This procedure is now rarely indicated for male pattern baldness in our practice. It is included here for historical or reconstructive reference
An alternative to hair grafting is the hair flap operation, devised by Dr. Jos Juri of Buenos Aires, Argentina. I learned the technique from him and am highly experienced in it. This operation is not commonly performed, as very few surgeons are familiar with its intricacies. The Fleming-Mayer flap is essentially the same operation. I now only occasionally perform it on highly selected patients who have limited balding and want thick hair in the front. I now strongly feel that it should not be performed on those young men who likely will have significant balding later in life.
The Juri flap operation relocates large areas of dense, growing hair. This operation creates a complete hairline in the shortest period of time compared to any other surgical options. The flaps contain between 6,000 and 10,000 follicular units each. The Juri flap procedure usually requires two minor preliminary stages prior to the more major flap transfer stage.
The surgeon draws the desired hairline on the scalp and marks off a four centimeter (1 1/2″) wide strip on the side of the scalp. Cuts are made on both sides of the strip and are then sewn closed. This procedure is done in the office and downtime is minimal. The patient wears a bandage for a day or two, after which he can comb and style his hair as usual, and resume normal activities.
The second stage is done a week later. A cut is made at the end of the hair flap and then is sewn closed. The patient may resume his usual activities the next day. Stages one and two may be modified from these descriptions.
The first and second stages are performed to reroute the blood supply so that the flap is nourished only by the blood vessels at its front.
The third stage is performed approximately 14 days after the first. The flap is lifted off the scalp except for its front attachment, which provides the blood supply. The designated bald area of the scalp is cut away and the flap is sewn in place. The front edge of the flap is trimmed in a special way that allows hair to grow through the scar for optimal concealment. The part of the scalp from which the hair flap was taken is closed by loosening the scalp skin above it and the neck skin below it so that the edges of the gap can be pulled together within the hair area, creating a hidden scar. Bandages are worn for four to seven days.
This operation is performed as out-patient surgery in the hospital or in the office operating room. The patient is advised to avoid heavy activities after surgery for one week. The discomfort after this operation has been noted to be minimal.
An interval of at least three months between flap procedures or scalp reductions is recommended.
Within two weeks, the stitches are removed and the hair can be styled. The dense, slightly backward growing hair lends itself well to having the hair combed back with or without a part. In cases of more severe baldness, a second hair flap can be taken from the opposite side of the head to be placed in back of the first flap. Following this, scalp reduction procedures can be done.
Under certain circumstances, non-staged (non-delayed) flaps can be performed.
Scalps scarred by injury or punch grafting may be more difficult to operate on, but good results have been obtained even under such conditions. Patients who have tight scalps can be treated with tissue expansion prior to flap surgery so that the donor site can be closed successfully.
Almost all hair flaps require an adjustment procedure at around four to six weeks after the transfer operation. This touch up operation is done under local anesthesia. The patient can resume full activities the next day.
As with any surgical procedure, the flap operation carries risks of anesthesia complications, bleeding, infection, and unfavorable scarring. More specifically, the greatest risk of this operation is necrosis (circulation failures leading to loss of tissue) of the flap itself or the donor site. Fortunately, the incidence of necrosis with the Juri flap is quite low and, if such a complication occurs, it can usually be improved by secondary surgery.
To refine the flap hairline, micro-grafts can be placed in front of the flap to create a better transition from the non-hair-bearing forehead to the flap hair.