eMedicine Specialties > Plastic Surgery > Hair

Hair Replacement Surgery, Hair Transplantation: Treatment

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

Treatment

Medical Therapy

Medical 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. Adverse effects are rare, less than 1%, and patients must remain on the drug indefinitely, since the benefit may be lost after discontinuation.

Surgical Therapy

The 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.

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.¹⁰ His techniques changed the mechanics, appearance, and character of the procedure.

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.¹¹ 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.^12,13

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.¹⁴ 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.¹⁵ 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.^16,17,18 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 Details

The hair transplant surgeon also must take into account the following characteristics of donor hair to predict results:

• Hair density: With poor density, a natural result is more difficult to achieve.
• Thickness of hair follicles: Fine, thin hair is harder to disguise than curly, thicker hair.
• Stringent versus curly hair: Natural curl produces a better result.
• Hair color: Light colored, gray, or salt and pepper hair is more natural than thin, straight, black hair.

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, nonsteroidal 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 Details

Topical 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 (Xylocaine) 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 use 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.¹⁹

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 Details

At 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-up

Patients 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.

Complications

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.

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