You are in: eMedicine Specialties > Plastic Surgery > HAIR Hair Replacement Surgery, Hair TransplantationArticle Last Updated: Jun 6, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics Jorge I de la Torre is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama Coauthor(s): Gary D Monheit, MD, Associate Professor, Department of Dermatology, University of Alabama at Birmingham; John D Kayal, MD, Consulting Dermatologist, NW Georgia Dermatology and Skin Cancer Specialists, LLC Editors: Joseph A Molnar, MD, PhD, FACS, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; Associate Director, of North Carolina Hospital Burn Unit, Wake Forest University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark E Krugman, MD, Assistant Professor of Plastic Surgery and Clinical Professor of Otolaryngology-Head and Neck Surgery, University of California at Irvine School of Medicine; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: hair replacement surgery, hair transplant, hair transplantation, micrograft, minigraft, alopecia, hair growth, male pattern baldness, baldness, androgenic alopecia, male pattern alopecia, cicatricial alopecia, traumatic alopecia, traction alopecia INTRODUCTIONSection 2 of 12
  Hair replacement surgery, a 40-year-old procedure, is now at a stage where its history can be re-examined, present procedures enumerated, and its future evaluated. The provocative observation that donor site, composite grafts, or occipital hair follicles, when transferred to the frontal area of the scalp, not only survive and grow but continue in a growth pattern throughout the patient's life has spurred a major subspecialty of cosmetic surgery. The innovations, refinements, and new techniques that emerged during the ensuing 40 years truly have made Norman Orentreich's original experiment a definitive subspecialty. This article reviews some of the prior advances during this time, where they stand now, and state-of-the-art techniques. History of the ProcedureThe science of hair transplantation defined the nature of male pattern baldness and predicted treatment programs for each pattern and stage. The work of Norwood, Ayers, and Stough defined candidates for hair transplantation and state-of-the-art methodology for the 1960s and 1970s using hand punches, graft sizes, and patterns of replacement. Objective observations by Dr Walter Unger, with meticulous hair counts, defined the ideal graft size of 4.0-4.5 mm for maximum hair growth. Additionally, particular patterns for best aesthetic results were reviewed. Microphotography by Dr Tom Alt clearly demonstrated which grafts were ideal and defined the techniques necessary to produce these ideal grafts. Innovators such as Uebel developed the approach of micrografts (1-3 follicles) or minigrafts (3-8 follicles) to improve the natural appearance of the grafts. The very best grafts were produced with a mechanically rotating power punch using a carbon steel trephine designed by Richard Shiell. Saline injected into the donor area to produce the proper tissue turgor for graft harvesting clearly produced superior grafts because the punches cut cleanly through the rigid scalp tissue. Cluster harvesting and closure of the donor site became the normal procedure, producing the least amount of scars in the donor area. These innovations in graft harvesting produced superior quality hair grafts for greater density and coverage of the recipient sites. Aesthetic concerns for hairline placement, growth and direction of hair grafts, and hair angulation in the recipient sites further refined major grafting techniques. ProblemTransplantation began as a punch graft technique using skin biopsy punches of convenient sizes. In the early years, the procedure was performed simply as a skin biopsy, with no specific planning. Hairlines were established as a consensus between the patient and physician, and random grafts were placed behind this point according to the desire and wishes of the patient. Typically, 20-30 grafts were placed at a time, donor areas were left open to granulate in by secondary intention, and multiple small treatment sessions occurred over years until both physician and patient were satisfied. Surprisingly, many of the results remained quite good. Patients with the best hair type, skin color, and densities, even after 30-40 years, continue to have adequate cosmetic results. Those with less than desirable cosmetic results experienced adverse effects including a tufting or corn-stalking appearance of grafts, inappropriate hair lines, cobblestoning, scars, and progression of hair loss beyond transplanted areas. Future advances and refinements were made in response to these problems. FrequencyAlopecia is a common problem within our population. In the United States, it is estimated that 35,000,000 men and 21,000,000 women experience hair loss. It is so common in men that it is actually accepted as normal. Androgenic alopecia in females is an increasingly frequent problem based on heredity and hormonal change. There is much speculation concerning the more frequent occurrence of this problem among premenopausal women but the answer remains obscure. Both of these conditions are considered "donor dominant" and thus amenable to hair transplant surgery. EtiologyDonor versus recipient dominance refers to the ability of hair grafts taken from an occipital donor area to grow and survive after transplantation to the frontal recipient site of alopecia. This phenomenon is explained by the presence of 5-alpha reductase in the cells of the recipient hair follicles. This enzyme, found in skin, is responsible for conversion of testosterone to dihydrotestosterone (DHT). Even normal circulating amounts of testosterone may be excessively converted to DHT or the hair follicle may be