Hair Transplantation
Hair Transplantation
The Theoretical Bases and the Historical Development of Hair Transplantation
It was essential to relize that the hair onions found in a horseshoe-shape on the vertex area and at the lateral side of the midscalp, are suitable for transplantation. They are not sensitive to hormonal effects, therefore the hair of most bald men remains at these areas.The hair onions transplanted from this area preserve this property and the transplanted hair onion adheres to the recipient area and produces normal hair, which does not fall out. This is the principle of donor dominance.
The transplanted hair is nourished by diffusion from its surrounding and after a regeneration period of 2-3 months it produces hair. From now on hair growth happens in the same way as at the original place, and it can even reach
The classic experiment and study of Orentreich in 1959 proved that hairloss can be surgically treated by using autologue hair. In the 60s and 70s surgeons started to use this method but the technical application was rather primitive (cf. picture E in colour appendix).
Orentreich thought the
Although hair growth was reached on the bald areaswith these procedures, in most cases the result was more disturbing than baldness itself. The unnatural placement and form of the turf-like and tangled transplanted hair was rather disturbing. The so-called donut-effect (i.e. the central necrosis of big circular grafts) only tops the unnatural look.
One of the frequently occurring complications in the case of such grafts is cobblestoning, which means that the prominent big grafts cause an uneven surface and cicatrisation on the scalp. The use of big grafts is especially diturbing at the frontal hairline zone, where natural very fine hair develops the special character and direction of the typical frontal hairline (cf. picure G, H in colour appendix and the chapter on “Planning and Making the Hairline”).
Usually 50-100-300 grafts were transplanted at once using this method. Therefore the operation had to be repeated at least 3-4-5 times to ensure the complete covering that is possible with this method.
The application of small grafts brought a change in the attitude towards hair transplantation, it developed and improved constantly, and became wide-spread around the world from the 1980s on. We can say that today this method is at its theoretical peak under the given conditions. Improvement could only be expected with a revolutionary refinement of the technical devices, or by increasing the quantity of the transplantable hair.
In the 80s it was Uebel (45) who managed to transplant 1000-1200 grafts per operation. These grafts were minigrafts according to recent terminology, containing 3-6 hairs and he used these together with 2-3 follicular unit (FU) grafts.
Unfortunately many doctors still use the 4-8 FU grafts prepared with unaided eye(?) as small grafts. this is not that disturbing in its appearance as punch grafts, but when multiply implanted it is unnatural and conspicuous especially in the frontal hairline. They can be used in autologue hair as condensation, but in the course of hairloss they can become visible and may need correction (cf. pcture G, J in colour appendix).
The planned application of micro-minigrafts, the refinement of graft dissection and implantation and the progress of tissue considerate techniques resulted in more natural and high-standard methods and appearance. Since the Innovation of Limmer (47) in 1988, I.e. the application of the microscope, it was obvious how fussy work was necessary to prepare grafts and to reduce transsection and preserve the follicles in order to provide the best result.
The recognition of the significance of FUs and their use in hair restoration techniques (Bernstein & Rassman) (49) meant that all the aims mentionedat the beginning could be fulfilled almost completely with the appropriate operation. It is easy to see at a very close examination of the scalp that hair grows in well separable, small bundles creating anatomical-physioligical units, i.e. follicular units. One such unit contains 1-2, 3-4 or rarely 5 follicles usually. There may be significant individual and ethnical differences.
The best quality grafts for transplantation can be prepared by magnifying with a binacular stereomicroscope or videomicroscope, which helps preserving the follicular units.
The grafts prepared this way contain only the necessary amount of subdermal and dermal tissue, which is often less than in the same FU, micro- or minigrafts (cf. the figure on “The 3 FU graft and micrograft”). Thus after the implantation hairgrowth will be natural with appropriate angulation and without cicatrisation. According to examinations, skinny grafts resulted 100% hairgrowth under optimal conditions, whereas chubby grafts resulted 113-134%. The reason for this lies in the growth of telogen hair to be found in the surrounding tissues, which cannot be seen freely, and which resulted in terminal hair later.
