eMedicine Specialties > Plastic Surgery > Hair

Hair Replacement Surgery, Hair Transplantation

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
Coauthor(s): Gary D Monheit, MD, Associate Professor, Department of Dermatology, University of Alabama at Birmingham
Contributor Information and Disclosures

Updated: Jun 2, 2009

Introduction

History of the Procedure

The 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.^1,2,3 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.⁴ 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.⁵ 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.⁶ These techniques were refined and developed into the megasession techniques as described by Barrera and others.^7,8,9

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 scarring 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.

Problem

Transplantation 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.

Frequency

Alopecia 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.

Etiology

Donor 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.

Pathophysiology

Androgenic 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.

Indications

Indications for hair transplantation include androgenic alopecia, male pattern alopecia, cicatricial alopecia, traumatic alopecia, and traction alopecia.

Relevant Anatomy

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.

Contraindications

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.

• Search for CME/CE on This Topic »

• Hair Replacement Surgery, Hair Transplantation in Women (Plastic Surgery)
• Hair Transplantation (Dermatology)
• Hair Transplantation, Follicular Unit Transplant Method (Dermatology)

• Management of Primary Cicatricial Alopecias: Options for Treatment