Alopecia: Hair Replacement Techniques

Baldness has plagued humans for so long that its origins are lost in the mists of time. Interestingly, some primates, such as chimpanzees and some monkeys, also suffer from age-related baldness.

Over time, a great many supposed cures for baldness have accumulated: from camel excrement to tree stump water and even less attractive substances. Records of such "cures" were first found in ancient papyri compiled 5,000 years ago. The Bible sympathized with those who had bald heads but could not find a cure.

Nowadays, there are elegant and effective surgical techniques for hair transplantation, and they are truly healing. These new techniques are based on combining small grafts of different sizes, paying attention to the smallest details of preparation and implantation of the grafts, determining the branches dictated by the quality of the hair, and adapting the procedure to each individual patient.

New techniques have truly revolutionized hair replacement surgery. As a result of advances, results in men with alopecia areata have reached astonishing levels of skill, effectiveness, and patient acceptance. Today's methodology requires a high level of planning and execution.

Other forms of permanent alopecia - alopecia areata in women, scarring from trauma or surgery, hair loss due to radiation, localized scleroderma, and hair loss associated with certain scalp diseases - also respond well to the expanded arsenal of treatments available to hair replacement surgeons today.

Until recently, micrografts were used only in the frontal area. However, the expansion of the use of small grafts to areas beyond the hairline of the forehead has greatly improved the quality of results. There is now a trend to transplant hair in "follicular units," a term that defines hair in its natural groupings of one to four strands. When transplanted, follicular units look quite natural.

Definitions of follicular unit transfer vary among surgeons. Limmer (personal communication) defined follicular unit transfer as follows:

• Follicular unit transplantation is, by definition, the redistribution of naturally occurring groups of follicles (follicular units) of 1-4 hairs, rarely more, harvested from the donor area by elliptical excision and careful microscopic dissection under a binocular loupe, and transplanted into needle tunnels or very small incisions in the bald recipient area. The donor tissue is carefully cut into these follicular units, removing "bald spots". No bald tissue is removed from the recipient area to minimize disruption of the blood supply, which is necessary for the grafts to take root. An H2-saturated collection (20-40 grafts per cm2) during the first session is usually done to obtain a cosmetic result sufficient if no further transplant sessions are to be performed.
• After collecting the donor strips, doctors use various methods to separate them. On the one hand, this is the use of a microscope to create transplants of follicular units consisting of 1-4 hairs, on the other hand, automatic cutting of donor tissue using special devices.

In this article, we will describe in detail our technique for restoring hair using follicular unit implantation. We call our approach the needle-puncture split graft technique. This widespread use of small grafts is a major step forward in achieving a natural look after hair transplantation, perhaps the most important in the last two decades.

Another important advance is the implantation of small grafts without first removing tissue from the recipient area. This technique, called slot grafting, maximizes the amount of hair in the graft and the coverage achieved with any amount of donor hair.

The slotted procedure, although capable of providing complete restoration, actually reaches its greatest potential when used to create a natural look with minimal donor hair availability. It also allows for effective transplantation of hair in patients with poor quality donor hair. Slotted grafts are successful because they do not disrupt the vascular network as round canal grafts do, and are extremely efficient and effective in using donor hair. Some practitioners combine slotted and round canal grafts, a combination that produces excellent results.

Although difficult to quantify, repeated observations show that the total number of hairs that survive and grow after slot-based transplants is greater than after traditional round canal transplants, possibly as much as 2 times.

Even without quantitative assessment, it seems obvious that this difference in engraftment must be attributed to differences in the degree of damage to the subcutaneous vasculature. Any damage to the interconnected network of arteries, veins, lymphatics, and nerves found here represents a physiological challenge that the tissues must overcome before the graft can be nourished. The disruption associated with the removal of cylindrical tissue fragments increases this problem.