Kim and Choi (60,61) found that healthy hair grows to a 100% from the lower two-third of the horizontally transsectional hair, while from the upper two-third it is only to 60%. If the germinative zone is not completely healthy, hairgrowth will be of a poorer quality (cf. figure 26).
Today the practical obstacle of hair restoration lies only in the limited availability of the donor area. Even in cases of extended baldness, natural covering with a significant result but barely visible traces of the operation is possible.
Planning and Making Modern Hair Transplantation
The Evaluation of the Patient
A. Physical Checkup
A. 1 The determination of the degree of baldness (cf. chapter on “The Physiology of Hairgrowth”). We can estimate the possibility of further hairloss and calculate its extension and form by considering the age of the patient, the state of baldness and the familiar anamnesy.
A. 2 The determination of the degree of miniaturisation on the recipient and donor areas (cf. chapter on “The Physiology of Hairgrowth”). We should determine the miniaturisation of the recipient area together with the previous factors. It influences the extension of the operation and the placing of grafts. Concerning the secure donor area, several descriptions exist (Alt, Unger) (65), but in general we can state that the occipital protuberance is the lower edge and the upper line is 6.5–7.0 cm from the reflection of the external auditory meatus according to the conservative view. The area where hairloss can be expected, should be avoided. The big amount of miniaturised hair is typical here. Unger thinks, the border is at least 8 terminal hairs on a
A.3 The determination of the features of the hair: the diameter, length, colour, texture and curlyness. The knowledge of these features is essential in estimating the expectd result of the operation. The diameter of the hair, which is usually 50–100mm, can be measured with a micrometer. The thicker the hair, the better the coverage that can be achieved (assuming the same amount of hair). In the case of dark, stronger and curlier hair the result will be more successful and spectacular as with bright, soft and straight hair.
A.4 The features of the scalp: laxity, flexibility and colour. Traces and scars of previous procedures and treatments should be noted. Previous surface treatment: the long-term use of agressive agents may lead to deformities of the dermis and epidermis, which means the reduction of of their elasticity mainly, and this makes implantation difficult. The colour of the scalp: the colour contrast of the scalp and the hair has an important impact on the visible result. Hairloss is more conspicuous in the case of a bright scalp and dark hair. The doctor should indicate the effect that results from this to the patient. Laxity is significant on the donor area mainly, it helps choosing the width of the donor stripe. The determination of laxity is subjective, the optimal width of the stripe can be well estimated with the necessary experience. Usually this is between 1–1.5 cm, in the case of a loose scalp it can be more than that. Flexibility is a completely different matter, which characterises the tightness and strength of the subdermal and subcutaneous tissues. There may be considerable subjective differences in these factors. Very soft tissues, mushy dermis can make graft dissection and insertion extremely difficult, and follicle transsection and loss are more frequent. On the other hand, graft dissection is usually easier in cases of crispy tissues, but insertion can be difficult because of the minimal flexibility of the opening on the recipient scalp. Information about previous operations and scars on the scalp is very important. Hair implantation is possible after replacement with semi thick skin or on any operational and other types of scars. Grafts have to be in touch with the surrounding tissues in order to ensure better diffusion. This way hairloss around the scars after forehead or face surgery can be replaced adequately.
A.5 Hair density and the estimation of hair quantity of the donor areas. Information about hair density is of major importance from the point-of-view of the operation. It can be measured with a densitometer, a trichoscope or a video-densitometer. Different authors describe the average hair density in different ways. There may be typical ethnical differences.
Hair density reduces around the temporal regions and increases towards the occiput. The average density should be measured best around
The number of hairs to be transplanted (I.e. the number of grafts or FUs) is an important basis for the extension of the operation and for patient information. There are no unified principles in this area.
