is called the hair cuticle, composed of hard keratin, and is responsible for anchoring the hair in its follicle by a system of interlocking scales on its inner surface. The infundibulum is the upper portion of the hair follicle above the sebaceous duct. It is lined by surface epithelium. The outer root sheath covers the inner root sheath and extends upward from the matrix cells at the lower end of the hair bulb to the entrance of the sebaceous gland duct. The basal layer of the outer root sheath contains inactive pigmented amelanotic melanocytes, which can produce melanin after injury such as chemical peels or dermabrasion and migrate toward the epidermis. Sebaceous glands produce sebum and open into the hair follicle.

Question 33

A 4-year-old patient with a full head of hair requires reconstruction of a congenital nevus to the vertex of the scalp. The lesion covers 30% of the scalp. Which one of the following is the best reconstructive option? A) Serial excision and direct closure B) Tissue expansion and local flap reconstruction C) Transposition flap and skin graft to the donor site D) Orticochea flaps with galeal scoring E) Free tissue muscle transfer and split-skin graft

Answer 33

Correct answer is B. The primary aim in this case is to fully remove the nevus and provide soft tissue cover while retaining a full head of hair. Two approaches to the management of congenital nevi on the scalp are serial excision or excision and tissue expansion. Serial excision is best suited to smaller defects that can be excised within three or four sessions. A defect of 30% is best treated with tissue expansion and local flap closure. Defects up to 50% of the hair-bearing scalp can be closed with tissue expansion and avoid bald patches. A transposition flap and skin graft would create a large bald area and would not be aesthetically pleasing. Free tissue transfer would be reserved for near-total scalp defects, particularly where bone is exposed. The Orticochea flap is not well suited to vertex defects because the location does not allow a large third flap to cover the donor defect.

Question 34

Which of the following is the most common cause of male pattern baldness? (A) Cyclical hair loss (B) Decreased plasma androgen level (C) Decreased plasma testosterone level (D) Increased plasma estrogen level (E) Inheritance

Answer 34

The correct response is Option E. The only cause of male pattern baldness is inheritance of an X-linked autosomal dominant gene. Male pattern baldness is also influenced by other minor genetic factors. The pattern and timing of baldness and the age of onset of hair loss are influenced primarily by all of these genetic factors. Cyclical hair loss is characteristic of normal hair growth. Plasma androgen, testosterone, and estrogen levels have not been shown to influence the rate or timing of baldness. However, increased levels of 5\_-reductase have been an isolated finding in the hair follicles of balding patients.

Question 35

A 37-year-old man presents to the office for evaluation and treatment of an area of localized hair loss. Physical examination shows a 2 × 4-cm ovoid-shaped area of baldness on the temporal scalp. The rest of the scalp examination is normal. On the basis of the clinical findings, which of the following is the most appropriate treatment for hair restoration? A) Hair transplantation B) Rotational scalp flap C) Serial excision D) Topical ketoconazole E) Triamcinolone injection

Answer 35

The correct response is Option E. The most likely diagnosis in this clinical scenario is alopecia areata (AA). AA is different from other forms of alopecia since it is a T-cell–mediated autoimmune disease affecting the regional hair follicles. The exact cause is not fully understood, but it is estimated to affect about 2% of the population. Severity can be limited to a singular lesion or extend to multiple confluent lesions with severe impact on a patient’s mental health. While any given lesion can spontaneously resolve, the first-line treatment is injection of triamcinolone combined with minoxidil topical therapy. The injections usually have to be repeated. Systemic therapy with Janus kinase inhibitors is reserved for severe cases of AA. Clinical examination of a fungal infection with tinea capitis differs from the patient presentation in this case. Findings may include scaly skin, brittle hair, and broken hair shafts (black dots). Treatment includes oral and topical antifungal medication such as ketoconazole. Hair transplantation is not a treatment for AA since the underlying pathology would also affect the transplanted hair follicles. While a rotational scalp flap may be an option for a bald spot of this size, it would not be indicated in the setting of AA. The main reason is that hair can regrow spontaneously or in response to other therapy modalities. Further, the transferred flap can also become affected by AA in the future. A rotational flap would be indicated for closure of primary defects or other causes (e.g., burn scar, previous skin graft). Serial excision is useful for a variety of pathologies such as scars, melanocytic nevi, or skin grafts. It would not be advised in the setting of AA.

