You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY Hair Graft Transplantation for BaldnessArticle Last Updated: Feb 13, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Jeffrey S Epstein, MD, FACS, Clinical Professor, Department of Otolaryngology, Division of Facial Plastic Surgery, University of Miami College of Medicine Jeffrey S Epstein is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American College of Surgeons Editors: J David Kriet, MD, FACS, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Director of Facial Plastic and Reconstructive Surgery, University of Kansas School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Keith A LaFerriere, MD, Clinical Professor, Fellowship Director, Department of Surgery, Division of Otolaryngology, University of Missouri at Columbia; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: hair graft transplantation for baldness, hair grafting, surgical hair restoration, follicular unit grafting, alopecia, male pattern baldness, MPB, androgenic pattern baldness, female pattern baldness, inherited pattern baldness INTRODUCTIONSection 2 of 12
  Hair loss occurs in more than 60% of men and in approximately 10% of women. Although a lack of scalp hair can potentially increase the risk of actinic damage and skin cancer, male and female pattern baldness are conditions that are, with few exceptions, treated electively. Balding is a major concern for many, and surgery to treat hair loss (ie, hair transplantation) is the most common cosmetic surgery procedure performed on men today. Yet, the market for hair transplantation is dwarfed by the immense market for products that treat hair loss without surgery. These products, which include shampoos, hair-care cosmetics, scalp massagers, laser combs, and many more, have no proven efficacy except for their ability to temporarily increase the volume of existing hair, resulting in a denser appearance than before. Exceptions are the 2 medications the US Food and Drug Administration (FDA) approved: minoxidil (Rogaine, available over the counter in the United States) and finasteride (Propecia, available by prescription only for men), which have limited but definite benefit. Interest in hair transplantation will probably increase as knowledge that most modern hair-transplantation techniques can create virtually undetectable restoration spreads. To this day, hair transplantation remains the treatment of choice for most patients with hair loss. History of the ProcedureIn the 1950s, surgeons such as Orentreich, Stough, Ayres, and Rabineau pioneered the earliest hair-transplant procedures. Although these early procedures resulted in hair growth on bald scalps, they were characterized by obvious pluglike appearances. However, the early experiences formed the foundation for hair transplant procedures, that is, the donor dominance of hair-bearing scalp to grow hair after it is transplanted into another part of the scalp (or body) as an autograft. The doll's-hair, or pluglike, appearance was the result of using grafts typically 4 mm in diameter. These plugs contained 15-20 hairs and were usually harvested with a circular punch, then transplanted into 4-mm circular recipient sites in the bald scalp. Once transplanted, hairs entered a 4-month dormant cycle (telogen), after which they began continued growth for as long as donor site hair grew. Scalp areas that contain hairs genetically programmed for permanence (ie, those on the sides and lower back portion of the head) were (and still are) donor areas. From the 1950s until the early 1990s, plug-graft transplantation was, with few exceptions, the most common hair-transplant procedure. Small grafts, created by halving or quartering the formerly standard 4-mm plug grafts became popular in the early 1980s. Over the last 15 years, developments in hair transplantation have followed this evolution toward smaller grafts to mimic the way hair grows naturally on the scalp. Until the last several years, with the popularization and further development of microscopic follicular-unit grafting, state-of-the-art hair transplantation involved transplanting a combination of minigrafts and micrografts. These 2 terms are open to definition, but a typical micrograft contains 1-2 hairs, whereas a minigraft contains 3-6 hairs. Combining these different-sized grafts by placing the micrografts along the hairline and the minigrafts further behind gives the surgeon a tool that potentially makes a hair transplant difficult to detect. Artistry, individualization of the specific procedure to the patient, and other variations in technique are of critical importance. Today, using the state-of-the-art procedure of follicular-unit grafting and guided by sound aesthetic judgment, surgeons can achieve virtually undetectable hair restoration. ProblemSome say, "A bad hair day is better than a no hair day." For millions of individuals, hair loss is a major problem associated with loss of self-esteem, insecurity, and even depression. Hair loss can range from early thinning or hairline recession to complete loss of hair along the top and upper sides of the head. A