abnormally receptive to DHT, creating androgenic alopecia. The donor follicles from occipital regions have less or no enzyme and thus are not influenced by hormonal factors. The mesenchyme-derived dermal papilla at the base of the mainly epithelial hair follicle controls the type of hair produced. This is probably the site through which androgens act on follicle cells by altering the regulatory paracrine factors produced by dermal papilla cells. Recipient dominant conditions refer to a diseased recipient area, which will destroy the healthy donor follicle when transplanted. These conditions include cicatricial or scarring alopecia, such as discoid lupus erythematosus, lichen planopilaris (lichen planus of skin and hair follicles), and other active scarring skin diseases of hair and scalp that attack the healing donor follicles. This disease can be treated medically and when the condition resolves, healthy hair grafts can be placed into the resultant but quiescent scar. PathophysiologyAndrogenic alopecia as described above accounts for most of the patients seen for hair restoration. However, there are numerous other causes for hair loss, and the treating physician should recognize that some of these are not amenable to surgical treatment as there is no unaffected donor site. Alopecia areata is an autoimmune hair cycle shift that can be present in any area of the scalp, including donor areas, so that all scalp hairs may be involved, leaving no healthy donor follicles. It also resolves with medication and topical therapy, with hair regrowth in most instances. Diffuse female alopecia also involves the entire scalp and thus is not amenable to hair transplantation. INDICATIONSSection 3 of 12
Indications for hair transplantation include androgenic alopecia, male pattern alopecia, cicatricial alopecia, traumatic alopecia, and traction alopecia. RELEVANT ANATOMYSection 4 of 12
The surgeon should be aware of the blood supply and sensory nerve innervation of the scalp for planning incisions. Circumferential donor incision for harvesting occipital grafts may compromise the blood supply for future transplantation of the crown. Sensory innervations of both donor and recipient areas can be planned around regional nerve blocks and local ring blocks. The supraorbital nerve and retroauricular nerve blocks are helpful for local anesthesia of the scalp. CONTRAINDICATIONSSection 5 of 12
Specific contraindications to this procedure include diffuse female pattern baldness, non–donor-dominant alopecia, and alopecia areata. The scarring alopecias are nondominant and, while active, do not respond to hair transplantation. These include discoid lupus erythematosus, lichen planopilaris, and other cicatricial alopecia. WORKUPSection 6 of 12
Lab Studies
StagingStaging alopecia into both pattern and degree of severity can be accomplished through the Hamilton classification. Patients with Hamilton patterns I and II have very early limited alopecia requiring minimal treatment if accepted as candidates. Conversely, patients with patterns VI and VII may no longer be candidates for the surgery since their alopecia is so extensive. The very best candidates fall into patterns IV to V, which produce the best, most natural results. TREATMENTSection 7 of 12
Medical therapyMedical therapy often may be used in conjunction with hair restoration surgery. Minoxidil (Rogaine) is available in 2% and 5% topical solutions. Unfortunately, cosmetically useful hair is obtained in only about one third of cases and Minoxidil must be used indefinitely to maintain a response. Finasteride (Propecia) is a type 2 5 alpha -reductase inhibitor available in 1 mg tablets and given once daily. It lowers the dihydrotestosterone on the scalp and serum of treated patients. Clinical trials have show finasteride to be effective in preventing further hair loss and increasing hair counts to the point of cosmetically appreciable results. Interestingly, hair loss on the temples is not improved. Side effects are rare, less than 1%, and patients must remain on the drug indefinitely since the benefit may be lost after discontinuation. Surgical therapyThe techniques described in the Introduction have given most hair loss patients procedures for excellent aesthetic hair replacement surgery. Still, for patients with extensive alopecia or those with thin black hair and pale white scalp skin, major grafts still produce a tufted or artificial appearance. In response to these patients, in 1986, Dr Wayne Bradshaw introduced micrografting techniques that involved the use of single hairs as an alternative method of hair replacement. The demonstration of his own scalp covered with thousands of single hair grafts at a major hair transplant meeting opened up the field to procedures other than major grafts and introduced size as a major variable in hair transplant surgery. Minigrafts and micrografts Micrografts, which consist of one or two hairs per graft, and minigrafts, which contain 3-8 hairs per graft, became part of the new tools available to the hair transplant surgeon. These smaller grafts, when properly placed, provide a more natural, less abrupt appearing hairline in contrast to the standard graft of 4.0 mm. Nordstrom demonstrated that the smaller minigrafts and micrografts are best placed into incision sites termed "slits" placed in horizontal rows along the frontal hairline. His techniques changed the mechanics, appearance, and character of the procedure. Slit techniques supported a simpler method for placing hair grafts. Large numbers of 1- to 3-hair micrografts are placed in slit incisions without using recipient punches to remove bald scalp. The technique can be used for younger patients with thinning hair without sacrificing existing hair follicles in the recipient