Chapter 76. Hair Transplantation

Hair is one of the few physical characteristics over which we have voluntary control. The length, the color, and how we style our hair are a reflection of our personality and how we project ourselves to the world. When our hair involuntarily begins to disappear, it is a source of ongoing emotional and psychological stress for many men and women.

Fortunately, modern techniques in hair transplantation can consistently restore a natural frame of hair around the face (Figures 76–1 and 76–2). The era of large, pluggy, unnatural transplanted hair, which existed from the 1960s until 1990s no longer exists. Currently, the cosmetic standard for transplantation is to create consistently natural appearing transplanted hair for men and women. This chapter will be an overview of state-of-the-art techniques in hair transplantation.

As with all surgical procedures, a consultation is vital to the success of the procedure. In addition to a physical examination, a thorough hair loss and medical history should be obtained. Key questions include: How long the hair loss has been going on? What medications have been used to date, and with what success? What is the goal of the patient from the procedure?

On physical exam, the caliber of hair follicles and available donor density are the two most important physical characteristics to determine. Patients with thick caliber, coarse hair and high donor density will be able to create the perception of thick transplanted hair while patients receiving an equal number of fine caliber follicles, with poor to average donor density will appear to have received much less hair.

The physician should review the ongoing nature of male and female pattern hair loss. Patients should be aware that the net perceived density of the procedure equals the number of follicles transplanted minus their ongoing hair loss. For all patients, the role of minoxidil and finasteride for men, and minoxidil for women should be reviewed. Both medications are FDA-approved and are highly effective to help maintain existing hair.

If a patient uses a medication and undergoes hair transplantation, there can be a substantial increase in perceived density, both short and long term. Despite the success of medications, it should also be emphasized that the medications are elective and can be stopped at any time. It is the obligation of the surgeon to plan a transplant anticipating future hair loss. If a patient ever does discontinue the medication and more of their original hair is lost, the transplant should appear natural both short and long term.

An overview of the procedure, preoperative and postoperative instructions should be reviewed.

The key to success is to create realistic expectations based on each patient's physical exam, ongoing hair loss, and individual goals.

Hair transplantation is based on the theory of donor dominance, which states that hair transplanted from the posterior scalp and moved to the front of the scalp will maintain its natural genetic destiny and not to be affected by male or female pattern hair loss. The donor ellipse and follicular unit extraction (FUE) are the two techniques for harvesting hair follicles.

Elliptical donor harvesting is performed in the vast majority of patients. It is comparable to any other cutaneous excision, such as for skin cancer removal. The donor hair is trimmed to a length of 1–2 mm (Figure 76–3). The patient is placed in the prone position for optimal ergonomics using a special prone pillow. The skin is infiltrated with local anesthesia. To obtain optimal hemostasis the infiltration should be performed in the dermis rather than the subcutaneous area. The ellipse is removed either with an individual scalpel or utilizing double bladed knives with two #10 blades. The width of the donor ellipse should be kept to 1 cm or less in order to have minimal tension on the donor wound. This should result in a 1–3 mm wide donor scar (Figure 76–4). Also, various techniques exist for minimizing the appearance of the donor scar, so that the underlying hair may “grow through” the scar. The length of the donor ellipse depends on the desired number of hair grafts for the procedure.

Once the ellipse is removed, the donor area is closed with a single layer of either sutures or staples. Extensive undermining and deep sutures are typically not necessary. The staples or sutures are removed in 7–10 days.

The main advantage of elliptical harvesting is its straightforward nature and the ability to harvest hundreds to thousands of follicular groupings with minimal trans-section of the follicles.

The main disadvantage of elliptical donor harvesting is the permanent thin scar that results from the excision as with any excision. For most patients, this is of no practical concern since existing hair on the posterior scalp will easily cover any scar.

For a minority of patients who like to shave their hair or wear their hair closely cropped on the posterior scalp, FUE is an alternative donor harvesting method. The chief advantage of FUE is the lack of the perceptible donor scar. FUE is performed by utilizing 1 to 1.2 mm steel punches similar to the ones used in dermatology for skin biopsies to harvest individual follicular groupings from the donor scalp (Figure 76–5).

As one would expect this is a more time consuming process, which is of no long-term concern but the potential disadvantage of FUE is greater transection of follicles as they are removed from the donor scalp. To date there are no definitive studies showing whether or not this of any consequence to the yield of hair removed from follicular unit extraction.

Currently, the overwhelming majority of patients opt for elliptical donor harvesting due to the shorter time needed and lower rate of follicle transection, leading to predictably excellent growth. For most patients, the donor scar is not a major issue so long as their hair is long enough to cover. Nonetheless, FUE is an excellent treatment option for those patients who may shave their hair in the future or like to wear their hair closely cropped on the posterior scalp.