On the other hand, careful insertion of the graft into the slit minimizes tissue trauma and allows nutrition to begin almost immediately to the grafted material. Slit grafting also minimizes scarring and doughnut formation. Slit grafting leaves the existing natural hair viable since it does not require tissue removal. It can be argued that compression by surrounding tissue is a problem with this technique. However, the more natural appearance achieved with this technique outweighs any consideration that might lead to the use of standard cylindrical grafting to create a frontal hairline. The use of cylindrical grafts should be limited to posterior areas (i.e., those more than a centimeter from the hairline). In such areas, particularly in total alopecia, the placement of small grafts, such as quarter grafts, into small 1.5 to 1.75 mm holes in the skin can be very effective. The graft placement profile is the same with both techniques. The number and size of grafts are also the same.

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Patient selection

There are many factors and variables to consider when planning hairline restoration and scalp hair reconstruction. The following list contains some of the most important considerations:

• Classification of baldness.
• Hair quality classification.
• Similarity of hair and skin color.
• Prognosis for further hair loss.
• Age of the patient.
• Patient motivations, expectations and desires.

Consultation

During the initial consultation, doctors decide who will be a good candidate for hair restoration surgery and who will not. We evaluate five qualities: the patient’s age, the area of baldness, the match between hair and skin color, the curliness of the hair, and the density of the donor area. If the patient is an acceptable candidate, the potential complications and benefits are discussed with the patient, and preoperative laboratory tests and medication preparation are planned. We usually test for hepatitis B, C, and HIV. A general medical history is taken, including information about current medications and drug allergies.

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Classification of baldness

The most widely accepted classification system for hair loss is the Norwood system. It describes the pattern of male pattern baldness in seven stages and their typical variations. Stage I is the least severe, with minimal hairline retreat at the temples and no parietal baldness. Stage VII is the most severe, with a classic horseshoe-shaped crown of remaining hair. The system is similar to that developed by Hamilton and yields similar results. The new thinking on alopecia suggests that these classifications may be used primarily as means of defining population groups for clinical trials rather than to guide treatment approaches.

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Hair quality classification

The term hair quality includes the characteristics of density, texture, crimp, and color. Broad criteria have been defined for the subdivision of hair quality. The different degrees of hair quality may overlap, and each quality may be further subdivided. Hair of coarse texture and above-average density is designated "A" and is of the highest quality from a transplantation perspective, while fine and sparse hair is designated "D" and has the worst donor quality. Two groups, "B" and "C", cover intermediate characteristics. In general, people with hair color that matches their skin color can expect better results than those whose hair color contrasts with their skin. Hair crimp is also an advantage.

Similarity of hair and skin color The most suitable hair for transplantation are blond, red, gray hair, and a combination of "salt and pepper". Brunettes and brown-haired people present a certain problem, especially those with straight hair. People with straight black hair and fair skin are the least suitable for transplantation. The final appearance after transplantation largely depends on the degree of similarity of hair and skin color. Matching minimizes visual contrast. The most favorable combination is dark skin combined with black, wavy hair. The most unfavorable combination is light, pale skin and dark, straight hair. In the latter case, the degree of visual contrast is increased by the visibility of any transplantation undertaken. Between the two extremes there are many combinations; even in one person, the hair color in the crown and back of the head can sometimes differ.

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Prognosis for further hair loss

Since androgenetic alopecia is genetically controlled and therefore hereditary, a rough estimate of future hair loss can be made from a carefully taken family history. Information on close relatives should be collected at the initial interview and used in conjunction with other factors such as age, current condition, and pattern of hair loss to make a prognosis. It is not possible to predict future hair loss with absolute certainty, and patients should be advised of this.

Age of the Patient Androgenetic alopecia is an ongoing process (i.e., it usually lasts a significant portion of a person's life). The patient's age indicates their place on the alopecia continuum. Knowing whether the patient is at the beginning or end of the process allows for more accurate planning. It is true that with today's techniques, satisfactory improvement in appearance can be achieved in virtually any patient, but it is also true that those who wish for the impossible will be disappointed.