area. Patients with female alopecia, cicatricial alopecia, and extensive alopecia were now candidates for slit graft hair transplantation. The older concept of removing bald scalp and replacing it with hair-bearing scalp thus had changed with the addition of slit minigrafting techniques. Many transplant surgeons converted to solely minigrafting and micrografting, and the old problems with the frontal hairline and its natural refinement were solved with these techniques. Fine micrograft hairs are placed in the front line and are backed up by larger micrografts and minigrafts. The average hair transplant patient can have the procedure completed in 2 or 3 sessions rather than 4, typical with standard grafts. Using these techniques, even poor candidates with thin dark hair can have natural, blended hairlines. Innovators such as Alfonso Barrerra have demonstrated that the "mega-session" approach allows the transplantation of thousands of micrografts and minigrafts during a single operative procedure. In most cases, an additional follow-up procedure, if necessary, is usually minor and brief. Slits and holes The traditional harvesting technique for obtaining minigrafts and micrografts still used standard hair transplant punches. Minigrafts and micrografts were harvested from 4.5-mm standard grafts by quadrisecting them to smaller grafts. Slits or recipient holes were made with 1.5-mm and 2.0-mm trephines, placing the slits or smaller holes near the frontal hairline and the larger ones farther back. The grafts then were placed into the recipient holes where bald scalp was removed and thus treated as a standard hair transplant procedure. A major debate ensued as hair transplant surgeons arguing over which technique was better, slits or holes, for minigrafts and micrografts. It was noted that the slit grafts compressed with healing to a single stalk from which 2-5 hairs would grow. This gave an artificial or tufted look when only slit minigrafts were used. The grafts did not have the natural density of holes for minigrafts. Similar minigrafts placed in holes seemed to remain spread out and did not have this compressed, artificial appearance. The advocates for holes emphasized that using the small holes to remove bald scalp was advantageous because density was greater than that obtained with slit grafting techniques alone. Others versed in both procedures have found that mixing slits with holes and varying graft size are major factors in obtaining a natural hair transplant. Harvesting technique New concepts in harvesting techniques have emerged to re-adapt for the smaller mini-micrografts. Removing major grafts and trimming them to 3 and 4 smaller minigrafts and micrografts is a tedious procedure, taking up most of the time for hair transplantation. The dividing techniques also left some donor material that could not be used. Simple excision of a strip, which then could be divided into the mini-micrografts, was performed, and since these smaller grafts did not need a round or cylindrical shape to fit into the recipient slits or holes, the strip harvesting technique became popular. The use of triple or quadruple blade knives to make 2-mm parallel excisions across the scalp has made the harvesting technique easier and more precise. These new advances allow the surgeon to accurately trim 1-mm and 2-mm grafts with no waste and little follicular damage. The donor excision site then is sutured or stapled very cleanly to a fine imperceptible line in the occipital scalp. From these strips, the surgeon accurately can predict the number of minigrafts and micrografts available for the procedure. Long-term results These technical innovations have given the transplant surgeon the ability to harvest and implant larger numbers of mini-micrografts and thus cover greater areas of balding scalp. As with all technical advances, clinical trials reveal some good results as well as drawbacks and adverse effects with the procedure. In the mid-1980s, extensive mini-micrografting was very popular. Not uncommonly, patients received 700-1000 minigrafts to cover extensive areas of bald scalp. It also was common to perform transplants in younger patients with bald frontal and occipital areas who were thinning in other areas. The "heyday" of extensive hair transplant surgery now is being re-evaluated 10 years later as patients have matured and the process of male pattern baldness has progressed. Dr Emanuel Marritt has examined the consequences of the procedures on patients 10 and 15 years after surgery. Those who have progressed to more extensive baldness have developed resulting deformities in hairline and hair growth. Particular problems have occurred as the progression of occipital hair loss draws the posterior fringe farther back and leaves occipital transplants with a halo of bald scalp surrounding the island of transplanted hair. This has created an unnatural appearance of hair growth with the surrounding bald halo. Similarly, hair transplantation of the frontal tuft or temporal peak alone in young patients in whom further progression of temporal hair loss occurred left these patients with unnatural islands of hair in the frontal scalp 10 years later. These problems can become impossible to resolve as the patient runs out of donor hair, and correcting the new areas of bald scalp that have emerged becomes impossible. Similar problems have developed with scalp reduction procedures in which the unrelenting progress of male pattern alopecia has exposed the scar lines, with no further donor hair to cover these balding areas. A new sobering conservative view is emerging in the field of hair transplantation: the surgeon should evaluate the patient both regarding the improvement he or she can provide in the immediate future and for long-term