eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Hair Graft Transplantation for Baldness: Treatment

Author: Jeffrey S Epstein, MD, FACS, Clinical Professor, Department of Otolaryngology, Division of Facial Plastic Surgery, University of Miami College of Medicine
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Updated: Feb 13, 2008

Treatment

Medical Therapy

Only 2 medications, minoxidil and finasteride, have received approval from the FDA for treating hair loss. Active clinical research is continually conducted to search for medications that are more effective than these, with pharmaceutical companies eager to market a product that more than 50 million Americans may desire.

Minoxidil (Rogaine) is a liquid applied directly to areas of the scalp undergoing hair loss. Originally indicated for the treatment of severe hypertension, minoxidil slows the progression of hair loss and causes fine hair regrowth in the back half of the scalp in 25-40% of men. Both the 2% (available in generic form) and 5% concentrations (ie, Extra-Strength Rogaine) are available over the counter. Both medications elicit few reported adverse effects; the most common are heart palpitations and headache. In women, the 2% concentration has a response rate similar to that seen in men, helping 20-40% of women retain their hair and, occasionally, achieve hair regrowth.

Minoxidil must be applied twice daily. Like finasteride, minoxidil must be used continuously to maintain hair regrowth. Otherwise, on cessation of the drug, most of the strengthened hairs fall out. The exact mechanism of action of minoxidil is unknown, but it may work by means of local vascular dilation or the nonspecific occupation of DHT-binding sites in the hair bulb.

Some physicians recommend the use of minoxidil after transplantation. Application to the grafted areas once per day can shorten the interval between the procedure and the growth of transplanted hair from 4 months to fewer than 3 months.

Finasteride (Propecia) is more effective than minoxidil in treating male-pattern hair loss. This 5-alpha reductase inhibitor blocks conversion of testosterone to DHT, the hormone thought most responsible for the miniaturization and eventual involution of scalp hairs in MPB. Finasteride 1 mg taken orally once per day is effective in approximately two thirds of men. The major benefits of finasteride are the slowing and occasional cessation of hair loss and even the potential regrowth of hairs, primarily in the back half of the head.

Several benefits accrue from the addition of finasteride in individuals undergoing hair transplantation procedures. First, finasteride potentially reduces the need for further procedures, increasing hair allocation to the anterior and middle scalp, areas that do not respond to medication. Second, by potentially minimizing and even reversing the miniaturization process of hairs in the back half of the scalp (including hairs in the donor strip along the back of the head), finasteride can increase the density of those transplanted hairs, thus improving surgical results.

Only men can take finasteride. Although uncommon, adverse effects can occur and include a less than 2% published incidence of reduced libido and decreased sexual function.

A new treatment modality to receive FDA approval is low level laser light therapy. This poorly understood treatment involves the several-time weekly application of a laser emitting device to "stimulate" hair growth of existing miniaturized hairs. It is not clear whether this technique has the equivalent benefits of medical treatments minoxidil or finasteride, but there may be some promise to it.

Surgical Therapy

Surgical hair restoration is the procedure of choice for restoring hair. The concept behind all forms of hair restoration is redistribution of hair rather than addition of new hair. Three hair-restoration procedures have traditionally been available: hair grafting, bald scalp reductions, and scalp-flap surgery. Today, hair grafting accounts for more than 95% (perhaps as much as 99%) of procedures performed. Hair grafting has a high success rate with a low incidence of complications, it is performed in the outpatient setting with little surgical preparation or specialized setup, and (most important) patient acceptance is high.

Bald scalp reduction is the excision of alopecic scalp. The excised area typically consists of the crown and occasionally extends anterior to the middle scalp. Relatively popular during the 1980s through the mid 1990s, scalp reduction is performed infrequently today. Reducing substantial areas of bald scalp without causing abnormal hair growth, scarring, and marked patient discomfort is difficult, and most surgeons recommend options other than bald scalp reduction for treating hair loss on the middle and posterior scalp.

Few surgeons perform scalp-flap surgery because of the need for specialized surgical training in the technique. In addition, most patients are not ideal candidates for the procedure unless they are motivated, unless they are in their mid 40s or older, and unless they seek a dense hairline with relatively limited hair loss restricted to the anterior scalp. A single scalp flap can contain as many as 10,000 hairs, resulting in the creation of a dense hairline in just 2-3 procedures performed in an interval of several weeks. Complications of scalp-flap surgery (including flap necrosis) can be devastating, though they are rare when an experienced surgeon performs the procedure.