full head of hair contains approximately 100,000 hairs. (People with red or blonde hair have somewhat more than this.) The loss of up to 30% of the number that was present during the peak of adolescence that occurs by middle age is part of the normal aging process. For thinning to become cosmetically noticeable, at least 50% of the hairs must have fallen out in a particular area. Loss of a smaller percentage than this generally does not result in the cosmetic appearance of hair loss. In addition to the loss of the number of hairs, the hair loss process causes individual hairs to thin, which further contributes to the appearance of hair loss. The Norwood Classification System recognizes and categorizes the typical sequence of the hair loss process in men.1 Early in the process (types 1-3), the hairline recedes, typically led by frontotemporal recessions. In the latter stages (types 4-7), progression of hair loss at the vertex (crown) gradually meets and joins the progressive hairline recession, resulting in varying sizes (in both coronal and sagittal dimensions) of the confluent vertex with frontotemporal regions of baldness. For women, the development of androgenic alopecia is classified into 3 stages. The typical pattern of hair loss in women is progressive diffuse thinning in an oval area along the top of the scalp. Hair loss along the hairline is usually spared. FrequencyThe incidence of hair loss in men approaches 60% by the age of 60 years. In women, this incidence is considerably lower, that is, approximately 10% at a similar age. Among racial groups, whites have the highest incidence of hair loss, African Americans have lowest incidence, and Asians have an incidence between the two. EtiologyHair loss in men almost always is due to androgenic pattern baldness, which is usually referred to as male pattern baldness (MPB). Although the exact cause of pattern balding is unclear, the trait is transmitted by means of a polygenic type of inheritance. Anecdotal reports indicate a stronger link to men on the maternal side of the family than on the paternal side. MPB is a progressive process that continues for the rest of an individual's lifetime. The eventual degree of hair loss is typically more advanced with a younger age of onset. In women, most hair loss is also genetic, though women have an increased incidence of hair loss caused by medical conditions, such as hormonal imbalance, trichotillomania, and poststress telogen effluvium. As with MPB, female-pattern androgenic hair loss is progressive. PathophysiologyIn men, pattern baldness has been established as an androgen-mediated miniaturization process of genetically susceptible hair follicles. Women with pattern baldness are presumed to undergo the same process. Pattern baldness requires linking of the hormone dihydrotestosterone (DHT) to susceptible hair follicles. In the body, DHT is created when the enzyme 5-alpha reductase converts testosterone. This conversion takes place in the bloodstream and locally in the scalp and other body tissues. DHT acts on genetically susceptible hair follicles to cause miniaturization of the hair, which eventually leads to follicle death. ClinicalMPB follows a classic pattern that is best illustrated by using the Norwood Classification System, which ranges from type 1 (minimal frontotemporal recession) to type 7 (loss of all but a small rim of hair).1 Types 2-6 categorize the typical progression of hair loss. The clinical presentation in women differs somewhat from that of men. In women, hair loss along the hairline is typically spared, with thinning throughout the top and upper sides of the head is more diffuse in women than in men. In the author's office, preoperative screening consists of a health-history questionnaire that includes questions about easy bruising, anesthesia problems, allergies, mitral valve prolapse or other conditions necessitating preoperative antibiotics, and all current medications (including herbal remedies). Study results have confirmed the superiority of good history taking and physical examination compared with any blood screening test for determining a patient's medical suitability for surgery. INDICATIONSSection 3 of 12
Nearly all men and most women who have androgenic or inherited pattern baldness can be treated with hair transplantation. As in all other elective cosmetic surgeries, the most important patient selection criterion in hair transplantation is the individual's motivation. Results of hair transplantation are usually most dramatic when the procedure is performed on individuals with advanced degrees of hair loss. In general, the greater degree of hair loss, the larger number of grafts transplanted. Hair transplantation may not be the most effective therapy for some medical causes of hair loss; in some instances, it exacerbates the condition. Therefore, workup to rule out other treatable causes of hair loss is important, especially in women, in whom nongenetic etiologies for the hair loss are more common than in men. In addition to MPB and female pattern baldness, a variety of conditions can be successfully treated with hair transplantation. Scarring of the scalp due to trauma or surgery and hair loss due to traction (seen with extended wearing of hair pieces or trichotillomania) can be repaired with hair transplantation. Finally, hair transplantation can be successfully used to restore hair to the eyebrows; eyelashes; beard, mustache, or goatee area; and even to areas of the body, such as the pubis or chest. RELEVANT ANATOMYSection 4 of 12