results. Too much emphasis has been placed on immediate coverage and appearance and not enough attention paid to the long-lasting effects of this permanent procedure, when male pattern alopecia progresses to a more extensive finality. The problem remains that surgeons cannot always predict which patients will progress to grade VI and VII classification and produce these unnatural results. Care should be taken in transplanting young patients in whom the full extent of alopecia at age 40, 50, or 60 years cannot be determined. At this time, hair transplant surgery is an exciting field with techniques both past and present that can be used for the benefit of patients. The object of the clinician is to individualize which of these techniques is best for hair replacement based on the patient's hair type, density, color, skin type, extent of baldness, and age. Each of these variables is factored into the formula, and a treatment plan is developed for the use of major grafts, minigrafts, micrografts, and the location of each of these in regions of the patient's head. Using each of these techniques, surgeons can individualize the correct hair replacement formula to meet patient needs. Over the last 40 years, hair replacement surgery has evolved greatly, but in many aspects, it has returned to its basics, which include the principles of removing and replacing bald scalp with hair-bearing scalp to produce a natural, long-lasting effect. Preoperative detailsThe hair transplant surgeon also must take into account the following characteristics of donor hair to predict results:
These characteristics should be noted and discussed in the consultation with the prospective patient. The patient should be free of all medications that may influence bleeding tendency such as aspirin, non-steroidal anti-inflammatory medications, blood thinners, and herbs or nutrients that create bleeding problems such as garlic, St Johns wort, and Ginkgo biloba. The patient may have a light meal prior to surgery and be given oral fluids as needed. The author uses mild anxiolytic sedation and local anesthesia. This includes diazepam 10 mg PO, meperidine 50 mg, and hydroxyzine 25 mg IM. Intraoperative detailsTopical anesthetic can be usually be used to decrease discomfort from the scalp block; however, sedation can be used during the administration of the local anesthetic. Bupivacaine (Marcaine) with epinephrine (1:200,000) is recommended to allow sufficient duration of action. This anesthetic is used to block the occipital and supraorbital nerves and to provide ample subcutaneous infiltration to the donor site and the upper forehead. In addition, approximately 100 mL of 0.25% lidocaine (Xilocaine) with epinephrine is used throughout the scalp for tumescent infiltration. The use of local anesthetic with epinephrine not only provides anesthesia to the scalp but also helps with hemostasis. Some surgeons utilize the team approach. Assistants can help prepare the grafts while the surgeon closes the donor site and begins graft insertion. With the patient's head positioned on a head rest, the head can be turned from one side to the other to facilitate harvest of the grafts from each side. The donor site can be closed with a running monofilament absorbable suture. Using preoperative markings, the anterior hairline can be created with the smallest grafts to obtain the most natural appearance. Large grafts can then be used to fill the more posterior areas. Postoperative detailsAt the conclusion of surgery, the donor grafts are covered with an adhesive or Telfa strip and the patient is wrapped in a head turban. The patient is kept for approximately 1 hour after surgery and given oral fluids and a light snack. The patient should be accompanied home and someone should stay with him or her overnight. Follow-upPatients are seen the day after surgery to check the transplanted grafts for positioning and survival. Dressings can be discontinued and the patient can begin washing the hair in 72 hours. COMPLICATIONSSection 8 of 12
Intraoperative complications include hemorrhage, lidocaine toxicity, and pain. Postoperative complications include hemorrhage, arteriovenous fistula, infection, scarring, poor hair growth, unnatural hairline, and doll's head appearance. OUTCOME AND PROGNOSISSection 9 of 12
The transplanted hair follicles typically appear to grow in the immediate postoperative period. Within a month, the graft follicles enter the telogen phase and are all shed. Hair regrowth then takes approximately 4 months, but the hair continues to improve in quality and quantity over the subsequent 2-4 months. Growth stabilizes at about 1 year and reports have indicated graft survival rates of over 95% in experienced hands. The present techniques and technology of hair transplant surgery can give a proper candidate realistic and natural appearing transplanted hair. Using 2 or 3 hair transplant sessions, the candidate has a successful outcome. FUTURE AND CONTROVERSIESSection 10 of 12
The most realistic transplants now are performed with micrografts that yield a realistic presentation. The latest technology can spare donated hairs so that each follicle takes and produces cosmetically acceptable hair. Future technology will further refine the surgeon's ability to use every hair and follicle to its utmost potential. In addition, further understanding of the hormone and follicular interaction may yield new medical management options. The new field of stem-cell research may present a completely new paradigm for the management of alopecia, including cultured hair grafts with improved viability and survival. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Hair Replacement Surgery, Hair Transplantation excerpt Article Last Updated: Jun 6, 2006 | ||||||||||||||||||||||||||