Taking into account the patient's age also allows for an assessment of the appropriate position and contour of the hairline. Patients aged 20 years and younger are usually dissatisfied with the transplantation, as it is very difficult to predict what form and course the future alopecia will take. Exceptions occur when the patient understands that the extent of future hair loss is unknown and therefore an accurate prediction of its course is impossible and still leaves much to be desired.

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Motivation

When discussing patient expectations, the surgeon should determine the patient's level of motivation and perception of the expected improvement. The patient should be well informed, highly motivated, and given a fair understanding of the expected results of the proposed procedure. A hairline that complements the facial structures and reflects the surgeon's chosen approach should be drawn and discussed with the patient. It is important that each patient have a full understanding of the expected cosmetic effect before surgery. Some believe that it is desirable to under-represent the potential benefits of the transplant.

Hairline placement

In determining the placement of the hairline so that it will create balance and compensate for facial irregularities, the surgeon must view the face as divided by imaginary horizontal planes into three segments of approximately equal vertical length. The anthropometric boundaries of these segments are: (1) from the chin to the columella; (2) from the columella to the glabella; and (3) from the glabella to the existing or anticipated frontal hairline. The position in which the superior border of the superior segment should be located serves as a general guide for determining the appropriate height of hairline placement.

However, this measurement should be used with caution, as it often results in the hairline being placed too low. In practice, the hairline is usually placed 7.5-9.5 cm above the middle of the bridge of the nose. This is a general guideline and should not be taken as an absolute parameter.

The hairline should be placed and designed to be age appropriate rather than perpetuating a youthful, ageless appearance which, in many cases, becomes unnatural and even unattractive. It is often necessary to place the edge of the future hairline slightly back from the remaining, original hairline. This conservative approach will allow optimal use of the donor hair and will give more adequate coverage. A low, wide hairline often results in inadequate donor hair, giving uneven donor hair coverage and a poor cosmetic effect.

The entire transplanted, reconstructed hairline should look natural, but not every hairline will aesthetically correct and improve the appearance. Since the contours of the line will be more or less permanent, their overall appearance should be acceptable to the patient throughout life. It is best to establish a natural, but age-appropriate hairline. A low hairline, characteristic of youth, may look natural enough at a certain age, but will become unacceptable over time. The frontotemporal angle, which is the area where male-pattern baldness begins, is most important in creating the final look.

Over the past 30 years, most transplant surgeons have created a strictly symmetrical hairline.

The general trend among surgeons has been to uniformly line up the grafts along the most anterior portion of the hairline. The result of this symmetrical approach can appear artificial. Hairlines, in their natural state, are not symmetrical, with crisp edges like a well-mown lawn. They have an uneven appearance, with hairs scattered up to 1 cm in front of the perceived hairline.

Hairdressing preferences, characteristic of the current fashion trends, should not dictate the shape of the hairline created, as they are transient and will certainly change. Sometimes it is possible to determine the year of previous transplants by the configuration of the hairline. The widow's peak is now rarely done, and its presence probably means that the transplant was done in the 1960s.

Transplantation into the slots

Between 1989 and 1998 we made a transition zone of single grafts that were deliberately placed in a not too uneven manner. These single hairs were used to create a transition zone to the grafts that were more densely placed in the scalp. The results were cosmetically pleasing, but still did not match the degree of unevenness of the natural hairline. Observation of our patients led us to the conclusion that the hairline should be more uneven so that its artificiality would be less noticeable. We now call this the zig-zag pattern. The shape of the hairline is marked on the patient before the recipient areas are marked. After the general outline is created, we use markers to draw a wavy or zig-zag line. In this case, the initially planned hairline is used for general positioning and then transformed into a wavy, uneven shape. The recipient areas are placed along this wavy line as a true edge. The density of the transplant in this area can vary. This irregular pattern is called a "sawtooth", "snail track" or "zigzag". Behind it, larger follicular units, up to four hairs, are transplanted to create greater density.