The scalp is divided into 5 layers, which are easily remembered by the mnemonic SCALP, which represents, in order from outermost to innermost layer, the skin, connective subcutaneous tissue, galea aponeurosis, loose connective tissue, and periosteum over the cranium. The skin contains all the epidermal appendages, including hair follicles, which extend into the connective subcutaneous layer. In areas that have undergone hair loss, thinning of the outer 2 layers usually occurs. This situation can be appreciated when one compares the thickness of the scalp in recipient areas to that in donor areas. The subcutaneous layer is well vascularized and contains the main penetrating branches of the named main arteries that travel primarily along the external surface of the galea. The importance of staying superficial along the connective subcutaneous tissue layer (when one makes slit recipient sites to avoid compromising circulation) has only recently become apparent. The scalp has an excellent blood supply. The supraorbital, supratrochlear, superficial temporal, postauricular, and occipital arteries are the primary vessels, and they typically travel with the veins. The galea aponeurotica is a nonelastic layer that connects the frontalis muscles anteriorly with the occipitalis muscle at its posterior aspect. The temporoparietal fascia, in which the superficial temporal artery travels, is also connected to the galea. The galea sliding over the loose connective tissue layer allows for most scalp mobility. This loose connective tissue layer and the periosteum below have minimal sensory innervation. The sensory innervation of the scalp closely follows the vascular supply. At the anterior aspect, the supraorbital and supratrochlear nerves provide sensation to the anterior half of the scalp. On occasion, sensation to the frontal scalp can diminish for several weeks when a large number of graft recipient sites are made along the hairline. The occipital nerve serves the posterior half of the scalp, whereas the supraauricular and superficial temporal nerves contribute innervation from the sides. Perhaps no anatomic feature of the scalp is more important with regard to hair transplantation than the microscopic distribution of hair. Scalp hairs usually do not grow individually; they most often grow in tiny follicular-unit bundles, which usually contain 2-3 hairs and occasionally 1 or 4 hairs. A follicular-unit contains these 1-4 terminal hairs, a sebaceous gland element, and insertions of the arrector pili muscles, all wrapped in an adventitial tissue sheath. These follicular units are dispersed throughout the scalp, where non–hair-bearing skin constitutes up to 50% of the total tissue. By transplanting only these follicular units and dissecting away the 50% of unnecessary non–hair-bearing tissue, the most natural-appearing results can be attained. CONTRAINDICATIONSSection 5 of 12
Perhaps the most difficult part of being a surgeon is knowing when not to operate. In elective cosmetic surgery, sound judgment must certainly be exercised. Individuals must be motivated to undergo hair transplantation. Although the author does not conduct a formal psychological evaluation by means of lengthy questionnaires and examinations, some surgeons use this method. During the consultation, the present author generally reads to the individual to ensure that he or she is mature enough to decide to undergo the planned procedure. A prospective patient who has realistic motivations and expectations before the procedure is likely to be happy after the procedure. Honest and thorough preprocedural consultation is perhaps the most important part of the process. Poor medical health is a potential contraindication for elective surgery of any kind. Individuals cannot be taking anticoagulants (eg, Coumadin, aspirin) before the procedure. Good surgical judgment must be exercised when one considers surgery in individuals with potentially complicating medical conditions. Age is not a medical contraindication. The author has performed procedures on men in their late 70s. Ensure that such patients provide medical clearance from their internist. Perhaps no single hair-loss condition calls for more conservatism in judgment than premature MPB. Teenagers and men in their early 20s are particularly self-conscious about hair loss because most of their peers still have full heads of hair. These young men often hold unrealistic expectations, desiring a youthful hairline that will not be appropriate as they age. Worse, early surgical correction uses a large number of donor hairs, which will be sparse in the future, potentially resulting in an unnatural look and a disappointed patient. In general, attempt