For example: if we transplant 300 10 FU big grafts, the sum total is 3000 follicles. Using 1000 pieces of FU (i.e. 300 single grafts, 500 two FU grafts and 200 three FU grafts), we can transplant 1900 follicles. However, the aesthetic result of the two methods is not equal. For the patient it is more obvious if we indicate the number of hairs to be transplanted, supplemented with the description of the follicular technique.
The number of transplanted hairs can be calculated from the size of the extracted stripe, the hair density and the loss during dissection and transplantation. The loss during the dissection is about 5% in optimal cases, and it has to remain below 10 – 15% depending on the differnet techniques. On the basis of theoretical calculations, the average scalp surface is 500 cm2 and there are 100.000 terminal hairs on the head without hairloss.
When total baldness is reached in cases of AA, 12.5% of the permanent hair zone can be used for transplantation, which is half the amount of the original hairy area that can be used without the visible thinning of the donor area. This means that 12.5% of the original amount can be used for transplantation, i.e around 62.5 cm2 (500 cm2 ´ 12.5 %). If the average hair density is 1 FU/ mm2 and each FU contains 2 follicles on average, then 6250 donor FU, i.e. 12.500 follicles can be transplanted. This number can vary according to the difference of hair density.
The 12.5% has to replace a loss of 75%. If we assume that all the available follicles from the donor area are transplanted, about 17% of the original density can be reached. Of course several procedures are needed to achieve this. Although this seems to be a low number, we know from the practice that a 17% coverage is a fairly good result, especially in the case of optimal scalp and hair features, and if the patient’s expectations are realistic enough. Apart from the sufficient amount of donor follicles, modern technical operation is an inevitable condition of a good result.
B. Consulting the Patient
The most important topics:
- • familiar and personal anamnesy (includes previous operations)
- • the patient’s expectations
- • the harmonisation of the expectations and the best possible operation technique
Oral information is of primary importance. We can only offer the optimal treatment after having discussed the expectations and assessed the conditions. We should only operate, if we have an assuring result both for the patient and for the doctor from the previous discussions. Everyone should be aware of the fact that a patient with an instabile attitude will not be satisfied with the best professionally correct result that can be achieved under the given circumstances.
If we take the time to consult with the patient who is determined enough, and whose needs can be met, then most probably he will be satisfied with hte result.
Planning the Operation
Ideally the plan of the operation is an actual and long-term one. We have to plan the frontal hairline, the frontal hairzone, the areas where diferent grafts are used, their distribution and extension. Any long-term plan has to take into account the number of grafts to be used for one operation, the degree of baldness, the possibility of further hairloss and the patient’s needs and expectations.
After the preoperative checkup we can determine how many grafts (FU) can be tansplanted with one operation and what result can be achieved considering the features of the patient’s own hair (density, thickness, etc.) (Avran) (63). Ideally we can demonstrate the expected outcome with the results of patients with the same kind of baldness and the same type of hair.
Computer-aided picture analysis can be a good method for bald patients, but it is rather dangerous in the case of patients with high expectations, as the operation will result in a different form, less hair, etc, which is difficult to explain afterwards.
Patients in the Norwood III, IV phase should be informed about possible later loss of their existing hair, which will change the look and may need further operations. This is important for young patients especially, thus we have to plan 20 – 30 – 40 years in advance.
Planning and Making the Frontal Hairline Zone
When planning the frontal hairline, generally we should take a possible later stage as the basis, which should be masculine, and not the teenage stage. Especially young patients in the Norwood II, III phase who have a bald father insist on their original hairline. Planning the form and the altitude of the hairline is best done before a mirror in accordance with the patient’s wants, aiming at a look that is natiral and fits the age (cf. pictures O, T in colour appendix).
Kahn’s rule can help in creating the altitude of the hairline: the internal most point of the curve is three transversal fingers above the upper forehead furrow. The plan of the altitude and the form of the hairline should be flexible, depending on individual factors. We shuld also bear in mind the expected hairloss of the existing hair (even the vellus type). There is nothing worse than a low and wrongly directed hairline, which is impossible to correct later (cf. figure 30). This problem occurs most often when planning the frontal line.
