Linear Morphea en Coup de Sabre (LM ECDS)

Abstract

Linear morphea en coup de sabre is a rare condition that presents with a linear band of alopecia and is suitable for surgical hair restoration. Hair transplant surgeons should be aware of the possibility of calvarial abnormalities when considering hair transplant procedures.

Key words: linear morphea en coup de sabre (LM ECDS), scleroderma, Parry-Romberg syndrome (PRS)

FIGURE 1. 18-year-old female presenting with LM ECDS

Introduction

Morphea, also known as localized scleroderma, is a rare disease seen in both adults and children. Most pediatric patients have the linear subtype, which can extend deeply into the subcutaneous tissue, muscle, and bone. Linear morphea on the head and neck, called en coup de sabre (ECDS), and Parry-Romberg syndrome (PRS), also called progressive hemifacial atrophy, are felt to be related variants within the morphea spectrum of disease.

Case Presentation

An 18-year-old female presented to the Farjo Hair Institute with a linear morphea en coup de sabre (ECDS) lesion left parieto-occipital scalp (Figure 1). The condition had presented in childhood and had been stable for many years. There were no extracutaneous stigmata, and although there was some fat atrophy, there was no overt bony abnormality.

Surgeon:

Gregory Williams, MBBS, FISHRS

Location:

London, England, UK

Contact:

dr.greg@farjo.com

Procedure: The patient opted for the linear strip excision method of donor hair harvesting and had 1,903 follicular unit grafts implanted using forceps (Figure 2). Implantation density was conservative given the scarring nature of linear morphea.

Post-operative healing was uneventful. The patient was reviewed at 10 months and was pleased with the results achieved (Figure 3) but wanted to increase density by repeating the procedure.

Discussion: Surgical excision was offered as an option to the patient but would still have left a non-bearing surgical scar and was declined by the patient. Successful hair transplant in LM ECDS has been published in the medical literature.¹,² A variety of neurologic symptoms have been reported, most commonly seizures and headaches.3 In addition, computed tomography (CT) and magnetic resonance imaging (MRI) can reveal calvarial and intracranial abnormalities even in asymptomatic patients, so hair transplant surgeons should be aware of this when planning hair transplant procedures.

In this case, funding was sought from the National Health Service and granted, so there were no surgical costs to the patient.

References

1. Dai, Y., A.E. Xu, and J. He. A case report of coup de sabre patient with hair transplantation. J Dermatol Treat. 2017; 28:546-548. https://www.ncbi.nlm.nih.gov/pubmed/28142293
2. Park, S.W., and H.Y. Wang. Survival of grafts in coup de sabre. Dermatol Surg. 2002; 28:763-766. https://www.ncbi.nlm.nih.gov/pubmed/12174076
3. Appenzeller, S., et al. Neuroimaging findings in scleroderma encoup de sabre. Neurology. 2004; 62:1585-1589. https://www.ncbi.nlm.nih.gov/pubmed/15136686 n

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ABHRS/IBHRS Code of Ethics Policy Statement

WHEREAS, the American Board of Hair Restoration Surgery (ABHRS) is a surgical certifying board organized to examine physicians in the area of hair restoration surgery; and

WHEREAS, the ABHRS is a surgical certifying board organized to promote the safe practice of hair restoration surgery;

NOW, THEREFORE, the ABHRS has established the following policy: As a Diplomate of the American Board of Hair Restoration Surgery, I pledge myself to…

Use every opportunity to improve public understanding of the role of the Hair Restoration Surgeon.

Cooperate in every reasonable and proper way with other physicians and work with them in activities contributing to the advancement of quality patient care.

Maintain the confidentiality of privileged information entrusted or known to me by virtue of my role as a hair restoration surgeon within the constraints of the law.

Accept no personal compensation from any party that would influence or require special consideration in the provision of care to any patient.

Provide patient care impartially, provide no special privilege to any individual patient based on the patient’s race, color, creed, sex, national origin or handicap.

Use only legal and ethical means in the provision of care to my patients and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception.

Maintain the highest standard of personal conduct.

Abide by the highest ethical standards in activities designed to attract patients to my practice including recognition and enforcement of the American Board of Hair Restoration Surgery advertising policy which requires Diplomate status should not be embellished, to utilize truthful advertising, and to designate my ABHRS membership as ABHRS Diplomate as opposed to “Board Certified” by the ABHRS.

Maintain loyalty to the goals and objectives of the American Board of Hair Restoration Surgery as stated in the American Board of Hair Restoration Surgery By-Laws.

Promote and encourage the highest level of medical ethics in providing competent medical service with compassion and respect for human dignity.

Recognize and discharge my responsibility and that of the Medical and/or Osteopathic profession to uphold the laws and regulations relating to the practice of hair restoration surgery.

Strive for excellence in all aspects of medical practice.

Continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues and the public, obtain consultation, and use the talents of other health professionals when the best interests of a patient so indicates.

The ABHRS Guidelines For Truth in Representation And Advertising have been established to help members avoid what can be universally considered as misleading or unacceptable messages.

We have encouraged ABHRS/IBHRS members to review their individual as well as group practice websites and marketing materials to assure that misleading or ambiguous language as defined in the following infractions are not included. Members of the public who are seeking professional services from a hair restoration surgeon should consider these terms as “red flags”. If they are used in a doctor’s marketing material or website, the consumer should beware.

The following issues/concepts are considered misleading or inappropriate:

False Statements and Copyright / Trademark Infringement

Including inaccurate credentials. E.g., claiming ABHRS (American Board of Hair Restoration Surgery) Diplomate status or IBHRS (International Board of Hair Restoration Surgery) status when the individual has not earned this designation, or claiming inaccurate expertise in hair restoration surgery in general.

The use of other physicians’ before & after photos as their own.

Violating the copyright of others with the illegal use of photos or text.

Ambiguous use of the ABHRS Logo which implies non-ABHRS/IBHRS diplomates are also diplomates.

Inappropriate Use of Staff

Specifically, the surgical act of creating extraction incisions for removal of live tissue, whether during follicular unit transplantation (FUT), or follicular unit extraction (FUE) procedures, is a non-delegable act, and must be performed by the physician of record. In addition, the creation of incisions for placement of grafts is also non-delegable, and must be performed by the physician of record. Evidence of unlicensed, non-physicians performing surgical procedures clearly outside of legally enforceable standards of care is in clear violation of ABHRS ethical guidelines.

Inappropriate, Misleading, Inaccurate Terminology

The use of the following, or similar terminology that misrepresents the physical realities of high quality hair transplant surgery:

“Scarless surgery”

“No incision”

“No touch”

“No cutting”

“Cloning”

“Hair multiplication”

“Non-invasive”

“Guaranteed results”

“Unlimited grafts”

“No risk”

“Pain free”

“Eliminates the need for additional procedures”

Abstract

Introduction

Case Presentation

Surgeon:

Location:

Contact:

References

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ABHRS/IBHRS Code of Ethics Policy Statement

False Statements and Copyright / Trademark Infringement

Inappropriate Use of Staff

Inappropriate, Misleading, Inaccurate Terminology

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