to delay the procedure in individuals in their 20s or younger, though the author has performed procedures in select individuals as young as 20 years. When counseling young men about hair loss, the author advises a conservative approach to give patients time to consider hair transplantation. If the patient and surgeon agree on transplantation, restore a relatively high hairline and instruct the patient to use minoxidil for the crown region. Perhaps in the future, as effective medical therapies that end or substantially slow MPB progression become available, a less conservative approach can be taken. For a number of medical conditions that are associated with or that can cause hair loss, treatment with hair transplantation is not appropriate. Examples are the active phases of alopecia areata, lupus, and infections. Scalp conditions, such as vitiligo and psoriasis, must be evaluated because hair transplantation can aggravate them. WORKUPSection 6 of 12
Lab Studies
Other TestsFurther testing (eg, ECG) is occasionally performed as the patient's medical condition dictates. TREATMENTSection 7 of 12
Medical therapyOnly 2 medications, minoxidil and finasteride, have received approval from the FDA for treating hair loss. Active clinical research is continually conducted to search for medications that are more effective than these, with pharmaceutical companies eager to market a product that more than 50 million Americans may desire. Minoxidil (Rogaine) is a liquid applied directly to areas of the scalp undergoing hair loss. Originally indicated for the treatment of severe hypertension, minoxidil slows the progression of hair loss and causes fine hair regrowth in the back half of the scalp in 25-40% of men. Both the 2% (available in generic form) and 5% concentrations (ie, Extra-Strength Rogaine) are available over the counter. Both medications elicit few reported adverse effects; the most common are heart palpitations and headache. In women, the 2% concentration has a response rate similar to that seen in men, helping 20-40% of women retain their hair and, occasionally, achieve hair regrowth. Minoxidil must be applied twice daily. Like finasteride, minoxidil must be used continuously to maintain hair regrowth. Otherwise, on cessation of the drug, most of the strengthened hairs fall out. The exact mechanism of action of minoxidil is unknown, but it may work by means of local vascular dilation or the nonspecific occupation of DHT-binding sites in the hair bulb. Some physicians recommend the use of minoxidil after transplantation. Application to the grafted areas once per day can shorten the interval between the procedure and the growth of transplanted hair from 4 months to fewer than 3 months. Finasteride (Propecia) is more effective than minoxidil in treating male-pattern hair loss. This 5-alpha reductase inhibitor blocks conversion of testosterone to DHT, the hormone thought most responsible for the miniaturization and eventual involution of scalp hairs in MPB. Finasteride 1 mg taken orally once per day is effective in approximately two thirds of men. The major benefits of finasteride are the slowing and occasional cessation of hair loss and even the potential regrowth of hairs, primarily in the back half of the head. Several benefits accrue from the addition of finasteride in individuals undergoing hair transplantation procedures. First, finasteride potentially reduces the need for further procedures, increasing hair allocation to the anterior and middle scalp, areas that do not respond to medication. Second, by potentially minimizing and even reversing the miniaturization process of hairs in the back half of the scalp (including hairs in the donor strip along the back of the head), finasteride can increase the density of those transplanted hairs, thus improving surgical results. Only men can take finasteride. Although uncommon, adverse effects can occur and include a less than 2% published incidence of reduced libido and decreased sexual function. Surgical therapySurgical hair restoration is the procedure of choice for restoring hair. The concept behind all forms of hair restoration is redistribution of hair rather than addition of new hair. Three hair-restoration procedures have traditionally been available: hair grafting, bald scalp reductions, and scalp-flap surgery. Today, hair grafting accounts for more than 95% (perhaps as much as 99%) of procedures performed. Hair grafting has a high success rate with a low incidence of complications, it is performed in the outpatient setting with little surgical preparation or specialized setup, and (most important) patient acceptance is high. Bald scalp reduction is the excision of alopecic scalp. The excised area typically consists of the crown and occasionally extends anterior to the middle scalp. Relatively popular during the 1980s through the mid 1990s, scalp reduction is performed infrequently today. Reducing substantial areas of bald scalp without causing abnormal hair growth, scarring, and marked patient discomfort is difficult, and most surgeons recommend options other than bald scalp reduction for treating hair