Separate technique of needle punctures and graft placement

Collection of donor strip

On the day of surgery, the patient is taken to the operating room, where a series of preoperative photographs are taken, the donor area is marked, shaved, and infiltrated with local anesthetic. An elliptical-shaped section of donor tissue is removed with a double-bladed scalpel. The donor site is then closed with staples. Immediately after the donor strip is obtained, it is handed to a group of three or four technicians who section it under a lighted stereomicroscope. Sectioning is accomplished by cutting the donor tissue into thin strips, one follicular unit thick, and then isolating a follicular unit from each strip.

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Creation of a recipient zone

After the donor strip is collected, the patient is moved from a horizontal position to a sitting position. The recipient area is anesthetized by blocking the supraorbital and supratrochlear nerves. Then, just anterior to the recipient area, we inject lidocaine with adrenaline, followed by bupivacaine with adrenaline. Adrenaline at a concentration of 1:100,000 is infiltrated intradermally throughout the recipient area. Receptive incisions are then made with an 18 G needle for smaller follicular units and with a 19 G needle for single-hair grafts creating the frontal hairline. The needles are inserted at an angle of 30-40° to the skin surface so that the transplanted grafts are tilted slightly forward, toward the patient’s nose. This gives the patient more options for hair styling. After all recipient sites have been created, our technician inserts the follicular unit grafts. This technique is called the separate needle puncture and graft placement technique because the creation of recipient sites with needles is separated in time from the insertion of the grafts. This is an important difference from the simultaneous creation of recipient sites with needles and the transplantation of grafts. Both methods have their supporters and opponents.

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Introduction of transplants

After creating the recipient zones, the technician inserts one transplant at a time using jewelry tweezers. Usually, to speed up the process, two technicians work with one patient at a time. Immediately after the operation, the donor and recipient zones are covered with Polysporin, Tefla and acrylic gauze. A strong compression bandage is kept for up to 24 hours. On the first day after the operation, you are allowed to carefully wash your hair with shampoo, with a warning not to remove any scales or films that have formed in the recipient zone. Patients take prednisolone for 5 days. You can return to work the day after the bandage is removed (on the 2nd day after the operation).

Discussion

The separate technique of needle punctures and graft placement allows for the transplantation of an average of 1,000 grafts in less than 5 hours. With minimal bleeding and good quality donor tissue, the operation can take significantly less time. The advantage of this technique is the doctor's complete control over the formation of the hairline, as well as the position and direction of each graft. The use of stereomicroscopic dissection limits the intersection of follicles, which can worsen the quality of the transplanted hair. In addition, after completing the marking of the recipient areas, the doctor is free to perform other work. The disadvantage of this technique is the need for training in working with a stereomicroscope to separate the donor tissue and create grafts.

Although there are supporters of the standard, large cylindrical transplant method, we use it because we believe that the cosmetic effect of the completed procedure does not correspond to the natural one. Transplantation of follicular units creates a result that is closest to the natural state.

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Scalp excision

It is not the purpose of this chapter to describe in detail the technique of scalp excision operations. However, a simple description of the most important features of the procedure may give perspective.

Scalp reduction is usually planned individually to suit a specific area of baldness. Various shapes are used (e.g. straight, paramedian, three-pointed star, and two- or three-diamond). In practical use, the elliptical, Y-, T-, S- and crescent shapes predominate. Modifications and permutations of the listed shapes are also used.

The straight ellipse is the simplest type of reduction. Although technically it is the simplest configuration, it is better to replace it with a paramedial one whenever possible. The latter is cosmetically less noticeable and has other advantages when creating a hairstyle.

The scalp excision operation is performed under local anesthesia (ring block). The midline and the expected outer borders of the area planned for excision are marked. The first incisions are made along the outer borders of the designated area. The Shaw scalpel (hot blade) helps keep the surgical field dry and reduces the time of the operation, as this instrument has a dual action - it excises and coagulates.