Hair grafting, the most common hair-restoration procedure, can be performed by using different techniques. From the early 1990s until recently, transplanting with micrografts (1-2 hairs), often combined with minigrafts (3-5 hairs), was considered state of the art. Today, most surgeons consider follicular-unit grafting the definitive procedure.

As discussed in Relevant Anatomy, transplanting only follicular units and dissecting away all non–hair-bearing tissue can offer several advantages. These follicular-unit grafts can be placed into tiny recipient sites, allowing for dense packing and reducing postprocedure crusting. The requirement for careful dissection reduces the accidental transection rate and therefore minimizes depletion of good hair follicles; a benefit that potentially maximizes hair yield from a particular strip of donor hairs. Finally, because hairs are transplanted in accordance with their natural growth in these tiny follicular units, the results are virtually undetectable.

Preoperative Details

As with any surgical procedure, thorough counseling before hair-restoration surgery is critical. Patients require education to make informed decisions regarding this elective procedure, ie, whether to undergo it, and, if so, which procedures. Because hair restoration is cosmetic surgery, discussing patients' areas of concern, explaining treatment options, and providing a realistic picture of expected results are important.

A thorough list of instructions is given to all patients before the procedure. Patients should stop taking all aspirin-containing medications, vitamin E, and ginkgo 10 days before the procedure and all nonsteroidal anti-inflammatory drugs (eg, ibuprofen) and alcohol 3 days before. To further reduce the risk of bruising and edema, patients are instructed to take vitamin C 2000 mg daily for 1 week before surgery. If the patient is to receive intravenous or twilight sedation, they should receive nothing by mouth (NPO) 8 hours before the procedure.

On the day of the procedure, a relaxing atmosphere should be created, enhanced by the usual administration of the chosen oral sedation. The present author has found that diazepam (Valium) 10 mg and zolpidem (Ambien) 10 mg are the most effective and safe options.

A valuable opportunity to further discuss expectations and goals with the patient and his or her significant others is presented when marking the planned transplant areas on the patient.

An aesthetic hairline design is crucial in providing a natural-appearing result appropriate for the individual at present and in the future. Aesthetic hairline design usually requires a hairline irregular and wavy appearing, with slight-to-substantial frontotemporal recessions. In basic hairline design, the central-most aspect of the hairline is placed 8-10 cm above the nasion (root of the nose). Then, the hairline carried laterally in an up-sloped direction when the patient is viewed on the Frankfort horizontal plane. This design results in the central aspect of the hairline being the lowest (most caudal). In many patients, the creation of a slight widow's peak results improves the natural appearance.

In patients with substantial caudal recession of the superior aspect of the temporal tuft, transplanting this area to build it superiorly is sometimes helpful. Fine grafts containing 1-2 hairs are typically used to create a thin but natural-appearing result. The resulting temporal horns, which often occur naturally, allow the lateral hairline to join with the superior temporal hairline, even if the transplanted hairline is high and thus prevent an isolated frontal tuft.

Note that all lines drawn to mark the hairline serve as a rough template, from which an irregular saw-tooth pattern can be transplanted to mimic natural hairlines. The goal of hairline creation is to create a hairline that is not discernible as a line.

A conservative approach is important when transplants are placed into the crown region because of the likelihood of progressive enlargement of the crown. If this occurs, additional grafting is required in the future to avoid the appearance of a donut-shaped area of bald scalp surrounding a central circle of transplanted hairs. Frequently, only the anterior one half to two thirds of the crown are transplanted densely, whereas the remaining crown area is transplanted less densely by scattering 1- or 2-hair micrografts to provide some minimal coverage to prevent the appearance of a shiny area.

The final step before the patient is transferred into the procedure room is to determine the necessary size of the donor area and then to trim the hairs to be transplanted. The donor site is usually in the middle-to-superior aspect of the back of the head, accounting for and avoiding any potential recession in the crown area. A number of techniques have been described to determine the size of donor area necessary to provide the required number of grafts.

Typical procedures consist of 1400-2800 follicular-unit grafts, but procedures as large as 3200 grafts are not uncommon.  Use of a densitometer, which measures the number of hairs per square centimeter, is the most accurate way to determine donor-site size. Approximately 75 follicular units are obtained from each square centimeter of area; therefore, a planned 2000-graft procedure requires a donor strip 24 X 1 cm.