With this seemingly simple procedure we can cause serious if we lack sufficient practice and expertise.
We can form the natural frontal zone of older patients of the Norwood V – VI – VII type by breaking the line temporarily. Forming the frontal forelock in the case of extensive baldness means the reconstruction of the natural state, when we make big density frontal covering placing smaller density grafts around. This method together with longer hair ensures optimal frontal coverage and gives a natural frame to the face (cf. pictures P in colour appendix).
The frontal or transitory zone should be developed at the border of the hairy scalp and the forehead. This area, being the most conspicuous one, is mostly critical. The frontal hairline zone is this area down to 2 –
Operation Preparations
Apart from the general rules of the patient’s prepararion, some special points have to be mentioned. The patient must not take Aspirin, drugs containing salicilat(?), anti-coagulants ar others causing haemophilia at least one week before the operation.
The patient should wash his hair the day before the operation. Haircut is necessary only at the donor areas, which can be covered easily later on. It is useless to cut the patient’s hair as it makes social contact difficult. The operation can be performed safely on a hairy scalp as well, and in fact this is what we do at all condensation procedures. Pre-operative Seduxen or Dormicum per os reduces pre-operative stress and prevents possible vaso-vagal sickness.
We desinfect the operational area in the usual way, the patient is laid in a half slanting position for the donor extraction, and for the recipient area implantation either he is laid on his back, is seated, or in a half seated position.
Anaesthesia
Usually this operation is best performed with local anaesthesia. Thus total sedation can be achieved with the least inconveniences and bleedings at the operational area. General anaesthesia is useless and it only increases operational risks. The most frequently used anaesthetics are lidocain (xilolain) and marcain (bupivacain).
The effect of lidocain together with epinephrine lasts 60 – 400 min. and that of marcain with epinephrine is 240 – 800 min. The maximally safe dose of lidocain – epinephrine is 7 mg/kg. The two drugs (lidocain and epinephrine) can be applied mixed (in a rate of 50 – 50 % or 40 – 60%) supplemented with a 1:50,000 – 1:200,000 concentration tonogen (or epinephrine).
On the donor areas anaesthesia is followed by subcutaneous tumescent infiltritation with the application of normal physiological salt solution or tonogen, which eases taking out the donor slit grafts. After the infiltration of the outer line of the recipient area, the whole scalp is sedated because of the circular saggitsl innervation of the scalp. This is called the round block technique. The tumescent technique can be employed on the recipient area as well, but we have to take care to stay in the intradermal – subdermal tissue and not to exceed the quantity to be administered. The liquid infiltrated below the galea flows in the direction of the face without any mishap, and is thus responsible for the post-operative edema to a great extent. An early sign of lidocain toxicity can be the numbness of the mouth and the tongue. Epinephrine can cause bradycardia and heart failure when taking beta blockers.
It is advisable to make anaesthesia with slim 22 – 27 Gauge needles and 1–2 ml syringes. Thus pain can be minimalised and liquid distribution optimalised. When applying a dermojet, the patient can be frightened by the loud noise.
The inconveniences of the frontal line stinges can be reduced with supra-orbital, supra-trochlear anaesthesia, although often this can be even more painful because the eyebrow area is very sensitive.
The Treatment of the Donor Area and the Removal of Different Slit Grafts
The donor tissue is usually taken out from the occipital area of the scalp in the form of single strips. Thus the trace that is left behind is minimal on the donor area. It is of general validity that the safety of this area has to be considered, which has been discussed previously. The strip can be taken out from ear to ear, or from one side in a ransversal direction curved to the ear. Slanting and longitudinal incisions should be avoided, as these often heal with pulling scars.
The application of the tumescent technique on the donor area helps a lot, because bleeding can be controlled and the injury of the galea while undermining the lifted subcutis can be avoided, and also the occipital injuries of the bigger formulae.