The undercut is made approximately 7-10 cm on each side of the incision. Once this is completed, the size of the tissue to be excised must be determined. In general, this can be done by manually moving the edges of the incision toward each other and cutting off excess or overlapping tissue.

The degree of tension that occurs in the fascia of the aponeurotic helmet must also be considered. An aggressive approach to reduction involves excising a relatively large volume of scalp, which will increase tension in the suture. A conservative approach dictates a smaller volume of tissue excision, minimizing tension in the suture. Both approaches have advantages and disadvantages.

Tissue expanders may be used during surgery to stretch dense hairy areas. Caution is advised when attempting reduction in patients with thin, tight scalps, as they are less suitable for the procedure than those with thick, elastic skin.

After the excision of the scalp tissue is completed, the aponeurotic helmet is sutured first, usually with 2/0 PDS threads. After the suturing of the aponeurosis is completed, the skin is brought together with staples.

The configuration of the areas removed during scalp excision is often modified to avoid leaving a cosmetically obvious scar. Various segments of the reduced specimen can be curved or adapted to more easily conceal the scar. Z-plasty should be used at the back of the reduced surface to further conceal this sensitive area.

After excision, for complete restoration and closure of the scar, hair transplantation is almost always performed.

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Parietal baldness

For the correction of parietal baldness, skin excision is preferable to grafting. In this case, patients with thick, elastic scalps are better suited for the operation than those with thin, tight scalps. Later, small grafts are transplanted into the scar area for camouflage. The use of grafts larger than 2 mm in the parietal area can lead to the formation of tufts. Only quarter grafts can be transplanted into this area. Also, one should not try to place the grafts too close to each other along the edge of the scar, as this can lead to a zipper effect and ultimately ruin the natural appearance.

An exception to the rule of preferential treatment of parietal baldness by scalp excision is made for patients with extremely thin or extremely tight scalps, and for those who fear reduction surgery because they believe it will be too painful. However, most patients are surprised to note that this surgery is comparable to a transplant session, and a significant percentage of patients prefer scalp excision surgery to a transplant session.

In most cases, more than one excision procedure is required. Limiting factors are the thickness and elasticity of the scalp. All patients should be advised that the resulting scar should be covered by subsequent hair transplantation.

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Medication support for scalp excision operations

Before surgery:

• Valium, orally, 20 mg 1 hour before surgery.
• Nitrous oxide during administration of local anesthetic.
• Lidocaine 0.5% (20 ml total) for ring block, then bupivacaine (Marcaine) 0.25% (20 ml total) for ring block.

After surgery:

• Repeated ring block with bupivacaine 4 hours after surgery.
• Percocet 1 g 4-6 hours as a pain reliever.
• Prednisone 40 mg daily for 5 days.

Female alopecia

Although attention to male-pattern baldness continues to dominate the lay press and medical literature, female pattern alopecia is frequently encountered by dermatologists. It most commonly presents as diffuse vertical frontal thinning of the hair. Women with a family history of baldness may develop either diffuse thinning or male-pattern hair loss. In this genetically predisposed group, varying degrees of baldness may be observed even when androgen levels are normal.

Recently, it has become possible to treat women with diffuse alopecia if they have sufficient hair density in the occipital region. The use of small grafts in female pattern baldness has become a convenient and effective method of increasing hair density in women, especially in the parietal and fronto-parietal regions. A number of quarter grafts are inserted between the existing hairs, and the final result appears as an increase in hair density. The technique of grafting into slits, which does not traumatize the tissue of the receiving bed, maximally protects the existing hair.

For women with male pattern baldness, the goals and approaches to treatment and transplantation are the same or similar to those for male pattern baldness.