Intraoperative Details

The patient is seated in a semirecumbent position, and local anesthetic is injected. Over the last 4 years, the author has used a computerized injection device called the Wand, which allows for the slow and controlled injection of agent. First, the donor area is injected superficially, followed by a slightly deep injection along the entire hairline to create a field anesthesia. In the author's practice, more than 80% of patients are given oral sedation, whereas local anesthetic is sufficient for the rest. The rare patient chooses to have intravenous sedation provided by a nurse anesthetist.

With the patient sitting, the scalp is prepped in sterile fashion. Approximately 25 mL of 1:50,000 epinephrine is injected into the donor region for tumescence. The single fusiform donor strip is most easily excised in a superficial subcutaneous plane, which helps in avoiding the occipital neurovascular bundle structures and other smaller vessels. If necessary, electrocautery is used, and the donor-site incision is reapproximated with a simple running 3-0 Prolene suture by staying superficial to the hair follicles to minimize compression injury and resultant alopecia along the donor-site scar.

At this point, the surgical personnel split into 2 teams. Good results in hair transplantation require a highly trained team of assistants to dissect grafts and to help plant them. One team consists of those who perform the slivering; this team sections the donor strip into many narrow strips that are 1 follicular unit wide. These narrow strips then can be divided into individual grafts consisting of a single follicular unit. These follicular units most commonly contain 2-3 hairs, but they can contain 1-4 hairs. Excess tissue not containing hair is excised to allow for the transplantation of just these follicular units.

Assistants perform graft cutting with the aide of binocular microscopes for most accurate dissection. This process is demanding and time consuming but critical for the success of the procedure. The typical assistant can cut 100 grafts per hour; hence, a team of 6 assistants can cut 1800 grafts in 3 hours. The grafts are cut on a Teflon cutting block by using Personna size-11 scalpel blades or double-sided razor blades. While awaiting transplantation, the grafts are stored in chilled preservative-free solution of isotonic sodium chloride.

As grafts undergo dissection, the surgeon creates recipient sites. The author's preferred instruments are tiny blades custom cut from single-edge Personna razor blades. These blades measure 0.6-1.3 mm, but blades of 0.6, 0.7, or 0.9 mm are most commonly used for grafts containing 1, 2, and 3 hairs, respectively. The 0.6-mm blade is typically used along the frontal hairline, where 1-hair grafts are placed most anteriorly, with the 2-hair grafts placed immediately behind into incisions made with a 0.7- or 0.8-mm blade. Finally, depending on the size of the 3- and occasional 4-hair grafts, the 0.9- or 1.0-mm blade is used to create the remainder of recipient sites.

Several concepts are important in the making of recipient sites, as the direction and location of these sites determine the direction and location of growth of the transplanted hairs. Usually, the more anterior along the hairline, the more oblique the angle of penetration of the recipient site. By working posteriorly, a continued anterior but less oblique direction of growth is maintained. When hairs are transplanted into thinning areas that still have original hairs, the direction of the recipient sites must mirror the direction of growth of these existing hairs to prevent transecting and damaging the hair follicles and to ensure an even and equivalently patterned growth of all scalp hairs. These recipient sites must be made between existing hairs to avoid transection of existing hair follicles. Although this process is a time-consuming challenge, such attention to detail reduces telogen effluvium (ie, rapid hair loss), which is observed when a substantial number of hairs are damaged.

In the crown area, the radial direction of growth of hairs is maintained. In the anterior portion of the crown, the hairs tend to grow anteriorly, while more posteriorly, the hairs indeed grow posteriorly. Somewhere between the anterior and posterior areas usually lies a circular whirl. On occasion, recreation of this whirl is necessary, especially when the entire crown is filled.

After the recipient sites have been created, the grafts are then inserted. This is an extremely challenging and delicate process because atraumatic placement of individual grafts is crucial to prevent lack of growth of the hairs and to minimize scalp edema. For graft insertion, the preferred tool is the curved and straight ultrafine jewelers' forceps. These forceps allow grafts to be handled and placed by grasping them only along the subcutaneous fat just deep to the follicle.

Postoperative Details

Graft placement constitutes the final step in the time-consuming hair-transplant procedure. A 2200–follicular-unit graft procedure typically requires 5 hours to perform when done by a surgeon and 8 assistants). Afterward, patients can leave the office bandage free. To prevent any periorbital swelling that sometimes results from edema along the frontal hairline from migrating inferiorly, a strip of elastic tape is placed across the patient's forehead. This tape is worn for the next 3 days and is easily concealed by wearing a baseball hat.