Question 36

A 25-year-old man has burn alopecia after sustaining a burn wound involving 35% of the hair-bearing scalp. Which of the following is the most appropriate method of reconstruction in this patient? A) Free flap reconstruction B) Micrografting C) Minigrafting D) Strip grafting E) Tissue expansion

Answer 36

Correct answer is E. In patients with burn alopecia, the hair-bearing area of the scalp is amenable to tissue expansion; therefore, it is most appropriate for reconstruction in this patient. With this technique, large areas of the scalp can be resurfaced with similar tissue, resulting in reliable, consistent hair growth. Grafting techniques, such as the use of micrografts, minigrafts, or strip grafts, are appropriate for management of male pattern alopecia but are unreliable in a patient with a compromised recipient site, such as a burn wound. Free flap reconstruction will allow rapid wound healing in a patient who has acute extensive and/or deep injuries involving exposed, devitalized skull.

Question 37

Which of the following best characterizes male-pattern alopecia?

Answer 37

The correct response is Option B. Male-pattern alopecia is characterized by a decrease in the anagen, or active, phase of the hair follicle and an increase in the telogen, or resting, phase. Patients with this condition have more of their hair follicles in the resting phase, and those in the active phase produce hair growth for a shorter time. Hair follicles can also be classified as either terminal, which produce larger, pigmented fibers, or villous, which produce finer fibers that have less pigmentation and are more difficult to visualize. Terminal fibers are found typically on the adult scalp, eyebrows, axilla, and pubic region, while villous fibers are noted on the forehead, bald scalp, and along the hairline itself. In patients with male-pattern alopecia, many follicles in the scalp are transformed from terminal to villous. Minoxidil is the recommended treatment of male-pattern alopecia. This agent halts the hair loss and increases the number of hairs as well as the diameter of the existing hairs, but is only effective in patients with mild to moderate baldness.

Question 38

A 19-year-old man who sustained burns to 40% of the total body surface area at 4 years of age comes to the burn clinic for consultation regarding correction of the scalp defect shown. Physical examination shows patchy alopecia of the temporal scalp and hypertrophic scarring. Which of the following is the most appropriate surgical procedure for reconstruction of this patient’s scalp? A) Hair transplantation with micrografts and minigrafts B) Orticochea flap C) Serial excision and closure D) Temporoparietooccipital (Juri) flap E) Tissue expansion

Answer 38

Correct answer is E. The patient shown has a large (>25 cm2) parietal scalp defect that resulted from a flame burn. It is clear that hair transplantation has already been attempted with minimal take and coverage. Hair transplantation with micrografts and minigrafts is a technique that has been described to treat large areas of burn alopecia. However, it is usually reserved for smaller areas, or as a revisional procedure to camouflage incisions that result from rotational flaps. Tissue expansion is the preferred method for secondary reconstruction of a large parietal scalp defect. Approximately 50% of scalp can be reconstructed with expanded scalp tissue, although this may require multiple stages. Expander complication rates may be as high as 25% and may include infection, exposure, extrusion, and device failure. Scalp expansion in children is difficult. There is a higher incidence of infection and decreased tolerance of pain. Moreover, there is a risk of skull deformation after a prolonged period of expansion. Therefore, deferral until the patient reaches young adulthood is reasonable.

Question 39

A 25-year-old woman sustains a contact injury to the posterior aspect of the scalp. Following debridement, she has a 6 x 4-cm defect of the posterior scalp with exposed bone. Which of the following is the most appropriate next step in management? A) Excision and primary closure B) Full-thickness skin grafting C) Coverage with a rotation flap D) Hair transplantation E) Tissue expansion

Answer 39

Correct answer is C. In this 25-year-old woman who has a 6 * 4-cm defect of the posterior aspect of the scalp, the most appropriate management is coverage of the defect using a rotation flap. This flap provides local hair-bearing tissue and can be used to cover defects as large as 6 cm. In order to advance an adequate length of flap, multiple relaxing incisions must be performed within the galea. If the galea is not carefully divided, injury to the subcutaneous vessels or hair follicles may result, leading to the onset of alopecia or delayed wound healing. Tissue expansion is most appropriate for patients who have large defects of the scalp (typically greater than 15%) because the scalp defect will be covered with similar tissue. Donor site scarring is not a factor in most cases, and the expanders can be left in place if further tissue expansion is required. In addition, the hair follicles will be oriented correctly; as much as 50% of the scalp can be covered with expanded tissue without altering hair growth. However, the process of tissue expansion involves multiple procedures and frequent office visits over a lengthy period of time. During the expansion process, the patient often expresses displeasure with his/her physical appearance. Excision and primary closure combined with extensive undermining are only appropriate for patients who have defects measuring less than 5 cm. Patients with small areas of scalp alopecia may undergo multiple staged excisions of the alopecic scalp followed by advancement of hair-bearing tissue. Because this process involves fewer procedures and less follow-up, it can be used as an alternative to tissue expansion. Although a full-thickness skin graft can be used for temporary wound coverage in a patient who will undergo further scalp reconstruction, it is not an appropriate long-term treatment because many donor sites do not provide adequate hair-bearing skin. Hair transplantation is currently being used with increasing regularity for treatment of traumatic or age-related alopecia.