loss on the middle and posterior scalp. Few surgeons perform scalp-flap surgery because of the need for specialized surgical training in the technique. In addition, most patients are not ideal candidates for the procedure unless they are motivated, unless they are in their mid 40s or older, and unless they seek a dense hairline with relatively limited hair loss restricted to the anterior scalp. A single scalp flap can contain as many as 10,000 hairs, resulting in the creation of a dense hairline in just 2-3 procedures performed in an interval of several weeks. Complications of scalp-flap surgery (including flap necrosis) can be devastating, though they are rare when an experienced surgeon performs the procedure. Hair grafting, the most common hair-restoration procedure, can be performed by using different techniques. From the early 1990s until recently, transplanting with micrografts (1-2 hairs), often combined with minigrafts (3-5 hairs), was considered state of the art. Today, most surgeons consider follicular-unit grafting the definitive procedure. As discussed in Relevant Anatomy, transplanting only follicular units and dissecting away all non–hair-bearing tissue can offer several advantages. These follicular-unit grafts can be placed into tiny recipient sites, allowing for dense packing and reducing postprocedure crusting. The requirement for careful dissection reduces the accidental transection rate and therefore minimizes depletion of good hair follicles; a benefit that potentially maximizes hair yield from a particular strip of donor hairs. Finally, because hairs are transplanted in accordance with their natural growth in these tiny follicular units, the results are virtually undetectable. Preoperative detailsAs with any surgical procedure, thorough counseling before hair-restoration surgery is critical. Patients require education to make informed decisions regarding this elective procedure, ie, whether to undergo it, and, if so, which procedures. Because hair restoration is cosmetic surgery, discussing patients' areas of concern, explaining treatment options, and providing a realistic picture of expected results are important. A thorough list of instructions is given to all patients before the procedure. Patients should stop taking all aspirin-containing medications, vitamin E, and ginkgo 10 days before the procedure and all nonsteroidal anti-inflammatory drugs (eg, ibuprofen) and alcohol 3 days before. To further reduce the risk of bruising and edema, patients are instructed to take vitamin C 2000 mg daily for 1 week before surgery. If the patient is to receive intravenous or twilight sedation, they should receive nothing by mouth (NPO) 8 hours before the procedure. On the day of the procedure, a relaxing atmosphere should be created, enhanced by the usual administration of the chosen oral sedation. The present author has found that diazepam (Valium) 10 mg and zolpidem (Ambien) 10 mg are the most effective and safe options. A valuable opportunity to further discuss expectations and goals with the patient and his or her significant others is presented when marking the planned transplant areas on the patient. An aesthetic hairline design is crucial in providing a natural-appearing result appropriate for the individual at present and in the future. Aesthetic hairline design usually requires a hairline irregular and wavy appearing, with slight-to-substantial frontotemporal recessions. In basic hairline design, the central-most aspect of the hairline is placed 8-10 cm above the nasion (root of the nose). Then, the hairline carried laterally in an up-sloped direction when the patient is viewed on the Frankfort horizontal plane. This design results in the central aspect of the hairline being the lowest (most caudal). In many patients, the creation of a slight widow's peak results improves the natural appearance. In patients with substantial caudal recession of the superior aspect of the temporal tuft, transplanting this area to build it superiorly is sometimes helpful. Fine grafts containing 1-2 hairs are typically used to create a thin but natural-appearing result. The resulting temporal horns, which often occur naturally, allow the lateral hairline to join with the superior temporal hairline, even if the transplanted hairline is high and thus prevent an isolated frontal tuft. Note that all lines drawn to mark the hairline serve as a rough template, from which an irregular saw-tooth pattern can be transplanted to mimic natural hairlines. The goal of hairline creation is to create a hairline that is not discernible as a line. A conservative approach is important when transplants are placed into the crown region because of the likelihood of progressive enlargement of the crown. If this occurs, additional grafting is required in the future to avoid the appearance of a donut-shaped area of bald scalp surrounding a central circle of transplanted hairs. Frequently, only the anterior one half to two thirds of the crown are transplanted densely, whereas the remaining crown area is transplanted less densely by scattering 1- or 2-hair micrografts to provide