On postoperative day 1, patients usually return to the office for a hair wash and checkup. The occasional "popped" graft can be returned to the recipient site at this time. On postoperative day 3, patients can wash the hair themselves by gently applying shampoo and rinsing with water. Sutures are usually removed on days 10-12. By this time, all crusting (typically minimal with the follicular unit grafting procedure) should be gone, and the scalp typically appears entirely normal except for possible slight erythema along the recipient site region. To speed the resolution of crusting and to promote rapid healing, patients can use a copper-containing moisturizing spray called GraftCyte. Postprocedural medications include cephalexin 500 mg for 3 days, prednisone 50 mg for 3 days, and ibuprofen or acetaminophen with codeine #3 as necessary. For most patients, discomfort is mild, and ibuprofen is adequate.

After the procedure, advise patients to avoid exertion for the first 48 hours. After this, light exercise, such as running and golf, can be resumed. By postoperative day 5, no further restrictions are placed on the patient with the exception of swimming with the head submerged, which must be delayed until postoperative day 10.

Follow-up

Advise patients that more than 80% of transplanted hairs fall out between postoperative days 14 and 21. With follicular-unit grafting, as many as 20% of hairs may continue to grow. The transplanted hairs reappear 3-4 months later and continue to grow for the patient's lifetime at a rate of approximately 0.5 in/month. To shorten this interval of hair regrowth to 10 weeks, patients are instructed to apply minoxidil daily for the first 3 months.

Approximately 50% of patients choose to undergo a second hair-transplant procedure at some point. This procedure can be performed as soon as 5 months after the first procedure. The most common reasons for patients wanting a second procedure are to increase hair density and to cover more areas than could be covered in the initial procedure. Patients sometimes return several years later to have an additional procedure or to fill in areas that have undergone hair loss. With additional procedures, the donor site almost always encompasses the first procedure's donor site, resulting in a continued single incision line and minimal scarring.

Complications

When performed properly, the results of hair transplantation are virtually undetectable. However, complications can arise from errors of technique, poor planning, and unpredictable patient factors.

As with any surgery, hair transplantation poses possible risks. Excessive bleeding due to undiagnosed coagulation disorders or secondary to medications can be bothersome at the least and (in rare cases) life threatening at the worst. Infections and anesthesia problems are 2 other potential, though unlikely, complications.

Complications more unique to the hair-transplant procedure are rare but can occur. Scarring of the donor site can include hypertrophic scar formation due to excessive tension and perhaps even a tendency toward keloid formation. Alopecic scar formation can result from excessively tight suture placement or from hair follicle cauterization. Scarring of the recipient site was more common when large-graft transplantation was performed. Such scarring included ridging, cobblestoning, and skin hypopigmentation.

Poor hair growth can occur and probably is largely dependent on technique. Graft desiccation, rough handling of the grafts, and faulty graft preparation can result in limited hair growth. Lack of growth must be distinguished from delayed hair growth because transplanted hairs occasionally require as long as 12 months to grow. Telogen effluvium or loss of original hairs in transplanted areas, usually an avoidable condition, can result from poor circulation or inadvertent trauma to already existing hair follicles, thus producing an initial early thinning of hair that can range from mild to cosmetically disturbing. Hairs usually return in 1-2 months, but this can be a difficult situation.

Errors of technique and of poor planning are preventable but occur all too often. The most common of these technical errors, which results in a transplanted appearance, is the use of excessively large grafts and unaesthetic hairline design. The importance of using 1- and 2-hair grafts, placed in the proper direction to create an irregular hairline of gradually increasing density as the surgeon proceeds centrally, cannot be overstated.

Failure to anticipate future hair loss in planning hairline restoration can result in an unnatural appearance as the patient ages. One of the most common problems can be development of large bald areas between the lateral aspects of the parietal hairline and the temporal peaks caused by recession of the temporal areas. Transplanting of the crown in a young individual who eventually develops excessive baldness can result in a circular region of transplanted hair surrounded by a rim of bald scalp.

Undesirable hair transplantation results can usually be dramatically improved by using a number of reparative techniques. However, the goal of hair-transplant surgeons should be the prevention of undesirable results.

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