There is the possibility of transsection, so the direction of the blade should be changed accordingly in the course of the dissection. This is most frequent in the case of the very soft dermal and subdermal tissues.
Excising the strips:
- • with multibladed knives: with 4–6–8 bladed knives (the blades at previously determined distances) we can excise several 1.5–2.5 mm wide stripes. The advantage is gaining several stripes at once that can be used for graft preparation. The disadvantage is that the non-visible incision area multiplies, which can increase the number of follicle transsection significantly.
- • manually: elliptic excisions are made, and 1–2 cm wide stripes can be excised depending on the flexibility of the scalp. This can be made with a double-bladed knife adjusted to the right direction. The advantage is the optimal controlability of the incision (cf. picture M in colour appendix).
Graft Dissection
An essential part of hair transplantation is the dissection of grafts and follicular units. We aim to transplant the excised hair quality in full quality.
Therefore we should always use blow-ups (magnifying glasses or miroscopes). Transillumination makes our work easier by illuminating the tissues from below. We can use various materials as a dissection pad: cork, wood, plastic, plexi and others, but mostly massive materials.
We should aleays watch the soundness of the hairs and the hair onions. All kinds of trauma should be avoided, the draining of the follicles is especially dangerous. The hair onions exttracted from the scalp, and kept under wet and cold conditions, can be safely transplanted within 6–8 hours. If this time is exceeded, the success of the transplantation reduces proportionately with time.
The Treatment of the Recipient Area, Tools and Methods
Several principles, tools and methods are well-known for the preparation of the recipient opening. We should aim to work atraumatically and effectively, without scars and bleeding. The opening can be slit, slot or hole, the first two of which are made without tissue removal, and the third one is done with it. In this case The woung surface is bigger, therefore healing is more difficult and extensive cicatrisation can occur. We should endeavour not to injure the aponeurotic galea when making the excision. The main blood- and lymphatic vessels and nerves run directly above it, at the lower part of the subcutaneous layer. Their injury would cause superfluous bleeding and would make revascularisation more difficult.
Tools:
- • circular minipunch knives These are the late offspring of the big punch knives employed for traditional techniques, but with significant alterations. Their diameter is between 1.5–2.5 mm. Some people use monitorised gimlets, but these are not in use nowadays. Although excising is accelerated, they are not suitable for fine work.
- • dilatators a ‘steel thorn’ is placed in the opernings, which helps to widen them and eases the insertion. Its disadvantage is a redundant workphase thus increasing the duration of the operation. It can be applied only for openings of size 2.5-
- • needles (normal hypodermic, No-Kor)
- • blades (size 11, miniblades, etc.)
- • automatic tools (see later)
The recipient openings and implantation
Hairs grow in a typical angle from the scalp: on the top they are vertical, and towards the forehead and the occiput they become flatter. The openings on the recipient site are excised vertically and sagitally – according to the previously mentioned principles and sporadically. If they are positioned too regurarly, the result will be an unnatural appearance.They should be placed as close to esch other as our practice, the tools and the hair density allows them to be.
The grafts can either be implanted in the prepared recipient openings, or inserte with the stick and place method, which means that implantation follows the excision of the openings immediately. Thus possible bleeding can be tamponated with the grafts.
Implantation can be easy or difficult, depending on the different quality hairy scalps of the different patients. Therefore we have to remain patient and precise – as in the other operational phases. We should aim at simple and ergonometric movements, and avoid both the mechanic injuries and the draining of the grafts.
Possible Complications of Hair Transplantation and their Treatment
- • The bad position and shape of the frontal hairline. The mistakes made in the position and the shape of the hairline (mainly too low and unnatural lines) are quite difficult to correct. The grafts that are in a wrong osition can be removed with a fine excision (cf. chapter ‘Planning and Making the Frontal Hairline Zone’ and pictures E, G, H in colour appendix).