some minimal coverage to prevent the appearance of a shiny area. The final step before the patient is transferred into the procedure room is to determine the necessary size of the donor area and then to trim the hairs to be transplanted. The donor site is usually in the middle-to-superior aspect of the back of the head, accounting for and avoiding any potential recession in the crown area. A number of techniques have been described to determine the size of donor area necessary to provide the required number of grafts. Typical procedures consist of 1400-2800 follicular-unit grafts, but procedures as large as 3200 grafts are not uncommon. Use of a densitometer, which measures the number of hairs per square centimeter, is the most accurate way to determine donor-site size. Approximately 75 follicular units are obtained from each square centimeter of area; therefore, a planned 2000-graft procedure requires a donor strip 24 X 1 cm. Intraoperative detailsThe patient is seated in a semirecumbent position, and local anesthetic is injected. Over the last 4 years, the author has used a computerized injection device called the Wand, which allows for the slow and controlled injection of agent. First, the donor area is injected superficially, followed by a slightly deep injection along the entire hairline to create a field anesthesia. In the author's practice, more than 80% of patients are given oral sedation, whereas local anesthetic is sufficient for the rest. The rare patient chooses to have intravenous sedation provided by a nurse anesthetist. At this point, the surgical personnel split into 2 teams. Good results in hair transplantation require a highly trained team of assistants to dissect grafts and to help plant them. One team consists of those who perform the slivering; this team sections the donor strip into many narrow strips that are 1 follicular unit wide. These narrow strips then can be divided into individual grafts consisting of a single follicular unit. These follicular units most commonly contain 2-3 hairs, but they can contain 1-4 hairs. Excess tissue not containing hair is excised to allow for the transplantation of just these follicular units. Assistants perform graft cutting with the aide of binocular microscopes for most accurate dissection. This process is demanding and time consuming but critical for the success of the procedure. The typical assistant can cut 100 grafts per hour; hence, a team of 6 assistants can cut 1800 grafts in 3 hours. The grafts are cut on a Teflon cutting block by using Personna size-11 scalpel blades or double-sided razor blades. While awaiting transplantation, the grafts are stored in chilled preservative-free solution of isotonic sodium chloride. As grafts undergo dissection, the surgeon creates recipient sites. The author's preferred instruments are tiny blades custom cut from single-edge Personna razor blades. These blades measure 0.6-1.3 mm, but blades of 0.6, 0.7, or 0.9 mm are most commonly used for grafts containing 1, 2, and 3 hairs, respectively. The 0.6-mm blade is typically used along the frontal hairline, where 1-hair grafts are placed most anteriorly, with the 2-hair grafts placed immediately behind into incisions made with a 0.7- or 0.8-mm blade. Finally, depending on the size of the 3- and occasional 4-hair grafts, the 0.9- or 1.0-mm blade is used to create the remainder of recipient sites. Several concepts are important in the making of recipient sites, as the direction and location of these sites determine the direction and location of growth of the transplanted hairs. Usually, the more anterior along the hairline, the more oblique the angle of penetration of the recipient site. By working posteriorly, a continued anterior but less oblique direction of growth is maintained. When hairs are transplanted into thinning areas that still have original hairs, the direction of the recipient sites must mirror the direction of growth of these existing hairs to prevent transecting and damaging the hair follicles and to ensure an even and equivalently patterned growth of all scalp hairs. These recipient sites must be made between existing hairs to avoid transection of existing hair follicles. Although this process is a time-consuming challenge, such attention to detail reduces telogen effluvium (ie, rapid hair loss), which is observed when a substantial number of hairs are damaged. In the crown area, the radial direction of growth of hairs is maintained. In the anterior portion of the crown, the hairs tend to grow anteriorly, while more posteriorly, the hairs indeed grow posteriorly. Somewhere between the anterior and posterior areas usually lies a circular whirl. On occasion, recreation of this whirl is necessary, especially when the entire crown is filled. After the recipient sites have been created, the grafts are then inserted. This is an extremely challenging and delicate process because atraumatic placement of individual grafts is crucial to prevent lack of growth of the hairs and to minimize scalp edema. For graft insertion, the preferred tool is the curved and straight ultrafine jewelers' forceps. These