Question 40

A 70-year-old man comes to the office because of a 6-month history of a wound in the right supraorbital region that is draining fluid. Photographs are shown. History includes type 1 diabetes mellitus, chronic obstructive pulmonary disease, and basal and squamous cell carcinoma in the supraorbital area, which was treated with Mohs micrographic surgery, cranial burring, split-thickness skin grafting, and radiation. He has smoked one pack of cigarettes daily for 60 years. Physical examination shows a 4 × 2-cm area of exposed bone with no mobility in the immediately adjacent skin. Echocardiography shows an ejection fraction of 25%. Examination of a specimen obtained on biopsy shows recurrence of squamous cell carcinoma. After excising the tumor, a bony deformity of the supraorbital rim and exposed dura are present. Which of the following is most appropriate to correct this patient's defect? A) Alloplastic reconstruction and a local flap B) Rib graft with local soft-tissue coverage C) Scalp flap D) Skin graft

Answer 40

Correct answer is C. In the scenario described, bony reconstruction will not impact function, and therefore soft-tissue coverage is adequate. A scalp flap is the most appropriate option because it will bring in blood supply and soft-tissue coverage without the risks associated with extended general anesthesia. Skin grafting would likely not heal in a radiated bed. The long history of a draining wound is a contraindication to the use of alloplastic material. Although a rib graft would provide bony support, it would also increase risk because of the donor site morbidity in the patient described, who has chronic obstructive pulmonary disease and is at high risk for postoperative pneumonia.

Question 41

A 15-year-old boy is referred to the office for management of alopecia areata. Physical examination shows that more than 50% of the scalp is involved. Which of the following is the most appropriate management? (A) Administration of finasteride (B) Construction of a scalp rotation-advancement flap (C) Injection of a corticosteroid (D) Transplantation of follicular units (E) Observation

Answer 41

The correct response is Option C. Alopecia areata (AA) is a recurrent nonscarring type of hair loss that can affect any hair-bearing area. Clinically, AA can present with many different patterns. Although medically benign, AA can cause tremendous emotional and psychosocial stress in affected patients and their families. The pathophysiology of AA remains unknown. The most widely accepted hypothesis is that AA is a T-cell mediated autoimmune condition that is most likely to occur in genetically predisposed individuals. Because AA is believed to be an autoimmune condition, corticosteroids have been used to treat this condition. Few studies are available regarding the efficacy of intralesional corticosteroids, but they are used widely in the treatment of AA. Intralesional corticosteroids are the first-line treatment in localized conditions. In a study including 84 patients, regrowth on treated areas was present in 92% of patients with patchy AA and 61% of patients with alopecia totalis (AT). Regrowth persisted three months after treatment in 71% of patients with patchy AA and 28% of patients with AT. Regrowth usually is seen within four to six weeks in responsive patients. Patients with rapidly progressive, extensive, or long standing AA responded poorly. Another study showed regrowth in most patients (480) treated with intralesional corticosteroids, except in two patients with alopecia universalis (AU). Hair growth may persist for six to nine months after a single injection. Injections are administered intradermally using a 3 cm3 syringe and a 30 gauge needle. Triamcinolone acetonide (Kenalog) is used most commonly; concentrations vary from 2.5 to 10 mg/cm3. Less than 0.1 cm3 is injected per site, and injections are spread out to cover the affected areas (approximately 1 cm between injection sites). Adverse effects mostly include pain during injection and minimal transient atrophy (10%). The atrophy rarely can be severe or permanent. Injections are administered every four to six weeks. For patients with extensive AA (\>40% hair loss), little data exist on the natural evolution. The rate of spontaneous remission seems to be less than in patients with less than 40% involvement. In one review of 50 patients with extensive AA, 24% experienced spontaneous complete or nearly complete regrowth at some stage during the observation period of 3 to 3.5 years. Without therapy, the relapse rate is high in patients with severe forms of AA. Surgery does not have a role in this condition. Finasteride (Propecia) works on alopecia secondary to male pattern baldness by affecting the 5 €‘alpha reductase enzyme.