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Poor results

What many incompetent people consider a bad result is often an incomplete transplant or is caused by improper care. Statistics based on 25 years of experience show that 85% of patients after hair transplantation were satisfied and would like to repeat the procedure. Of the 15% who did not want to continue the treatment and were completely dissatisfied, approximately 90% did not complete the treatment as prescribed. Thus, the vast majority of dissatisfied patients are those who did not want to make the necessary efforts. With the introduction of new techniques, the number of satisfied patients increases and the scope of correctable disorders expands.

There has been a revolution in the field of hair transplantation. Older approaches that used large, round grafts with no regard for hair quality are now archaic. Technological advances have made it possible to treat a wider range of hair loss patterns and etiologies. Today's techniques and attention to detail make it possible to bring hair restoration closer to the goal of a flawless transplant: a natural hairline and an overall appearance that has subtle signs of surgery.

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Complications of transplant procedures

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Fainting

Fainting may occur after a few milliliters of anesthetic have been administered. It may also occur at later stages of the procedure. Administering anesthesia in a horizontal position usually prevents this condition from occurring.

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Bleeding

The occipital region is the most common area of arterial bleeding. This bleeding is best stopped by suturing. Compression is often required for adequate hemostasis. This is done by applying elastic bandages to the donor area and maintaining constant moderate pressure for 15-20 minutes after the grafts have been taken and the wound has been closed. After the session is completed, the compression bandage is put back in place and kept in place for the next 8-12 hours. If bleeding develops after the patient leaves the office, the patient is advised to apply constant pressure first by hand and then with a clean bandage or cervical sling. If bleeding does not stop, ligation is indicated. If bleeding occurs in recipient areas where implants have been inserted, removal of the transplanted tissue and suturing of the bleeding source may be required. After healing, a small scar usually remains, which can later be excised and, if necessary, replaced with a small graft.

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Edema

Postoperative swelling of the scalp and forehead is common, especially if the transplant was extensive. Swelling can be reduced with oral prednisolone. Swelling usually resolves as healing occurs.

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Infection

Infection develops in less than 1% of cases, but nevertheless it should be avoided and treated.

Scarring

Scarring from small hair grafts is rarely of such magnitude as to warrant serious consideration. Keloids may occasionally develop in black individuals. If the patient's history indicates the possibility of developing a keloid, a 3-month break should be taken after the first session. This will allow enough time for the keloid to form and a decision can be made about whether to continue treatment.

Poor hair growth

Ischemia, poor hair survival, or even graft loss may result from grafts being placed too tightly. In some patients with fine hair, growth of transplanted grafts may be minimal, regardless of the transplantation method used.

Different

Patients with limited grafts and thin normal hair may experience temporary hair loss to their chagrin, but should be advised that hair will grow back. Arteriovenous fistulas may occasionally develop in the occipital region and are easily isolated and ligated.

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Care

Meeting the aesthetic needs of hair transplantation is not limited to designing the frontal hairline and other areas, but also extends to providing the patient with proper aftercare advice. Once patients entrust themselves to a hair transplant specialist, it is necessary to pay attention to the current styling and maintenance needs. Proper aftercare advice and recommendations are necessary to achieve maximum transplantation efficiency and patient satisfaction.

There are many reliable treatments on the market that enrich the structure and give visible thickening of the hair. To achieve the full effect, a hair dryer is necessary. For patients with thin, straight hair, permanent treatment is desirable. Although many men are reluctant to visit a stylist, this reluctance is inappropriate and must be overcome. The doctor may recommend or even insist on perming the hair, especially for patients with quality classes C or D.

Some patients may benefit from additional scalp veiling with Couvre or scalp camouflage cream. These products refract light in areas of sparse hair, making them less noticeable. The appropriate hair length should be determined for each individual. It is advisable to seek the help of an expert stylist for this.

Advice and referral to specialists in this field is the responsibility of the hair reconstruction surgeon, as the patient's final appearance is a critical factor in the overall success of the treatment.