forceps allow grafts to be handled and placed by grasping them only along the subcutaneous fat just deep to the follicle. Postoperative detailsGraft placement constitutes the final step in the time-consuming hair-transplant procedure. A 2200–follicular-unit graft procedure typically requires 5 hours to perform when done by a surgeon and 8 assistants). Afterward, patients can leave the office bandage free. To prevent any periorbital swelling that sometimes results from edema along the frontal hairline from migrating inferiorly, a strip of elastic tape is placed across the patient's forehead. This tape is worn for the next 3 days and is easily concealed by wearing a baseball hat. On postoperative day 1, patients usually return to the office for a hair wash and checkup. The occasional "popped" graft can be returned to the recipient site at this time. On postoperative day 3, patients can wash the hair themselves by gently applying shampoo and rinsing with water. Sutures are usually removed on days 10-12. By this time, all crusting (typically minimal with the follicular unit grafting procedure) should be gone, and the scalp typically appears entirely normal except for possible slight erythema along the recipient site region. To speed the resolution of crusting and to promote rapid healing, patients can use a copper-containing moisturizing spray called GraftCyte. Postprocedural medications include cephalexin 500 mg for 3 days, prednisone 50 mg for 3 days, and ibuprofen or acetaminophen with codeine #3 as necessary. For most patients, discomfort is mild, and ibuprofen is adequate. After the procedure, advise patients to avoid exertion for the first 48 hours. After this, light exercise, such as running and golf, can be resumed. By postoperative day 5, no further restrictions are placed on the patient with the exception of swimming with the head submerged, which must be delayed until postoperative day 10. Follow-upAdvise patients that more than 80% of transplanted hairs fall out between postoperative days 14 and 21. With follicular-unit grafting, as many as 20% of hairs may continue to grow. The transplanted hairs reappear 3-4 months later and continue to grow for the patient's lifetime at a rate of approximately 0.5 in/month. To shorten this interval of hair regrowth to 10 weeks, patients are instructed to apply minoxidil daily for the first 3 months. Approximately 50% of patients choose to undergo a second hair-transplant procedure at some point. This procedure can be performed as soon as 5 months after the first procedure. The most common reasons for patients wanting a second procedure are to increase hair density and to cover more areas than could be covered in the initial procedure. Patients sometimes return several years later to have an additional procedure or to fill in areas that have undergone hair loss. With additional procedures, the donor site almost always encompasses the first procedure's donor site, resulting in a continued single incision line and minimal scarring. COMPLICATIONSSection 8 of 12
When performed properly, the results of hair transplantation are virtually undetectable. However, complications can arise from errors of technique, poor planning, and unpredictable patient factors. As with any surgery, hair transplantation poses possible risks. Excessive bleeding due to undiagnosed coagulation disorders or secondary to medications can be bothersome at the least and (in rare cases) life threatening at the worst. Infections and anesthesia problems are 2 other potential, though unlikely, complications. Complications more unique to the hair-transplant procedure are rare but can occur. Scarring of the donor site can include hypertrophic scar formation due to excessive tension and perhaps even a tendency toward keloid formation. Alopecic scar formation can result from excessively tight suture placement or from hair follicle cauterization. Scarring of the recipient site was more common when large-graft transplantation was performed. Such scarring included ridging, cobblestoning, and skin hypopigmentation. Poor hair growth can occur and probably is largely dependent on technique. Graft desiccation, rough handling of the grafts, and faulty graft preparation can result in limited hair growth. Lack of growth must be distinguished from delayed hair growth because transplanted hairs occasionally require as long as 12 months to grow. Telogen effluvium or loss of original hairs in transplanted areas, usually an avoidable condition, can result from poor circulation or inadvertent trauma to already existing hair follicles, thus producing an initial early thinning of hair that can range from mild to cosmetically disturbing. Hairs usually return in 1-2 months, but this can be a difficult situation. Errors of technique and of poor planning are preventable but occur all too often. The most common of these technical errors, which results in a transplanted appearance, is the use of excessively large grafts and unaesthetic hairline design. The importance of using 1- and 2-hair grafts, placed in the proper direction to create an irregular hairline of gradually