Question 42

Which of the following is most closely associated with the anagen phase of the hair growth cycle? (A) Active hair growth (B) Destruction of the follicular bulb (C) Duration of two to three weeks (D) Keratinization of the base of the hair (E) Lack of hair growth

Answer 42

The correct response is Option A. Inheritance is the only known cause of male pattern alopecia. Although hereditary alopecia is controlled by a single, dominant, X-linked autosomal gene, polygenetic modifying factors, such as androgen production and age, affect its expressivity. The growth cycle of hair follicles is divided into three distinct phases Ð anagen, catagen, and telogen. In the anagen phase, which lasts approximately three years, the hair actively grows through division and keratinization of the follicular cells. Approximately 90% of the scalp hairs are involved in this phase. In the catagen phase, the follicular bulb is destroyed and the base of the hair is keratinized; this phase lasts approximately two to three weeks. Finally, in the telogen phase, the follicle is inactive and active hair growth ceases. Approximately 10% of the scalp hairs are in this phase at one time.

Question 43

A 35-year-old man with male-pattern alopecia undergoes punch grafting for reconstruction of the anterior hairline. Which of the following best describes the pattern of hair growth seen in the grafted area postoperatively? (A) Immediate normal growth (B) No growth for one month followed by immediate normal growth (C) Immediate hair loss followed by new normal growth after three months (D) Growth for one month, followed by no growth for three months, and then resumption of new normal growth (E) Growth for one month, followed by hair loss, and then new normal growth after three months

Answer 43

The correct response is Option E. Following punch graft transplantation, the patient has hair growth for one month, followed by hair loss, and then new normal growth after three months. Once grafting is completed, there is an initial period of false growth lasting three to four weeks. The hair follicles then pass into the telogen phase, and this newly grown hair is shed. The telogen phase lasts two to three months; following this, normal permanent hair growth begins at a rate of 1 cm monthly. Therefore, a total of approximately six months is required for the onset of permanent hair growth in the grafted area.

Question 44

A 25-year-old woman comes to the clinic to discuss eyebrow reconstruction. She reports that she tweezed her eyebrows several times a day because of perceived asymmetry, and she now has complete loss of eyebrows. She insists on receiving hair transplants and says that she is depressed because of her lack of eyebrows. Which of the following is the most likely DSM-5 diagnosis? A) Body dysmorphic disorder B) Borderline personality disorder C) Excoriation (skin-picking) disorder D) Major depressive disorder E) Trichotillomania

Answer 44

The correct response is Option A. Body dysmorphic disorder is considered an obsessive compulsive and related disorder in the DSM-5. Criteria include preoccupation with perceived appearance flaws for at least an hour a day, repetitive behaviors related to the preoccupation, clinically significant distress as a result of the preoccupation, and exclusion of an eating disorder. The differential diagnosis includes major depressive disorder, trichotillomania, excoriation disorder, agoraphobia, eating disorders, and dysmorphic concerns. What differentiates body dysmorphic disorder from excoriation disorder and trichotillomania is the underlying preoccupation with symmetry and appearance seen in body dysmorphic disorder. In some cases, patients report a pleasurable sensation during hair pulling in trichotillomania. Thus, patients with body dysmorphic disorder can engage in skin picking and hair pulling, but the underlying motivation is different. Excoriation disorder is a body-focused repetitive behavior, on the obsessive compulsive spectrum, but it is not motivated by perceived asymmetry or appearance as is body dysmorphic disorder. Depression can coexist with body dysmorphic disorder, but it does not have a preoccupation with appearance as a criterion. Borderline personality disorder is a Cluster B personality disorder, characterized by unstable emotional responses to stimuli and relationships.

Question 45

An 83-year-old man undergoes radiation therapy and surgical resection and coverage with a cranial bone graft to treat meningioma. The graft becomes infected and is removed 6 weeks after the procedure. One year later, the patient is scheduled to undergo reconstruction of the resulting 23-cm2 defect in the skull. Which of the following is a relative contraindication for the subsequent use of hydroxyapatite in this patient? A) Age of patient B) History of infection C) History of radiation D) Location of defect E) Size of defect

Answer 45

Correct answer is c. Hydroxyapatite cement is widely used in cranioplasty. In one study, the complication rate of the use of hydroxyapatite in patients who have received irradiation to the scalp was 100%. Therefore, its use is not recommended in this population. Use of hydroxyapatite is not recommended in large, full-thickness defects in the pediatric population because it is largely nonresorbable and may be deleterious to the rapidly growing skull. Reduction in the incidence of infection has been shown when a period of 1 year has elapsed between the initial injury or infection and the reconstruction with hydroxyapatite. Use of hydroxyapatite in frontal areas causes twice the incidence of infection than in its use in all other areas. Hydroxyapatite is approved by the FDA for reconstruction of bony defects up to 25 cm2 in size.