- • Too large and unnatural grafts. These are especially prominent in the frontal zone, but they can also be really disturbing when placed sporadically on the top in cases of extensive baldness. The correction is possible using smaller grafts, which makes the hair look more dense.
- • The cobblestoning effect. Graft excision and condensation are advisable.
- • A thick wide scar at the back. The analysis of the absurdity of the donor site would exeed the limits of this chapter. If we choose the length of the donor strips correctly (i.e. according to the features of the sclap, usually the stripes should be 20-
- • Inflammation is quite rare and if it occurs, it is mild and can be well treated. According to the literature the chance of its occurrence is less than 0.1%.
- • Epidermal cistes may occur after piggy backing, or if a graft sinks below the surface of the skin. The ciste should be opened, emtied and the inflammation has to be treated with disinfectives. In the case of more serious inflammations the systematic dosing of antibiotica should be applied. In many surgeries it is called the ‘clean’ operation, i.e. sterile tools are used, but antisepsis is not ensured in any other form. According to the statstics and practice it is a well-tried method.
- • Hairloss or weak hair growth. Increased hairloss is rare, it is more usual in the case of women when telogen effluvium is more frequent. This does not require any treatment, usually a temporary spontaneous regression can be expected. It is not usual for transplanted hair to grow, the reasons are unknown (X factor), but it can be traced back to technical circumstances (eg. the draining of the grafts).
- • Scalp necrosis is rare, almost unlikely to occur - as opposed to reduction. It requires individual treatment (eg. transplantation, the use of flaps or expanders, etc.).
Post-Operative Care
The covering bandage can be applied at the operative area for a few days, but many people do not use them in practice. Hairwashing with water and disinfective shampoo is advisable the day after the operation. The use of irritating agents should be avoided for at least 2 weeks. Also the scalp should not be exposed directly to intensive sun for appr. 3 months. The use of copper peptyd is recommended (see earlier).
In order to prevent an edema on the facial-forehead area, physical burdening, too many movements or bendings have to be avoided. Some specialists suggest taking steroids. Pre- and post-operative antibiotic treatment is well-known from the literature, but the authors usually say that most often it is needless, because of the extremely good blood-circulation of the scalp, which has a low inflammational rate as a consequence.
Atraumatization
Many specialists expect the improvement of hair restoration from the introduction of atraumatization. As we could see from the description of the previous procedures, the different tools and devices have been developing together with the methods applied. Also, the changing techniques need newer devices.
Atraumatizing devices have occured in graft dissection and implantation, and the aim is to make work easier, faster and safer.
The graft slicing devices have speeded up dissection, but as this happens blindly, the number of transsections may increase. The comparative examination of the succesful functioning of the newest cutters (eg. Mangubat cutter) is in progress.
There are several tools on the market that can ease the excision of the recipient openings and the insertion of grafts. The Choi implanter is a pencil-like device that can hold single grafts, and after it is filled, it stitches in the scalp and the graft can be implanted with one movement. The problem is that the filling of the grafts needs a lot of time and work. Only very fine single hairs can be filled in, and that grafts may be injured or drained.
The Budjema implanter helps the insertion of the grafts in the excised recipient openings. This pen-like tool can lift with the help of vacuum and these can be easily inserted by letting the vacuum out. This tool makes implantation easy and fast, and graft injuries can be avoidedby using vacuum, but the openings have to be excised before.
Rasman’s Rapid Fire Hair Implanter Carousel makes both the excision and the graft insertion in one move. Thus the two labour and time intensive processes of hair transplantation can be contracted and shortened significantly. Grafts can be safely and quickly implanted. However, the device does not work with 100% efficiency because of the different property scalps. The carousel that can hold 100 grafts has to touch these sveral times. (This tool is in the introductory phase at the moment.)
Conclusion
The best suitable method for the treatment of male pattern baldness is autologue hair transplantation using follicular units. This method can also be used for the treatment of other hairloss problems.
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