increasing density as the surgeon proceeds centrally, cannot be overstated. Failure to anticipate future hair loss in planning hairline restoration can result in an unnatural appearance as the patient ages. One of the most common problems can be development of large bald areas between the lateral aspects of the parietal hairline and the temporal peaks caused by recession of the temporal areas. Transplanting of the crown in a young individual who eventually develops excessive baldness can result in a circular region of transplanted hair surrounded by a rim of bald scalp. Undesirable hair transplantation results can usually be dramatically improved by using a number of reparative techniques. However, the goal of hair-transplant surgeons should be the prevention of undesirable results. OUTCOME AND PROGNOSISSection 9 of 12
Results of hair transplantation can be extremely rewarding for the surgeon and the patient. When a team of trained and experienced assistants perform the procedure properly, it flows smoothly, with different members of the team participating and their work directly contributing to the final result. Patients must be given realistic expectations. Furthermore, the importance of joint planning by the patient and the surgeon for future hair loss cannot be underestimated. FUTURE AND CONTROVERSIESSection 10 of 12
During the 1990s, leaders in hair transplantation debated several topics. Out of the debates emerged several commonly (though not unanimously) accepted truths. First is the superiority of hair grafting versus bald-scalp reduction and scalp-flap surgery in almost all situations. Second is the inferiority of lasers to conventional cutting devices to form the recipient site. Third is the acceptance of large-session micrografting, also termed the megasession, in which 2000 or more grafts can be transplanted safely in a single procedure. At the time of this writing, nearly all hair-transplant specialists agree on the superiority of follicular-unit micrografting over traditional micrografting and minigrafting. Although follicular-unit micrografting is technically more demanding and time-consuming than other procedures, it yields superior results in terms of creating a natural appearance because hairs are transplanted as they grow naturally in the scalp. The procedure also enables dense graft placement when desired because individual grafts are small and thereby permitted small recipient sites and closer spacing. In addition, follicular-unit grafting reduces accidental transection of hair follicles during the graft-dissection process because dissection is performed under microscope visualization; therefore, wastage of valuable donor hairs can be reduced. The future of hair restoration is exciting, primarily because of medical advances. Improved effectiveness of control of hair loss coupled with minimization of adverse effects result from the use of 5-alpha reductase inhibitors that are specific for the hair follicle or from the use of medications that work by alternate pathways. In addition, gene therapy may have future application in hair loss treatment. After the full human genome is mapped, the genes that cause alopecia can be located and potentially replaced with genetic sequences not associated with hair loss. Conservative estimates place implementation of this type of therapy well into the 2010s and perhaps later. Hair cloning (technically cell multiplication) may offer the surgeon a virtually unlimited supply of donor hairs. By cloning multiple copies of just a few donor hairs, patients with even extensive hair loss can expect complete scalp coverage, all with minimal donor-site morbidity. Most likely, follicle stem cells will be multiplied then injected into areas of thinning to initiate the regrowth of hairs. Candidates for hair cloning include not only those with advanced hair loss but also those with scarring or poor supplies of potential donor hairs because of burn injury or previous poorly performed hair transplants. A rather new technique that has found a limited indication is follicular unit extraction (FUE). Rather than involving the removal of a donor strip as with follicular unit grafting, FUE involves the individual removal of follicular units from the scalp using a small-sized (typically 1 mm) punch. These individual follicular units can then be transplanted as with other transplantation techniques. The main benefit of the FUE technique is the absence of a donor-site scar; however, the technique has some limitations. These limitations include the somewhat lower reliability of hair growth with these extracted grafts, the extensively greater amount of time needed to remove each graft, and, therefore, the higher cost per graft. Currently, the best indication for this procedure is for the treatment of very limited male pattern hair loss in those individuals who choose to shave their hair or wear it very short, in whom a donor strip would potentially leave a scar. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Hair Graft Transplantation for Baldness excerpt Article Last Updated: Feb 13, 2008 | |||||||||||||||||||||||||||||||||