Hair transplantation is performed in the majority of patients using local anesthesia. The challenge with transplantation is the need to keep the scalp anesthetized for several hours as recipient sites are created and then grafts are placed into the area. We use various concentrations of lidocaine with epinephrine to maintain comfort for the patient and hemostasis in the areas of graft placement. Also, a combination of different techniques including nerve blocks of the supraorbital and supratrochlear nerves and field and ring blocks to the scalp as well as the use of longer acting anesthetics such as bupivicaine.

For a minority of patients who request to be sedated, or require cardiac monitoring during the procedure, IV sedation is an excellent alternative. As with all IV sedation procedures, if performed, it should be done only in a certified operating theater with an experienced anesthesiologist present at all times.

From the 1960s–1990s 10 to 20-hair, 3 to 5 mm plugs were utilized. This unfortunately resulted in the “pluggy, doll's hair” appearance of transplanted hair. This is an unfortunate public legacy of hair transplantation. Contemporary surgery maintains the natural anatomy of 1–3 hair follicular groupings as they grow on the scalp. Once the donor ellipse is removed, it is placed in chilled saline and carefully dissected into these 1–3 hair follicular units. The majority of hair transplant teams use magnification to aid in the dissection of the follicular groupings from the donor ellipse (Figure 76–6). The key to success is to have excellent ergonomic conditions, which include plenty of light, good room temperature, and comfortable seating and counter space for separating the grafts.

Unfortunately, for decades, hair transplant surgeons took the meaning of hair line literally. Besides using unnaturally large plugs, they were placing the hairs in very straight, “picket fence” lines across the frontal scalp. Hairlines are actually irregular transition zones from glabrous to hair bearing scalp. Contemporary transplantation mimics this with irregular, “feathered” hairlines in both the frontal, temporal, and posterior scalp in men (Figure 76–7). The frontal hairline should be placed at least 7–9 cm above the glabella and have a natural temporal recession. In addition, the surgeon should avoid placing grafts in the vertex of very young male patients (twenties to thirties) given the difficulty of predicting his future hair loss. Precious donor hairs may be used up to fill a continuously expanding “bald spot” otherwise grafts placed in the center can look very unnatural when isolated by lost surrounding hairs.

Recipient sites are created using a variety of instruments, ranging from #18 to # 21 gauge needles to specialized spear points or chisel tips. When making the incisions, it is important to follow the natural angle of hair growth and avoid transecting existing hair follicles. The depth of the sites should be 4–5 mm, to mimic the natural depth of hair follicles in the skin. Depending on the density of existing follicles, 10–30 recipient sites per cm2 are made for optimal density.

Grafts are placed into the recipient area utilizing microvascular forceps. All grafts should, at all times, remain chilled and never desiccate while being transferred from the chill saline Petri dish into the scalp.

An experienced hair transplant team can place an average of 500–1500 grafts, over a period of takes three to 6 hours. After the last graft is placed, a dressing is applied to protect the grafts while they heal overnight. Patients return home and may resume regular activities, but should avoid heavy exercise for 3–4 days. A short course of prednisone to prevent frontal edema and extra strength acetaminophen can be used as needed during the first few days after the procedure if there is any discomfort or headache. The day after the procedure, the dressing is removed at home by the patient. The patient should feel well and should be encouraged to shower. This will help remove hemorrhagic perifollicular crusting. Most of our patients with existing hair elect to do the procedure at the end of a work week, so they have the weekend to convalesce. Sutures or staples are removed in 7–10 days. Transplanted hair begins to grow 3–6 months after the procedure and the full cosmetic impact occurs approximately 1 year after the surgery (Figures 76–8, 76–9, 76–10, 76–11, 76–12, and 76–13).

Patients with unnatural hairlines and /or inappropriately placed grafts can be substantially improved through a variety of techniques. Patients who received large “pluggy” grafts in the past can be improved by adding one to three hair follicular groupings between the existing plugs. This is similar to filling in gaps between trees with bushes to make it a more natural and softer appearance (Figure 76–14, 76–15, and 76–16). If the large grafts were placed in the scalp where they never should have been, such as the vertex, they can be removed using a 3–4 mm punch biopsy. When the plugs are removed, they are redivided and placed back into the scalp as follicular groupings. Significant emotional and psychological distress can be relieved by simple corrective techniques.

Contemporary transplantation offers a consistently natural appearing result for both men and women. Well-trained teams utilizing large numbers of one to three hair follicular groupings are able to produce natural short and long-term results when done appropriately. The future may offer cloning. Cloning of follicles will not affect the aesthetic result but will give an unlimited donor density and eliminate the need for donor harvesting from the scalp. Presently, there is privately funded research in the area, but it will be many years before we can offer this to our patients.

We would like to acknowledge Min S. Ahn, MD for his contribution to this chapter in the previous editions of CDT.